Editore"s Note
Tilting at Windmills

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September 4, 2007
By: Shannon Brownlee

OVERTREATED....Wow! Who knew that a simple idea like putting doctors on salary (in organized, group practices like the Mayo Clinic and Kaiser) would provoke so much discussion? Thanks for all the comments.

Today, I'm going to pick up the thread from yesterday's wild ride and focus on the link between costs and unnecessary care, which is the central theme of my book.

One poster stated: "You can't just say that you're going to cut out the 5% of procedures that are harmful." OK, but instead of focusing on harmful care, let's look at unnecessary care (which, it turns out, is also harmful). The amount of unnecessary care delivered in this country isn't 5 percent. It isn't even 10 percent. It's closer to 20-30 percent. That means we're wasting between $400 billion and $700 billion on care that isn't doing us any good.

How do we know this? The best work has come out of research at Dartmouth that has uncovered wide variations in how much care patients receive in different parts of the country. The Dartmouth researchers have found a two-fold difference in per capita spending on Medicare recipients in different regions.

That difference can't be explained by variations in the price of medical services. Of course prices differ in Biloxi and Boston, but not enough to account for the two-fold variation in spending. It also can't be explained by differences in the prevalence of illness in different parts of the country. (Yes, people are generally sicker in Biloxi than in Seattle, but that can't account for the difference in spending either.)

The only explanation for it is that doctors and hospitals in different regions are giving Medicare patients a lot more — and a lot more intensive — care.

This wouldn't be a problem if all that extra care was resulting in better health outcomes. It would be great for the citizens of Boston and other places where patients receive the most care. But the extra care isn't producing better health. Studies looking at patients with specific conditions, like hip fractures or heart attacks or colon cancer, show that they aren't living longer or even healthier lives in places where they are getting more care.

That can only mean one thing: Patients who live in regions where more care is being delivered must be getting a lot of useless care.

Most of that useless care, it turns out, is done in hospitals, and the vast majority of it consists of small procedures, the "little stuff" of medicine, as Dartmouth's Elliott Fisher likes to call it. Like endoscopy — sticking a scope down a patient's throat to see why he's coughing. Like CT scans and blood tests, and little devices called vena cava filters, which are surgically implanted into a large vein in the abdomen or chest to prevent clots from reaching the lungs and causing a potentially deadly condition called a pulmonary embolism.

A good part of the useless care also consists of visits from specialists. Let's take a specific example here. During the last two years of life, the average patient who tends to get most of her care at UCLA will see a doctor 104 times. The average patient who gets most of his care at the Mayo Clinic will see a doctor 50 times during that same period. You can think of those two patients as being basically the same at the outset. Same disease. Same prognosis. Unfortunately, those 54 extra doctor visits at UCLA didn't make a difference in the outcome. But they did add nearly $4,000 to the average per capita cost of care at UCLA.

Is this happening because doctors at UCLA are rubbing their hands together, thinking up ways to pad their incomes by seeing patients more often? Of course not. They are doing the best job they know how.

Nonetheless, they are delivering a lot of unnecessary care — much of which is driven by the way different hospitals are organized and how the medical cultures within them evolve. But that's fodder for another post.

Shannon Brownlee 10:42 AM Permalink | Trackbacks | Comments (59)

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Defensive medicine. That is what this is mostly about.

Posted by: Gore/Edwards 08 on September 4, 2007 at 11:09 AM | PERMALINK

Shannon Brownlee wrote: "Most of that useless care, it turns out, is done in hospitals, and the vast majority of it consists of small procedures, the "little stuff" of medicine, as Dartmouth's Elliott Fisher likes to call it. Like endoscopy -- sticking a scope down a patient's throat to see why he's coughing."

This caught my attention because I may be getting an endoscopy soon to check out some intermittent recurrent upper GI issues. The question for "patients" or "health care consumers" is, how are we to judge when such a procedure is "necessary and appropriate" and when it is "useless"?

Posted by: SecularAnimist on September 4, 2007 at 11:11 AM | PERMALINK

Well, it does cost more to live in LA than in Rochester, MN.

I refuse to atribute it all to altrusm. Doctors know when a visit is excessive. The doctors at the Mayo clinic are not necessarily more aware of the level of necessary visits than those at UCLA.

Posted by: Mudge on September 4, 2007 at 11:14 AM | PERMALINK

I'd be curious to know of the 50 visits (or 104 at UCLA) how many different doctors account for those. Everytime a new doctor enters the fray, he has to have a few extra visits to "ramp up" and get to know the patient. And in watching my FIL battle leukemia, I learned that every doctor has a slightly different approach, so if you're seeing new doctors over the course of months, you'll get a bit of a patchwork treatment.

I think risk management and quality assurance in medical care is atrocious. You'd never tolerate from the airlines or electrical utilities what you get from the medical community. Topic for another thread.

Posted by: Swaggering Jingoistic RSM on September 4, 2007 at 11:27 AM | PERMALINK

Whew! Do us a favor and report back when you're caring for an elderly parent and wanna talk about all the "useless" medical care they're getting, will ya?

Twice in the five years of my mother's long slow slide towards the end of life, she had CAT scans that turned up nothing, for just one example. You'd, I'm sure, call that useless. But the only way we know they were useless is in hindsight.

Or is it your proposition that we should just let elderly folks face the last years of life with increasing discomfort, disability and fear? I'd argue if there's any "useless" care going around for the elderly, it has to do with heroic (and often disabling) life-saving efforts, not these small investigations and treatments to relieve smaller plaugueing discomforts and impediments to daily living.

I guess I probably also need to point out, since you clearly haven't a clue, how difficult it can be to diagnose and treat the elderly's health problems, both major and minor, as a result of memory loss, hearing loss, confusion and just plain unwillingness to talk freely about bodily functions and dysfunctions, even with doctors-- not to mention the gross shortage of gerontologists and criminal lack of knowledge on the part of even very caring internists on the sometimes very large differences between function and symptomology in the very elderly and the rest of us.

In other words, it can take multiple visits and medications to deal with something in an elderly person that can be taken care of with one quick to-the-point discussion with a younger patient.

Before you yak away any more about "useless care" for the elderly, at least, you need to educate yourself on the subject of the problems of elderly health care.


Posted by: gyrfalcon on September 4, 2007 at 11:29 AM | PERMALINK

SecularAnimist: This caught my attention because I may be getting an endoscopy soon to check out some intermittent recurrent upper GI issues.

Maybe you need to eat more meat (sorry, couldn't resist).

Posted by: alex on September 4, 2007 at 11:37 AM | PERMALINK

Wish my mother had used at least one of those 50 Mayo visits - She was a nurse in KC - Went to two specialists from her old hospital - Both of them missed her cancer - One inferred that she was psycosomatic and that perhaps a trip up I-35 to Mayo was what she needed, if she refused to believe his outstanding opinion.

She waited and finally found another specialist in KC - Cancer on the bladder - She was dead in six months.

Trust the outstanding opinion doctor is enjoying his golf down at Cherokee Village.

Posted by: thethirdPaul on September 4, 2007 at 11:48 AM | PERMALINK

Hey gyrfalcon -
Read the article. The elderly do no better - they do WORSE - when more tests are ordered and more procedures performed. You appear to believe that more = better (i.e. the American way) and that's just not the case. I recently watched as my father declined and then died. There are many procedures out there that are painful for the patient that do not add much in the way of improving diagnosis or prognosis. Doing them just so you can "do everything" is silly. Perhaps you should take your own medicine and educate yourself before going off on others.

Posted by: Capri on September 4, 2007 at 11:51 AM | PERMALINK

Doctors do protest too much. My typical visit consists of waiting in the lobby for 15 minutes, talking to the nurse for 10 minutes, waiting in the patient room for another 15 minutes, and the talking to the doctor for 5 to 10 minutes depending on the complaint. Even if the doctor gets reimbursed $30 for this visit, it seems to be a fair compensation of his time to me.

Posted by: gregor on September 4, 2007 at 11:55 AM | PERMALINK

gregor,

That is why it is critical in the selection of a physician, to determine the level of reading material in his or her lobby.

Posted by: thethirdPaul on September 4, 2007 at 11:59 AM | PERMALINK

It is partly a function of billing models. I am a medical researcher in a very important midwest research medical hospital affiliated with an important university.

At my hospital (MRMUH, Midwest Research Medical University Hospital, a pseudonym), all practices bill separately. That means that instead of centralized billing with 10 people for the hospital, there are maybe 60-100 billing units, each with 5 billing people. Many between-unit transactions are done using internal billing - my work is billed per hour.

This nutty system is very hard to track, is IMMENSELY duplicative, and ensures that multiple tests are done in different units.

Posted by: POed Lib on September 4, 2007 at 11:59 AM | PERMALINK

There is also a very dangerous fallacy here. That is taking two groups of patients with the same outcome (death) and concluding that because the outcome was the same, any difference in treatment was meaningless. Well, sure, but the patients you are looking at are only a subset of the group of patients receiving those particular treatments. If the rest of the similarly-treated group has a more positive outcome than their counterparts, then there is a meaningful difference in outcomes.

To put it in numbers, look at 300 patients treated at UCLA vs. 300 patient treated at Mayo. If 50 UCLA patients die within two years and 200 Mayo patients do, then there is a strong argument that UCLA is superior -- although the difference in treatment doesn't matter for the 50 UCLA patients and 200 Mayo patients who died.

Posted by: Joe on September 4, 2007 at 12:04 PM | PERMALINK

Dear SecularAnimist, even if I were an MD I wouldn't want to tell you whether you need an endoscopy. If you are concerned about the need for an endoscopy, or really any procedure, you should ask your doctor (sorry for sounding like a TV drug ad). It's a perfectly legitimate question, and your doctor will probably welcome the chance to talk to you about why it's needed and what he or she expects to find out. That said, if you aren't happy with the answer, go get a second opinion. That's always a good idea whenever you are in doubt.

I think Gyrefalcon may have misinterpreted the central idea in the post. So here it is again: All that extra care did not produce better health outcomes.

That's the whole point of health care, isn't it? To care for people, to keep them as healthy as possible, and most important of all to relieve suffering, especially in the elderly. If the care being delivered fails to do that, then it's not good care. Right?

I'm advocating taking BETTER care of the elderly, rather than simply giving them more.

Posted by: Shannon Brownlee on September 4, 2007 at 12:11 PM | PERMALINK

The American system of health care is a symptom of our most incurable disease, capitalism.

Posted by: chance on September 4, 2007 at 12:16 PM | PERMALINK

From one of the more unsophisticated codgers here, I thank you for, not only your thread, but, your postings, especially the one at 12:11 PM.

Posted by: thethirdPaul on September 4, 2007 at 12:17 PM | PERMALINK

As an engineer who works where they make those "little devices called vena cava filters", Are you really claiming they are usless?

Posted by: David on September 4, 2007 at 12:20 PM | PERMALINK

Everyone is ignoring the elephant in the room which is the fact that by objective standards the US has the poorest outcomes of any industialized nation. Also, very poor infant mortality. All this despite spending substantially more per capita.

An area of particular interest to me is care of chronic conditions like type 2 diabetes. Care of type 2 diabetics is better almost anywhere than the US. It comes down to what the medical culture perceives as an acceptable result. Much treatment is rendered on the basis of this is the way we do it.

Look at the stastics on the rising incidence of C-section in the delivery of babies. It is less safe for both the mother and the baby and yet it is happening. It costs more, requires more after care, and can cause problems with future pregnancies.

Posted by: Stuart on September 4, 2007 at 12:24 PM | PERMALINK

Shannon,

Again, a very interesting post. From the MD perspective on the inside, I think you highlight several important things: First, research is good at picking out treatments for known diseases but very poor at figuring out process like disease diagnosis. Second, the amount of information increases substantially every year and it becomes impossible for primary care physicians to "know everything." That is why I think that NPs will become the new first entry into the system with a low threshold for referral. A good example is the vena caval filter. Most studies show that in patients who can have their blood thinned, it does not help outcomes, however, many practicing docs want the "protection" of a filter. They just can't see how it can't work, it is blocking blood clots from traveling, after all. This area is beset by a small number of studies with softer outcomes, so opinion counts more than usual and most docs don't have time to find all of the medical literature on this relatively unusual topic. Third, although I dread to tread here, I think the changes in medical education, with reductions in hours worked have led to an reduced ability to take care of patients. I am not arguing that trainees should have some sleep, but I would say that internship should be looked at more like military basic training than driving a truck: lives are at stake. We have taken too much away from trainees so they are afraid to make decisions. Also, trainees see patients far more often than practicing docs, which may explain the difference in treatment of inner-city Los Angelenos atUCLA compared to Minnesota farmers and Saudi billionaires at Mayo.

Thanks,

Josh

Posted by: In the line of fire on September 4, 2007 at 12:26 PM | PERMALINK

I have a couple of supporting anecdotes, both, interestingly, comparing health care practices in MN with those in other parts of the US...the first was my MIL who used to winter in Florida. She had a heart attack there and complained afterwards about the quality of care--she felt that it was invasive, that all sorts of procedures were being prescribed that were unnecessary. A second is an elderly friend of mine who was taking blood thinners to prevent clots. She moved to another part of the country where she found the medical practices far more intensive. They were messing around with her drugs. In any case she had a stroke, and I, for one, think it was because of the treatment she was receiving.

This is not to say that all healthcare in MN is so fantastic. I could also offer anecdotes of cases where a doc didn't give a fairly routine procedure and failed to catch something.

So, Shannon, are there best practices out there? Routine screening practices, say? I wonder if--in addition to the paperwork, which makes everyone suffer--there is a kind of tail wagging the dog chaos going on, in which HMOs or Medicare will cover the costs of certain tests, and docs have their individual preferences, and the consistency from one doc to the next is very low.

Posted by: PTate in FR on September 4, 2007 at 12:31 PM | PERMALINK

"To put it in numbers, look at 300 patients treated at UCLA vs. 300 patient treated at Mayo. If 50 UCLA patients die within two years and 200 Mayo patients do, then there is a strong argument that UCLA is superior -- although the difference in treatment doesn't matter for the 50 UCLA patients and 200 Mayo patients who died."

I cannot agree. Your comment ignores the differences in the patients at the outset. Mayo is a hospital that treats very very sick persons, and often patients are refered there after treatment failure elsewhere. Other centers treat less ill persons. Thus, Mayo patients die at a higher rate, because they get sicker patients. The two locales must be equated in some manner at the outset for degree of illness, so that correct comparisons can be made.

Posted by: POed Lib on September 4, 2007 at 12:36 PM | PERMALINK

Shannon,

Are you aware of any research that shows increased billing by docs living in areas with higher living costs (LA, NYC) versus areas with lower costs (eg, I assume, Minnesota)? Just wondering.

Posted by: djinn on September 4, 2007 at 12:36 PM | PERMALINK

Studies looking at patients with specific conditions, like hip fractures or heart attacks or colon cancer, show that they aren't living longer or even healthier lives in places where they are getting more care.

That can only mean one thing: Patients who live in regions where more care is being delivered must be getting a lot of useless care.

I haven't read the book, but I sure hope you made a more complex analysis than this. You seem to be analyzing by region, and there are many regional factors that affect health other than levels of medical care.

Just one example: Minnesota, where the Mayo Clinic is (and a lot of local patients are) is listed as the second-healthiest state in the U.S.

California, where UCLA is, is number 19.

There are a number of other demographic issues that need to be corrected for. Maybe you did all that, but it should be mentioned.

Did you do any analysis at a single facility where similar patients were exposed to varying levels of care? This would be quite difficult, but might give more accurate answers.

Posted by: maryjane on September 4, 2007 at 12:37 PM | PERMALINK

I just recently went in for an elective glaucoma test, because I felt like I had pressure in my eyes. The feeling turned out to probably be related to allergies. But it was an enormous relief to know I wasn't getting glaucoma.

The visit copay was $20. The glaucoma check took 5 minutes of the doctor's time. I have no clue what he billed the insurance company, but frankly, despite the peace of mind this negative test result gave me - it wasn't $20 of labor, even if you amortized the cost of the equipment, his education, and office rental. No way in hell.

This system is broken.

Posted by: osama_been_forgotten on September 4, 2007 at 12:39 PM | PERMALINK

Did the study take into account patient demographics? If 2 patients with diabetes get the same amount of care, but come from different socio-economic backgrounds the results can be different.

Posted by: Aquarius on September 4, 2007 at 12:49 PM | PERMALINK

Addressing the "same patient" issue - Another thing is quality of life. In MN they may have suffered far more than in CA. Patients aren't products, they're people.

One other thing - you state the median income of doctors is 215k - that's quite disingenuous. Whats the AVERAGE income. It's far less.

Posted by: wwc on September 4, 2007 at 1:18 PM | PERMALINK

Presumably there is the Platonic ideal of the perfect amount of medical care for each patient. The classic criticism of private medical insurance systems is that thay discourage desirable treatments for a profit motive. Now we are citicising physicians for over treating Medicare patients.
I doubt that any medical payment system can reach perfection; however perhaps we should look upon systems that that under treat more favorably.

Posted by: bfr99 on September 4, 2007 at 1:38 PM | PERMALINK

I see that this is turning into a seminar in quasi-experimental designs, led by the blind.

When you make a comparison like this, you are doing a "quasi-experimental" design. That means that you are comparing things without important conditions, such as random selection of cases. Usually, you want to randomly select cases and then compare, because the random selection ensures that systematic bias does not exist. When you just have a bunch of persons in Situation X and Y to compare, you can't use this important condition to ensure that the groups are somewhat equal at baseline.

Comparing MN and CA is very difficult. I work with an important clinic in MN, and know a few things:

1) Minorities are far less prevalent in MN than in CA.

2) MN clinic is tertiary, CA clinic may be secondary.

3) Testing everyone at one clinic exposed to different levels of care would not tell us anything. NOTHING. That's because each institution has rules about treatment. People are unlikely within an institution to be exposed to different levels of treatment.

4) Some cities in the US have VERY competitive medical climates (no patient cross-referral, no participation in trials of other physicians). Some are less so.

5) Not all patients are created equal. Some are sicker than others. Some are older than others. Some have many more secondary conditions.

Posted by: POed Lib on September 4, 2007 at 1:38 PM | PERMALINK

Many good questions.

Djinn, I have no information about billing practices varying in regions with different costs of living. But unnecessary billing is fraud, and what I'm talking about here isn't fraud, but variation in medical practice.

Several posters have brought up the question of best practices, and appropriateness of care. Part of the reason there is so much variation in how much care patients receive in different locations is there's so little valid (i.e. likely to be true) scientific evidence to show what works in medicine, what doesn't, and for which patients.

That probably sounds ridiculous. We live in the age of organ transplants and surgical robots and drugs that can cure cancer, after all. But the fact is, at least according to the Institute of Medicine, only about half of anything your doctor does has any evidence to back it up.

That's doubly true, as Josh points out, for the processes of caring for patients. How do you do a good job of managing a diabetic? A person with chronic heart failure? How often should you test the diabetic for nerve damage? Blood sugar? when does a person with heart failure really need to be hospitalized?

Doctors are making a lot of decisions to treat or hospitalize patients in the absence of good evidence, and under the (false) assumption that more intense care is better.

Posted by: Shannon Brownlee on September 4, 2007 at 1:40 PM | PERMALINK

A few thoughts...

A model that works in California probably won't work in rural Michigan or South Dakota.

If there is overtesting it is largely a function of the bizarro malpractice system (maybe 25% of all CT scans and MRI scans are pure defense).

One of the biggest problems is noncompliance by patients, exactly how do we fix that? The John Edwards mandatory doctor visit? The UK Tory denial of care concept?

If there is health care reform I hope is it not driven by economists or politicians or journalists.

Posted by: save_the_rustbelt on September 4, 2007 at 1:42 PM | PERMALINK

wwc: you state the median income of doctors is 215k - that's quite disingenuous. Whats the AVERAGE income. It's far less.

Are you sure you don't have (arithmetic) mean and median confused? While it's theoretically possible to have a distribution where mean is less than median, in practice it's quite unlikely.

While behind the times, this

http://www2.monstertrak.com/help_manuals/outlook/ocos074.html

shows median for all docs (1993) was $156,000, and mean was $189,300. I've never seen an income distribution where the median was higher than the mean.

Posted by: alex on September 4, 2007 at 1:45 PM | PERMALINK

Which of you, if you were sick particularly with a miserable but not debilitating illness would not wish to spare no expense to alleviate it?

Posted by: MNPundit on September 4, 2007 at 1:51 PM | PERMALINK

MNPundit--
The issues raised here are different. If you are going to spend $100,000 on your medical care, wouldn't you want to be sure that the doctors were doing things that improved your health?

Brownlee--
Are the doctors at UCLA paid salaries or per visit? I live near Chicago, and the doctors at the University of Chicago and Northwestern generally are salaried. Based on my limited experience with those two hospitals, I would say that Chicago doctors make more visits than Northwestern doctors because they like to work collaboratively and discuss patients more.

Posted by: reino on September 4, 2007 at 2:26 PM | PERMALINK

Some of the most annoying examples of unnecessary care that are actually harmful involve obstetrics. Circumcision in particular is a practice that this country never should have picked up, and having picked it up, we should have abandoned it decades ago.

Posted by: Steve on September 4, 2007 at 3:00 PM | PERMALINK

Hang on -- UCLA inner city hospital? -- I think not

UCLA -- in Westwood --

Westwood -- bordered by Bel Air on North
Brentwood / Santa Monica on West
Beverly Hills on East
Venice / Palms / Beverlywood to south --

Ok -- middle class to south --

UCLA completes with Cedar Sinai and St Johns for patients

If you want to talk about inner city hospitals in LA -- St Vincents (private), or County Medical or Harbor UCLA (in Torrance, and public, and not to be confused with UCLA Med Center)
http://www.ladhs.org/hospitals/
(Amusingly they have not updated the Web site to take down the closed MLK hospital)

UCLA Med Center is an odd case -- not public, (not run by LA County), but is run by UC system -- but not really public -- not much indigent care, unless comes in through emergency room --

Posted by: Matthew on September 4, 2007 at 3:17 PM | PERMALINK

Shannon, you contradict yourself.

Earlier you argued that we should put doctors on salary because we don't actually save money by cutting reimbursements (or not raising them sufficiently to reflect increases in the cost of living for doctors). Part of the support for that is that doctors increase their piece-work when reimbursements go down, resulting in "useless" procedures.

But that implies that if we want to cut out the "useless" procedures, we can really only do so by paying the doctors more! So there's little real savings to the system here.

Posted by: EthanS on September 4, 2007 at 3:29 PM | PERMALINK

Another problem is the misallocation of resources: suppose there were seniors' centers with heated therapeutic pools, social and recreational programs? Transportation to rec programs and aggregate dining? Decent living standards as the basis of SS payments?

Would that not prevent a LOT of illness and treatment demand? Increase quality of life for the many, allow more intensive resources to be targeted at the REALLY sick?

Posted by: Alison on September 4, 2007 at 3:54 PM | PERMALINK

Just to clear up a couple of things. $215,000 is the median income for dermatologists. I quoted a dermatologist in the first post. The median is a perfectly good measure: it means in this case that half of dermatologists make less, and half make more. And that figure, by the way, is take home pay before taxes.

Primary care doctors make considerably less money than most specialists, especially those who perform procedures. Primary care doctors are struggling to make ends meet these days, in large measure because managed care squeezed them very hard in the 1990s. Half of primary care residencies go unfilled because young med-school grads are well aware of the fact that it is the most poorly-paid specialty. YOu have to be truly committed to patients to go into primary care these days. We need more primary care doctors in a big way, and probably more health care professionals like nurse practioners and physician's assistants. We don't need more specialists on average, but they should be better distributed. YOu can't find a OB/GYN for miles and miles in many rural areas.

UCLA is an academic medical center, a tertiary care hospital. It is considered one of "America's Best Hospitals." I have no idea if its doctors are salaried, but I would bet they aren't. Most hospitals that are affiliated with medical schools don't pay their physicians a salary for their clinical work.

Did the study take into account patient demographics?

Yes, the study I'm referring to took into account patient demographics, including race, age, income, sex, education level.

are there best practices out there? Routine screening practices, say? I wonder if--in addition to the paperwork, which makes everyone suffer--there is a kind of tail wagging the dog chaos going on, in which HMOs or Medicare will cover the costs of certain tests, and docs have their individual preferences, and the consistency from one doc to the next is very low.

Yes, there are best practices out there. They're called clinical guidelines, and some of them are based on very good science. Others are not. And yes, consistency from one doctor to another can vary tremendously. Also from one hospital to another.

Finally, the phenomenon of overtreatment is not driven primarily by defensive medicine, though that's what many physicians believe. Sure, doctors do unnecessary tests and procedures to ward off lawsuits, but only a fraction of overtreatment is attributable to defensive medicine. Here's the citation for a paper on this topic:
Katherine Baicker, Elliott S. Fisher, and Amitabh Chandra "Malpractice Liability Costs And
The Practice Of Medicine In The Medicare Program," Health Affairs 2007 vol 26 no 3.

And finally, Shannon, you contradict yourself. I don't think so. The corollary to "doctors respond to cuts in reimbursement by increasing volume" is not: "the way to cut volume is increase reimbursement."

What I would suggest instead is that the path to reducing unnecessary care is for doctors to work within systems, like Mayo and Intermountain Healthcare, where they are salaried, their practices are monitored, and there is constant conversation among them about what constitutes best practices and how to coordinate the care of patients. Modern medicine should be a team sport, but it's still dominated by individual doctors working solo or in groups smaller than three.

Posted by: Shannon Brownlee on September 4, 2007 at 4:12 PM | PERMALINK

the path to reducing unnecessary care is for doctors to work within systems, like Mayo and Intermountain Healthcare, where they are salaried, their practices are monitored

But there's the rub: doctors will migrate to salaried systems only when salaried doctors are paid just as much as piece-work doctors. Part of that migration implies doctors giving up the "unnecessary" additional care in exchange for still getting paid as if they were doing it.

Any sector-wide savings would come by reduced capital, equipment, and support staff costs, if any.

Posted by: EthanS on September 4, 2007 at 4:28 PM | PERMALINK

The last paragraph in Shannon's 4.12 PM comment is the major point.

In Seattle, almost all the hospitals are "teaching hospitals", affiliated with the U of W, and that includes the med school, school of nursing, social work, and some other. All the hospitals have 24/7 resident coverage for patients, and, while not all the doctors are linked, they are all aware of a best-practice framework.

Compared with Seattle, the rest of the state is medical anarchy, and it shows. In a private hospital in Tacoma once I had to call the MD about a patient- the telephone answering service referred me to an MD "covering" his patients- and this happened with six more calls, the last answering service referring me to the MD I had originally called! Working in that private hospital I found that most of the docs were working three-day weeks, which kind of puts the lie to their complaints about low incomes.

Frankly, I think unnecessary lab tests are a drop in the bucket compared with the other screwups and wrong procedures, which in turn arguably pale before the paperwork and extra costs of private insurance companies.

Incidentally, and doctors here can correct me if I'm wrong, but the doc has to read your chart before seeing you and make notes after, so my guess is about 15-20 minutes minimum for each patient seen. When they see four patients an hour and Medicare reimburses $30 per patient, they're making about half what you pay a lawyer.

Posted by: serial catowner on September 4, 2007 at 4:38 PM | PERMALINK

The Dartmouth Atlas of Health Care shows there is a correlation between the supply of health care and the amount Medicare is billed. The national average for reimbursements per hospital enrollee is $6,611. In Miami, it's $11,352. The average price tag per patient in New Jersey is $8,076.

http://www.dartmouthatlas.org/

The Atlas shows that outcomes are not better in Miami and Jersey than in areas where per-patient spending is lower (even when those areas have similarly high costs of living). Why is this even disputed? We know that the U.S. spends more per capita than other countries without better outcomes. Why would this be surprising on a region-by-region basis?

Is this kind of information even known -- let alone discussed -- in the medical community?

The reason this is a problem for all of us is that physicians where I am -- Washington state --want higher reimbursements and are dropping Medicare patients in the meantime. But the politicians in Jersey and Florida are not going to go along with formulas that redress the balance. So, the only solution to helping doctors here is spending more overall when that hasn't been proven to be better for patients.

Posted by: zenger on September 4, 2007 at 4:49 PM | PERMALINK

Slow-walking a test report to keep you in the hospital longer...

Doing a procedure when they can't do a follow-up ends up sending you somewhere else so they can start all over and do the first procedure again.

Consulting doctors who never do anything just adds costs.

Doing "defensive" medicine just to add to piece work and profits.

Endless doctors' office visits for the elderly who are constantly worried and therefore taken advantage of by doctors who see them for a moment and then do nothing except schedule another appointment.

Routinely saying they can't pinpoint the problem, so they'd better use another test until you've been to 50 doctors and some young kid says, "Oh yeah, that's simple." and you realize you've been ripped off 50 ways.

Being told your father has emphyzema when it's lung cancer and they just didn't want to treat him because there's no profit.

There are an endless number of ways these "doctors" rig the system to make money. It's horrific and they should all be forced onto salaries, so they can't do anything in the way they "practice medicine" to increase their pay.

Posted by: MarkH on September 4, 2007 at 4:50 PM | PERMALINK

How do we determine how much is too much (or to little) on a case by case basis?

Each procedure is designed to work, scientifically.

But if they don't work as an applied whole... When do we know?

Posted by: Crissa on September 4, 2007 at 5:10 PM | PERMALINK

"Incidentally, and doctors here can correct me if I'm wrong, but the doc has to read your chart before seeing you and make notes after, so my guess is about 15-20 minutes minimum for each patient seen. When they see four patients an hour and Medicare reimburses $30 per patient, they're making about half what you pay a lawyer."

That's gross pay too, so the salary for the medical assistant who took the BP, the receptionist who booked the appointment, the billing specialist who gets 15-20% for squeezing the payment out of the insurance company, medical insurance for all of the above, as well as the landlord and the power company all need to be paid out of that $120/hour (actually, I think it's up to about $36/15 minutes). I just paid an electrician to fix a couple of problems at my house and I thought he was pretty reasonable at $85/hr and his overhead included a truck and a cell phone.

I see patients for 7 hours day and sit in my office, off the clock, returning phone calls and doing paperwork for another 3-4 hours per day.

Posted by: J Bean on September 4, 2007 at 6:12 PM | PERMALINK

The primary problem of what constitutes "appropriate" medical care is that it is determined ex post facto. The second is that while you're looking at aggregate information, decisions are made with individual patients.

Doctors worry about getting sued if they didn't do a test and it is later determined that it would have made the difference in diagnosing a rare/severe disorder. I wonder how much of the variation has to do with state malpractice laws and rates.

It may be the case that on average patients with fewer tests/procedures do as well as those with more tests. But on individual cases, not doing tests/procedures can feel incomplete and as if care is being rationed. As someone who has had a very difficult-to-diagnose problem, I greatly resented the folks at my health system telling me I didn't need an MRI, etc., because it wouldn't really change the resulting care. Knowing what was really wrong with me made all the difference in the world, even if they didn't treat me differently as a result.

Posted by: rle on September 4, 2007 at 7:09 PM | PERMALINK

S:

I worked at Medicare when the Dartmouth study came out. It's a very old study (late 80's?). The variation was East to West (Bangor was low and Boulder was high). The confounding problem was that the study looked at TURPs (Trans-urethral Prostatectomies, also known as a blunt dissection of the penis) just as Medicare began covering PSA (Prostate Specific Antigen)testing. This means that artifacts of marketing the test could have very big effects on the TURP rates.

Most epidemiologists expected that the testing would uncover a cohort of men with unrecognized Prostate problems, but insurers assumed that the Eastern rate was the 'right' rate and Western doctors were all sadistic thieves. My understanding is that current rates are much more homogenous and, a further complication, there are other treatment modalities, in addition to the TURP. I don't think anyone, including Dr. Wenburg at Dartmouth, was ever able to prove which rate was 'right', only that they were different.

The problem with a lot of the statistically derived insights, is that, at a hospital level, it's even worse at a group or practice level, the number of cases is so low and the clinical guidelines are so leaky, that it's almost impossible to tell if doctors are really practicing differently. In my opinion, managed care keeps rates of certain procedures low by arbitrarily denying needed and un-needed care.

Posted by: wmcq on September 4, 2007 at 9:02 PM | PERMALINK

Remember the MD in one of Tom Lehrer's songs, who graduated and went on to specialize in "diseases of the rich"?

Posted by: number6 on September 4, 2007 at 9:47 PM | PERMALINK

Shannon, when you mentioned the 215k, you had quoted a Derm doc, but in the context of your snarky sentence it seems you're talking about all doctors. I'm married to a family medicine doc so I take it personally when it's implied they're all getting rich off sick people. Specialties like derm and radiology stay in the money because they restrict their training opportunities. I assume because you're some sort of expert you knew the link you were drawing.

What makes me mad is I see my wife work her ass off to make, after student loans are factored in, a middle class living, and then read some semi-coherent policy prescription that calls for her and her peers to take the brunt of a broken system. Sure, put her on salary, but pay off her student loans, pay her back wages for residency (we calculated once she was making less than minimum wage) and don't page her in the middle of the night.

Posted by: wwc on September 4, 2007 at 9:57 PM | PERMALINK

There are a lot of factors in play that doctors have to try and balance and cost just isn't all that high on the list. I don't think it should be, but that's just me.
I was hit by a car while riding my motorcycle squeezing the lower leg between the bike and the car. The orthopedic surgeon and the plastic surgeon who put most of the leg back together were superb. 25 years later, I developed a bone infection in that leg mostly due to aging of the skin grafts and who knows what else. I went to a friend, an orthopod, who sent me to a microsurgeon who did a muscle flap after an orthopod debrided the site. Thousands of $s, tens of thousands. Then 6 weeks of antibiotics at 9 grand a month. Didn't take for long; tried it again, debridement (there isn't enough morphine to withstand this procedure) muscle flap, antibiotics. Several months later, infection reappears for the third time. Not able to stand the prospect of the above cycle, I had a transtibial amp. Cost: less than $12 grand, all in versus over $150 grand for the previous procedures.

On a cost basis, the muscle flap/debridement/antibiotics were unnecessary, they didn't work.

Posted by: TJM on September 4, 2007 at 10:21 PM | PERMALINK

UCLA has a lot of doctors listed as faculty.
http://www.humc.edu/staff/staff97.html
Are you sure that their patients aren't seen by salaried doctors? The hospitals affiliated with universities that I know of have their faculty members spend some time doing research and some time seeing patients, and they get paid salaries.

I'll take you up on the bet, and I'll trust you to do the research.

Also, thanks for addressing my quote in your post, and I apologize for being part of the wild ride here. In addition to many of us disagreeing with you, we're disagreeing with each other and learning things in the process.

Posted by: reino on September 4, 2007 at 10:44 PM | PERMALINK

As interesting and relevant as the Dartmouth studies (and others like it) are to the debate about the structure of health care financing and delivery, I think the most important implications are consistently overlooked.

Clearly, we can see that there is much less certainty about the "correct" answers/treatments/interventions than most would suspect. Fine. We understand that there is an inherent uncertainty. But medicine is really much less "science" than many would think. I would say "art" but I don't think that accurately describes it.

Analyzing medicine as a process, like the "scientific process," offers insight in to the some of its underlying structural problems. We would hope that - despite its inherent uncertainties - the knowledge base of the medical professions would derive from a self-improving system as similar as possible to the more basic of sciences. Although at any point x our understanding (and outcomes based on such) may be imperfect or unsatisfactory, so long as the proper mechanisms are in place our knowledge should constantly grow and improve. I know this is a bit abstract, so I will try to get to the point.

Is this how medicine operates? The simplest way is to simply ask two questions: why and how?

(1) Why should I do x intervention (or nothing), doctor?
(2) How do you know, doctor?

Do we expect perfection at this point? Of course not. If the answers are - in terms of cost/benefit: (1) this should be the best response to this problem/condition because it will have x method of action, etc. (2) based on the best of our collective understanding (based on scientific evidence) . . . even with no guarantees, then we should not expect more.

Is there in place an efficient and rational method for the dissemination of information, and a mechanism by which this cost/benefit information can constantly be expanded, revised, amended, or discarded?

Look at Vioxx. Setting aside the issue of withdrawal and Merck's malfeasance in obscuring the "cost" side of the equation, why was this drug, which was only marginally (if at all) more effective than Alleve, prescribed in the first place? Ostensibly, it addressed a problem (GI bleeding) that is really much less of a problem than claimed. But I don't want to get bogged down in these issues. My point is that somewhere there was an information failure, and many irrational individual decisions - medical and economic - were made. Now there certainly is much credit, blame, and focus to be directed at the FDA in this story, but the [lack of] response from physicians has always been what has troubled me most. Yes, there is a too much new info out there to do examine every study and read every paper. But regardless of the wisdom of relying on such a conflicted source for information on said product, where was the concern/outrage/disgust at being intentionally misled?

To some extent we - the collective patients - don't really give a damn how you - the academic and clinical medical professionals - allowed this to happen. You are the experts. You have the monopoly. You have the expertise and we trust you and pay you accordingly. Again, we don't need perfection. If you were lied to, we can understand. But how can we be sure this does not happen again? Where are the self-correcting mechanisms? If someone misleads me as you were misled, I know what my basic response would be.

Fen-phen? A radiology tech was the one who first noticed the problems it was causing (though others were starting to see such things also). Um . . . not re-assuring in regards to self-correction.

Drug-eluding stents? Why? Seemed like a plausible idea?

Just to make an intentionally specious, yet serious, observation: 18,000 deaths annually have been said to be attributed to lack of insurance (Kaiser or RWJF?), while estimates put iatrogenic/preventable deaths [conservatively] at 98,000 annually (IOM, 1999). This number is 8 years old and does not include preventable deaths that occurred outside hospitals.

Equally disturbingly, autopsy studies show that not only do doctors misdiagnose 40% of terminal patients (1/3 of which if corrected could have prevented death) but also that this error rate HAS NOT IMPROVED SINCE 1938.

The list is endless, but the specifics of each case are much less important than what each of these say about the broader systemic mechanisms operating [or not operating as it were].

One need not delve too deeply in to the more metaphysical definition of "value" to realize that if the "free-market" is to work at all in health care, then information must - at a minimum - be much more accurate and useful than it is. Similarly, if you are a proponent of the purest version of top-down socialized medicine, then you will still need a much better understanding of the efficacy of your various treatment options than what is currently available.

Unfortunately, we seem to have a "system" where empirically and measurably inefficacious decisions propagate. Until doctors - as a profession - clean their house, all of this lovely economic and political debate will really be for naught.

Posted by: Morris Berg on September 4, 2007 at 11:29 PM | PERMALINK

alex:
Regarding median and mean: those tend to be the same or close to it when data are normally distributed (a bell curve). Or, put another way, this is the medical version of Bill Gates walking into a bar and raising the mean net worth of everyone there by a great deal, but the median remaining largely the same. In medicine, a relatively small number of highly paid, usually procedure-based, specialists make huge salaries, while the larger number of internists, pediatricians, family physicians, etc. make much less.

reino:
http://www.humc.edu/staff/staff97.html
That is Harbor-UCLA Medical Center, which is 20 miles or so south of UCLA Medical Center. Harbor is a public hospital, partly funded by LA County. UCLA Medical Center is a university hospital emphasizing tertiary care. Both are teaching hospitals, with attending staff that hold UCLA faculty appointments. Faculty salaries come from a variety of sources: research grants, university funds (for the few faculty who have tenure), patient care revenue, and others. At public hospitals such as Harbor, which provide care for so many uninsured and underinsured patients, "others" might include money from the County, since it's not possible to generate one's salary from seeing so many un/underinsured patients. At UCLA, the hospital sometimes supports the salaries of faculty, usually in procedure-based specialties such as surgery, who bring in lots of revenue to the hospital.

Morris Berg:
Solving problems like the Vioxx fiasco will require the kinds of changes at FDA that are unlikely to happen under this administration. FDA is far too beholden to the industry it is supposed to regulate. As for the rest of health care, the problems derive from a variety of sources, which include, but are not limited to, doctors.

The evidence-based medicine movement is an effort to address the lack of scientific grounding in too much of what happens in hospitals, clinics, and doctors' offices. I support the kind of research that will provide a secure evidence base. It will never, however, address all or even most of the many clinical scenario that arise. So what happens to the patient whose demographics diverge substantially from participants in the otherwise relevant studies? Or the patient with a condition too rare to be studied in a controlled fashion? The problem with the airline safety analogy in health care is that it fails for patients like this. It has been applied, to good effect, to some extent in fields such as anesthesiology with routines that don't vary much from patient to patient. But that is not the case in many other disciplines, where the variability across patients seen daily is quite broad.

And finally, what is the responsibility of society, which is, after all, among other things, a group of patients, in creating a health care system that is sustainable? The medical profession is absolutely part of the problem. So is a society that refuses to accept death, even when not iatrogenic, as an immutable reality.

Posted by: chinois on September 5, 2007 at 6:05 AM | PERMALINK

UCLA has a lot of doctors listed as faculty.
http://www.humc.edu/staff/staff97.html
Are you sure that their patients aren't seen by salaried doctors? The hospitals affiliated with universities that I know of have their faculty members spend some time doing research and some time seeing patients, and they get paid salaries.

It's my understanding that at many academic medical centers physicians are paid a salary for being on the faculty, but they receive reimbursements for their clinical work.

But we're focussing on the issue of salaries, and that's just a shorthand way of saying doctors need to be in organized practices. At most hospitals, doctors have "admitting priviledges," which means they don't actually work for the hospital, just in the hospital. They are in private practice in the community and the hospital, as it's called, is the "doctor's workshop." That means there's often little coordination of care, or even direct communication between physicians, much less any real oversight of practices by the hospital.

There's a lot of bad blood between physicians and hospitals, often over who should be profiting from the most lucrative procedures.


Shannon, when you mentioned the 215k, you had quoted a Derm doc, but in the context of your snarky sentence it seems you're talking about all doctors.

Sorry for the confusion. I'm with you all the way on your points that primary care physicians are working their butts off for the lowest pay among the specialities. And I'm also a big advocate of training more PCPs, not more specialists. We've come to worship specialists in this country, but it's the PCP who is the most important to maintaining the health of a community.

PCPs should be better paid -- or their patient loads need to be lighter. During the managed care era, many PCPs found they had to see more and more patients per day in order to maintain their incomes, which were already at the bottom of the ladder and fell faster than those of physicians in other specialties.

That said, PCPs still make a lot more than the average American. In a famous paper titled “It’s the Price, Stupid,” three health care policy analysts and an economist pointed out that American doctors have much higher incomes than their peers in the rest of the developed world. The average American specialist earns $274,000 a year, and the average general practitioner makes $173,000, amounts that are, respectively, 6.6 and 4.2 times the income of the average patient in the U.S. The rates in other countries average out to 4 and 3.2.

I worked at Medicare when the Dartmouth study came out. It's a very old study (late 80's?).

This research is ongoing, as is the variation in spending and medical practice. see www.dartmouthatlas.org

Is this kind of information even known -- let alone discussed -- in the medical community?

After being roundly ridiculed for 30 years, Wennberg's work is finally getting traction among many physicians, and it is cited repeatedly by places like the Institute of Medicine.


Posted by: Shannon Brownlee on September 5, 2007 at 6:47 AM | PERMALINK

shannon brownlee: "Modern medicine should be a team sport, but it's still dominated by individual doctors working solo or in groups smaller than three."

chinois:"The evidence-based medicine movement is an effort to address the lack of scientific grounding in too much of what happens in hospitals, clinics, and doctors' offices... It will never, however, address all or even most of the many clinical scenario that arise..."

It seems then that a lack of evidence is part of the problem, and this could be helped by better communication among doctors and focused, proper systematic research. While it is true that every patient is a unique case, statistics is a wonderful thing and can aggregate information. I also wonder if the question hasn't been asked in quite the way we are asking it in this thread--that medical research is fragmented and often focused on comparing drug treatments (which works better, a or b) rather than the systematic question of "among practice for treating condition X, what results in the best outcomes for the patient? What variables influence patient outcomes?"

I suspect that if we had a functional federal government, with competent people who an interest in asking the right questions, one could start to accumulate evidence quickly. One could start with the high frequency illnesses and work down the list. No, not every condition and situation would be covered, but I bet 95% could be.

In psychology, years ago, it was figured out that actuarial predictions, based on statistical models were much better predictors of outcomes than individual clinical judgments. Humans clinicians (among others) have resisted that finding and continue to insist that they, at least, are good judges of people, but that's a finding that may also apply in medicine. I suspect the AMA has a vested interest in keeping medicine fragmented, because in a chaotic system, individuals can...mmm...get away with murder.

Posted by: PTate in FR on September 5, 2007 at 6:59 AM | PERMALINK

Doctors worry about getting sued if they didn't do a test and it is later determined that it would have made the difference in diagnosing a rare/severe disorder. I wonder how much of the variation has to do with state malpractice laws and rates.

Defensive medicine and malpractice worries account for some of the overtreatment, but only a fraction. See
Katherine Baicker, Elliott S. Fisher, and Amitabh Chandra "Malpractice Liability Costs And
The Practice Of Medicine In The Medicare Program," Health Affairs 2007 vol 26 no 3.


Is there in place an efficient and rational method for the dissemination of information, and a mechanism by which this cost/benefit information can constantly be expanded, revised, amended, or discarded?

The quick and dirty answer to this question is No. We have no organized system for investigating what works in medicine, what doesn't, and what the best processes are for caring for patients. The FDA doesn't do this; nor does the NIH. Academic medical centers, which are supposed to be the place where medicine advances, aren't doing it in a systematic way either.

The evidence-based medicine movement is an effort to address the lack of scientific grounding in too much of what happens in hospitals, clinics, and doctors' offices. I support the kind of research that will provide a secure evidence base. It will never, however, address all or even most of the many clinical scenario that arise. So what happens to the patient whose demographics diverge substantially from participants in the otherwise relevant studies? Or the patient with a condition too rare to be studied in a controlled fashion?

You're right on the money. This is where patient preference has to come in. We now have a standard called "informed consent," which is a legal document that says the patient understands the risks involved in any treatment. But in reality, patients aren't really informed much of the time, at least not in a way that helps them grasp the tradeoffs between and risks inherent in various treatments. We need a new standard that several reformers have taken to calling "informed patient choice."

Posted by: Shannon Brownlee on September 5, 2007 at 7:02 AM | PERMALINK

The average US medical graduate finishes school with six-figure educational debt, facing 3-8 years of mandatory training with compensation that precludes making any dent in paying that debt and hours that prohibit making additional money. Physicians in most of the rest of the developed world don't graduate with that kind of debt. To attract more doctors to primary care, loan forgiveness or other incentives will need to be put in place.

Are you suggesting that "informed patient choice" doesn't happen now for patients with rare diseases? On what basis? What is the evidence that this would contain, rather than raise, costs?

There is research out there devoted to patient outcomes and cost-effectiveness. While there needs to be more, an illustrative issue with the latter is that it depends on point of view. What may be cost-effective for a patient or society may not be so for the insurer. How would you propose that be resolved? Forcing insurers to pay will only give them even more incentive to drop patients with chronic illness. There is too much of that going on as it is.

Posted by: chinois on September 5, 2007 at 10:47 AM | PERMALINK

PTate: seems then that a lack of evidence is part of the problem, and this could be helped by better communication among doctors and focused, proper systematic research. While it is true that every patient is a unique case, statistics is a wonderful thing and can aggregate information. I also wonder if the question hasn't been asked in quite the way we are asking it in this thread--that medical research is fragmented and often focused on comparing drug treatments (which works better, a or b) rather than the systematic question of "among practice for treating condition X, what results in the best outcomes for the patient? What variables influence patient outcomes?"

Yup! THere's no systematic effort being made to find out which practices are most effective and for which patients. Two of the Democratic presidential candidates have included the need for such research in their health care plans. YOu can guess which two -- and surprisingly enough, John Edwards isn't one of them.

chinois: Are you suggesting that "informed patient choice" doesn't happen now for patients with rare diseases? On what basis? What is the evidence that this would contain, rather than raise, costs?

Yes, that's exactly what I'm saying, and it applies to most common surgical procedures and many screening tests, as well.

There's a pile of interesting research looking at what patients choose depending upon the way they receive information about a recommended test or surgery.

The take home message of this research is that when patients are fully informed, which means they've been given information in a way they can understand, and they've gotten help sorting through their own preferences and tolerance for risk, they tend to be as much as 50 percent less likely to choose an invasive surgery or a screening test when compared to patients who get information in the usual way. Which is to say, from their doctor.

That's not to suggest in any way that doctors are deliberately misleading. Not at all. But they often can't or don't provide information in a way that is digestible for patients. THey also have their own biases about what's right for a particular patient, and those biases are incredibly hard to hide.

Annette O'Connor, from the U of Toronto is an author to look up if you're intersted in this topic.


Posted by: Shannon Brownlee on September 5, 2007 at 2:13 PM | PERMALINK

All of these excuses -- defensive medicine and the like -- don't explain the differences in the number of procedures and how much is spent on a region-by-region basis.

The excuses offered are true everywhere. So, back to the region-by-region differences, please.

Posted by: zenger on September 5, 2007 at 4:05 PM | PERMALINK

"Yup! THere's no systematic effort being made to find out which practices are most effective and for which patients. Two of the Democratic presidential candidates have included the need for such research in their health care plans. YOu can guess which two -- and surprisingly enough, John Edwards isn't one of them."

Oh come on, Shannon, what the %^$#$ are all of those studies published in all of those weekly journal about? They sure seem like systematic efforts to find out which practices are most effective.

Posted by: J Bean on September 5, 2007 at 11:27 PM | PERMALINK

Oh come on, Shannon, what the %^$#$ are all of those studies published in all of those weekly journal about? They sure seem like systematic efforts to find out which practices are most effective.

Pretty amazing, isn't it? But all those pages and pages of stuff in the medical journals isn't really answering the right medical questions. A lot of it is badly designed, poorly performed, incorrectly interpretted ... hmm, what's the word I'm searching for? "Junk" is the term a former editor of the New England Journal used. Actually, she used an earthier word, but you get the picture. There's an enormous volume of useless crap published in the medical journals, in large measure because it's aimed mostly at selling pharmaceuticals, not increasing medical knowledge. Read all about it in the upcoming issue of the Washington Monthly.

Posted by: Shannon Brownlee on September 8, 2007 at 9:59 PM | PERMALINK




 

 

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