Ms. Inappropriate Defends The Status Quo

I think I would have liked the younger Lisa Rosenbaum, the cardiologist who last week in the New England Journal of Medicine launched a missile at the “less is more” movement. Here’s how her piece begins:

They called me Ms. Appropriate. When I was a cardiology fellow, health care costs were skyrocketing, and I considered devoting my career to curbing inappropriate use of medical resources. My first target, as a supervisor of cardiac stress tests, was referrals of patients for unnecessary testing — annual stress tests, for instance, or “clearance” for cataract surgery. That soon became my gateway into broader efforts to combat health care waste.

In the following 2,500 words or so she goes on to dismiss or even belittle this younger and simpler version of herself, along with all those who continue to express concern about overuse. But after reading her piece I still don’t understand what was wrong about Ms. Appropriate.  Perhaps she wasn’t saving the world but as she describes it how was it a bad thing she was doing? Why would we not want to ask hard questions? Does she really mean to suggest that “referrals of patients for unnecessary testing” or annual stress tests or clearance before cataract surgery should not have been discouraged?  The very fact that everyone knows that this kind of overuse is still ubiquitous suggests that campaigns like “less is more” are absolutely necessary and beneficial.

Why would she want to become Ms. Inappropriate?

In this and several earlier pieces in NEJM Rosenbaum has shown herself to be an instinctive conservative who seeks to defend and preserve the existing order by raising impossible barriers against efforts to reform or change the system. She appears to take it personally when the behavior of physicians is called into question by critics or in the popular press.

In my opinion we should indeed be careful about plunging ahead and making changes without careful consideration of the consequences, but it should also be clear to anyone with a pair of eyes that our current healthcare system is profoundly sick, and is a result of monumental decisions that were never fully tested or questioned in the first place. “Less is more” is not about a fundamental change to medical practice, it’s about returning to an earlier philosophy that starts with the first principle, do no harm, and then proceeds with humility and caution.

Rosenbaum assumes that those who support the “less is more” philosophy are in fundamental opposition to those who express concern about underuse. But believing that “less is more” does not  mean or imply that underuse is not also a legitimate issue or that it should be ignored. Rosenbaum has served up a false dichotomy and a straw man, designed, intentionally or not, to protect the status quo. And the status quo is indefensible.

Underuse and overuse stem from different causes. Underuse is usually not directly caused by physicians. It is most often a product of systemic socioeconomic imbalances. Underuse is a sin of omission, caused by a flawed system in which large numbers of disadvantaged people have limited access to health care; overuse is a sin of commission, in which large numbers of advantaged people have access to a surfeit of healthcare. Put another way: underuse exists where there are too few physicians; overuse where there are too many.

Time and again in her piece Rosenbaum acknowledges that there is plenty of genuine waste and abuse in the system. But as a health care insider she is afraid that public criticism of the system “may channel general disenchantment with the health care system.”  I hate to break it to Rosenbaum, writing from her perch at the Brigham & Women’s Hospital, but there’s a LOT of general disenchantment with the health care system right now, and it’s not going away, and the “less is more” campaign plays only one small part in the much larger drama of disenchantment. Does Rosenbaum really want to defend the current system? If she’s against “disenchantment” is she really “enchanted” with the current system?

Rosenbaum supplies more ammunition to her opponents. The “less-is-more mantra may dominate policy discussions partly because of the sheer visibility of waste. In hospitals, waste is apparent everywhere, from daily calcium measurement to MRIs for low-back pain. And excess is enabled by a system in which it’s easier to order a test than to carefully consider its necessity. Unfortunately, it’s not clear that we have evidence-based knowledge about how to eliminate waste safely. [emphasis added]” This is really a remarkable statement from someone seeking to downplay “less is more.” Is she proposing that before we attempt to confront highly visible and uribquitous waste we need to perform randomized controlled trials?” This seems nothing less than absurd.
Let me repeat: the current system is indefensible and unsustainable. Health care accounts for nearly 18% of the US GDP, far more than any other country, and yet we don’t get our money’s worth and by many measures we severely underperform other developed countries who spend far less on healthcare. “Less is more” won’t solve all our problems, of course, but at the very least it acknowledges that we have a serious problem and it proposes one possible solution among many others. Rosenbaum’s writings imply that the greatest threat to our healthcare system is its critics, which is a bit like blaming the telegraph operator for the Titanic.

Rosenbaum accepts the fact that there may be 4 million unnecessary hospital admissions each year. She writes that “because we can’t always predict which admissions will be beneficial, we also need to consider the risks posed by admitting fewer patients.” Once again, this is a straw man argument. Nearly everyone in the general debate accepts this general concept. Followed to its logical conclusion we would all be admitted to the hospital on the day of our birth and remain there for the rest of our lives. Anything less and I can guarantee there will be people out there who will have heart attacks outside the hospital. Rosenbaum fails to mention that there are costs and additional risks inevitably associated with treatments. The “less is more” crowd simply wants to insist that these factors be explicitly discussed and considered.

Rosenbaum decries “the cultural narrative about waste often implies that greed drives high volume” but then goes on to admit, as she must, that “undeniably, fee-for-service reimbursement creates incentives to do more and enables occasional unconscionable violations — the cardiologist and cardiac surgeon who made a fortune performing unnecessary revascularizations or the oncologist now in prison for prescribing chemotherapy to patients without cancer. And we all know physicians who profit handsomely from unscrupulous behavior. But given the laws of statistics, there will always be outliers doing more than other physicians in the same situations, so if variation can only mean waste, there will always be offenders.” But, once again, Rosenbaum’s own words are her own worst enemy. If the egregious cases are indeed “undeniable” then how can they be ignored? An oncologist delivering chemotherapy to someone without cancer is not a “statistical outlier.” He or she is a criminal. No one is saying we should go after people just because they are statistical outliers. But we should investigate cases of egregious overuse, and we need to develop a system that can fairly identify and evaluate egregious cases. Further, her acknowledgement that “we all know physicians who profit handsomely from unscrupulous behavior” could serve as a motto for the “less is more” movement. If every physician knows about such physicians why are they not being confronted?

Rosenbaum offers a weak defense of “some physicians” who may “do too much in order to compensate for lack of experience or expertise.” She gives the example of an inexperienced “cardiologist who refers all patients with any chest pain for coronary angiography. An ACO practice manager would tell this outlier to match his peers’ angiography referral rates lest the practice incur a penalty. But how do we know he’ll reduce inappropriate, rather than appropriate, use?” Again, this argument does not withstand scrutiny. Does Rosenbaum really support allowing an inexperienced or inexpert cardiologist to keep referring all patients with any chest pain for coronary angiography? In this example she embraces a healthcare system that allows massive egregious overuse of an invasive and expensive procedure like coronary angiography. Why, instead, does she not look for ways to limit egregious behavior from an incompetent physician?

Rosenbaum decries “the bias introduced by the less-is-more mind-set.” She is concerned that the public is incapable of detecting such bias when a study spotlighting overuse gains public attention. This might be a fair point, except that it fails to take into account the much larger opposing bias. She sniffs her nose at the odor of “less is more” bias but is incapable of detecting the poisonous atmosphere that comprises the air she breathes. “Less is more” is a response and corrective to the orders of magnitude larger bias created by the hype machine of the medical-industrial-academic complex. Where is Rosenbaum’s concern over the ubiquitous and astonishingly well-funded advertising, PR and CME campaigns devoted to promoting ever increased usage of drugs, devices, tests, and procedures?

Consider, for instance, her discussion of the recent reception of ORBITA. She writes about her disappointment over “the rush to inflate the study’s significance by people who normally decry the perpetuation of hype and misinformation.” In my opinion ORBITA provoked a wide range of responses. The overall discussion was healthy and refreshing. But let’s grant for a moment that the response to ORBITA was indeed excessive. Why is Rosenbaum not at least equally concerned about the 40 years of hype supporting PCI and the failure of the interventional cardiology community to perform an adequate placebo controlled trial in all that period? How many patients during that period were exposed to an invasive procedure and accompanying drug regimen without full knowledge of the limited benefits of the procedure, or at least knowledge of the limited evidence base for any such benefits? Why is Rosenbaum not concerned about that long and continuing history of misinformation and deception?

Rosenbaum offers no evidence to support her statement that the “less is more” crowd makes “grandiose claims alleging the value of doing less.” I am not aware of anyone making grandiose claims, but I will be happy to join Rosenbaum in criticizing such claims. I have not heard anyone claim that “less is more” will lead to some sort of medical nirvana. My own belief, which I believe is shared by many in the “less is more” community, is that genuine improvements in the healthcare system will be difficult to implement and impossible to pay for until we begin to rein in the excess and abuse that Rosenbaum herself concedes in the course of her article.

Rosenbaum’s article concludes with a bizarre  personal anecdote:

A few years ago I had a mysterious illness, ultimately attributed to a probable NSAID allergy. But before diagnosis, as I bounced from specialist to specialist, inflammatory bowel disease entered the differential, and one physician insisted I undergo colonoscopy. For months, I refused. To me, the benefit of avoiding the test far outweighed the small risk of missing an unlikely diagnosis. Surprisingly, it was much easier for me as a patient to accept that uncertainty than it was for my doctor, who said she couldn’t live with herself if she failed to diagnose the disease. When I relented and the test was negative, I knew her relief was far greater than mine. But I also knew that had I been the doctor, I would have been similarly unsettled by uncertainty.

Does Rosenbaum really mean to suggest that she supports a decision that her doctor couldn’t justify on medical grounds and that she herself, a patient who is also a medical doctor, didn’t want? Her argument is that she did it for the doctor, to settle her doctor’s uncertainty. This is an astonishing admission. If Rosenbaum herself, as the patient, had been consumed by uncertainty then there may have been some reasonable justification for the procedure. But instead, as she herself notes, the procedure was performed to satisfy the doctor. Contrary to Rosenbaum’s intent, this strikes me as a perfect anecdote to support “less is more.”

Followup post:

Nuance And The Healthcare Apocalypse