Nuance And The Healthcare Apocalypse

(Updated)

If you actually have a life you may not be aware that there’s been a fierce debate on Twitter and the blogosphere over Lisa Rosenbaum’s NEJM article decrying the oversimplification and self-righteousness of the “less is more crusade.”  In response to fierce criticism, from myself, the Lown Institute, and others, Saurabh Jha praised and defended Rosenbaum for embracing nuance and subtlety in her discussion of the issue.

Rosenbaum and Jha both emphasize one key point: simply saying “less is more” or focusing exclusively on overuse misunderstands the inescapable complexity of the problem. Their most important point, I think, is that the “less is more” advocates refuse to acknowledge or they downplay the general principle that “less is more” involves trade-offs, that it’s not always easy to know exactly when or where to cut back, and that there will inevitably be at least some negative consequences from reducing care.

Let me be the first to agree with Rosenbaum and Jha. This nuanced view reflects a fundamental principle that will be inescapable as long as our tests and treatments are anything less than perfect. As an example Jha cites the new blood pressure guidelines. “There is a real trade-off between extending longevity in many, and conscripting many, many, more to the ranks of disease,” he writes. “I believe we’re overstretching… but we can at least agree on the trade-off.”

This type of nuanced discussion is indisputable— but it can also be used, as I believe is the case in Rosenbaum’s article, as an academic obscuration of a much more pressing and immediate problem. I think Manesh Patel got to the heart of the issue in a tweet:

The less is more movement often focuses on just clearly or overt bad – important but easier to tackle compared to nuances of true clinical decisions

This is the point Rosenbaum and Jha miss. It is precisely because the less is more movement focuses on egregious and easily identified and fixed problems that it should take precedent.

Nuanced discussion is perfectly valid within the context of a health system that has some basis in reason and rationality. Unfortunately reason and rationality are often missing in action in the US. To cite just two recent examples that I noticed in the last few days.

First, Harlan Krumholz tweeted about his father, who went to an orthopedist

“to find out about a knee replacement. He is encouraged to have stem cell adjunctive injection for out of pocket $2500. As far as I can see, not @US_FDA approved. And little data. How can this be?”

Second, a devastating story in the New York Times about elderly patients, some with dementia, who are getting screened for cancer and undergoing treatments that dramatically reduce their quality of life. Here’s how the story begins:

“Elena Altemus is 89 and has dementia. She often forgets her children’s names, and sometimes can’t recall whether she lives in Maryland or Italy… Mrs. Altemus, who entered a nursing home in November, was screened for breast cancer this summer.

Would anyone really deny that these anecdotes are broadly representative of so much that is wrong with the US healthcare system? As it happens, the Times article contains a brief discussion about precisely the kind of trade-offs that Rosenbaum and Jha discuss, but it would be hard to argue that the “less is more” perspective that is an inevitable conclusion of this article should be diminished by any application of a nuanced take on the story.

In fact, these examples are precisely why we need “less is more.”

The problem with Rosenbaum’s article is that it brushes aside urgent problems like these out of fear that we might forget to pay attention to the nuances behind picking a blood pressure target for guidelines. For once it should be possible to have our cake and eat it too— i.e., use a blunt instrument for egregious abuse and a sharper scalpel where more precise (nuanced) cuts are needed. But, importantly, we need to prioritize these egregious cases. In fact, until we address these egregious problems it will be nearly impossible to focus in an intelligent and thoughtful way about the more nuanced stuff.

Another way to look at this idea is to think about it on a macro level. Consider this chart taken from Wikipedia, showing health care cost as a percentage of GDP over time in 8 developed countries:

There is room for a reasonable and nuanced debate about whether our system should look more like the UK (now around 8% of GDP) or Switzerland (12%). But there is simply no scenario in which the US system, which is now about 18% of GDP, makes any kind of sense— unless of course you make your living from that sector!

I recently came across a comment that described the US healthcare system as a bubble. I don’t know if this makes sense but the thought was deeply troubling. Bubbles grow and grow, without reason or constraint, until they burst. It is hard to see how our US healthcare system can continue on its current trajectory, or whether we can even maintain healthcare spending at current levels. To mix in another metaphor, the house is on fire. Let’s put it out first before choosing the best fireproof material for the future. I don’t believe a nuanced discussion about “less is more” helps us put out the fire.

Update:

Kevin Lomangino, managing editor of Health News Review, sent the following comment:

There is one aspect of this debate that has only been tangentially touched on and which I believe deserves more attention. And that is this: The drive for more care and more expensive care is the default position of the increasingly commercial US healthcare system. Whether it’s specialist physicians, hospitals, or pharmaceutical companies, all of the big players have a vested interest in more care. There is no judgment in this statement — it’s simply a fact that medicine is big business and there are massive budgets devoted to promoting more care. The “less is more” movement is like a gnat on this elephant, trying (vainly in most cases, it would seem) to curb the greatest excesses with comparatively tiny resources. And yet Dr. Rosenbaum uses her platform to selectively argue the status quo message, which is like further amplifying the sound at a KISS concert.

I think this is a departure from the historical role of NEJM, and I think that’s why this issue has generated so much discussion. I can imagine Rosenbaum’s essay being published in any number of specialty journals and barely causing a ripple. But NEJM under past editors has set a high bar for editorial independence – for example refusing to publish editorials or review articles by authors with financial conflicts of interests throughout the 1990s. NEJM’s current editorial leadership has backtracked on those policies (for example in its industry-friendly resistance to data-sharing). And here we see an NEJM correspondent vigorously arguing the position that also benefits the commercial forces that support the journal financially (e.g. through advertising and reprint sales).

I’m not impugning Rosenbaum’s motives and I think her essay, while fundamentally wrong in its emphasis, is intelligently and persuasively argued. What’s concerning is that there is a massive conflict of interest in NEJM arguing the position that benefits its sponsors. The fact that it chooses to fight this battle – which is in zero danger of being lost by the forces promoting more care – raises red flags to anyone concerned about the editorial independence and integrity of the journal. In my opinion, that’s a big part of why it’s created such an uproar and why it deserves the criticism it has received.