While medicine offers tremendous benefits to patients who are acutely ill, when clinical issues are not life-threatening there is often a good reason for providers to be wary, lest they test too often and treat too aggressively.
Finding ways to strike a “Goldilocks balance” — treating not too little or too much — was the theme of a lively keynote address at the Value Institute Fall Symposium, Nov. 15 at the John H. Ammon Medical Education Center.
The keynote speaker was Gilbert Welch, M.D., MPH, professor of Medicine and Community & Family Medicine in The Geisel School of Medicine at Dartmouth University, whose research has often focused on the problems created by medicine’s efforts to detect early disease. The title of his talk — and the subject of a Christiana Care panel discussion that followed — was: “Less Medicine, More Health: Seven Assumptions That Drive Too Much Medical Care.”
“Gil Welch has a healthy skepticism about new treatments and medical breakthroughs. He is very much part of the Dartmouth School that questions the assumption that more medical care is always better,” said Vernon Alders, MHCDS, MBA, MSW, corporate director of Organizational Excellence and a Value Institute-Dartmouth Scholar. “Dr. Welch is truly one of those great teachers who makes you question the way things are, allowing you to think differently about your work. In addition, he and his colleagues have been instrumental in shaping national health policy, influencing public opinion and advancing the science of health outcomes evaluation.”
Dr. Welch pointed out that a recent survey of primary care physicians revealed that almost half felt that many patients receive too much medical care. He laid out seven assumptions that are important for clinicians to challenge. The first assumption is that all risk can be lowered.
This was shown in the ACCORD (Action to Control Cardiovascular Risk in Diabetes) study, in which the National Institutes of Health ran a clinical trial on intensively lowering blood glucose treatment strategies for patients with diabetes and cardiovascular disease. In 2008 the trial was ended 18 months early when 257 patients in the intensive treatment group died compared with 203 in the standard treatment group. “The disturbing truth is that risks can’t always be lowered, and trying produces its own risks,” Dr. Welch said.
Dr. Welch’s second assumption to challenge is that it is always better to fix a problem if there is a mechanical intervention available. In reality, this is not always true, as was shown in the COURAGE study, a clinical trial of more than 2,200 stable ischemic patients, in which Christiana Care’s William Weintraub, the John H. Ammon Chair of Cardiology and director of the Center for Outcomes Research, was a principal investigator.
In the trial, one group of patients was asked to manage their heart disease with optimal medical therapy (medication and lifestyle changes). In a second group, the use of optimal medical therapy and percutaneous coronary intervention (PCI) were used together, though this did not extend the life of patients. PCI is a procedure to open narrowed arteries which is sometimes known as angioplasty with stent. “The disturbing truth is that trying to eliminate a problem can sometimes be more dangerous than managing the problem,” said Dr. Welch.
In his view, other assumptions worthy of challenge include:
- Finding a disease sooner is always better. The high prevalence of benign prostate cancer in older men is one example of how early diagnosis can needlessly turn people into patients.
- It never hurts to get more information. Medicare lists more than 2,000 blood tests it will pay for, and there are 3 billion data points in the genome, all of which could result in information that is more frightening than useful for patients.
- Action is always better than inaction. In terms of back surgery, a retrospective study showed that refraining from surgery often produces a better outcome. Two years following a back injury, 33 percent of the patients who treated their pain without surgery were not back at work, while 74 percent of those who had surgery had not returned — and 85 percent of the latter group were on narcotics.
- Newer is always better. In fact reliability is not well-established with new products and procedures. For example, early enthusiasm for the use of a bone marrow transplant in the treatment of metastatic breast cancer has not proved to be effective over time.
- It’s all about avoiding death. If this were the only important value in life, why would we climb mountains or swim in the ocean? And why wouldn’t we lower the national speed limit to 55? Values such as quality of life can take precedent over aggressively fighting death. “We should also recognize that a fixation on preventing death can diminish life,” he said.
A Christiana Care panel engaged with Dr. Welch in a wide-ranging discussion moderated by Eric V. Jackson, M.D., MBA, associate director of the Value Institute and director of the Center for Health Care Delivery Science. Insights from the panel included:
- Omar Khan, M.D., MHS, FAAFP, physician leader for the Primary Care & Community Medicine Service Line and medical director for Community Health and the Eugene duPont Preventive Medicine & Rehabilitation Institute addressed the importance of family doctors. He pointed out that primary care physicians have the opportunity and privilege of becoming an integral part of their patients’ lives, encouraging their efforts to improve their diet and exercise, and helping them negotiate the puzzling and sometimes conflicting advice that can lead to unnecessary interventions.
- Teresa Corbo, Pharm.D., MHCDS, FASHP, vice president of Christiana Care Pharmacy Services, and Value-Institute-Dartmouth Scholar, was asked how the less-is-more approach applies to prescriptions. She said that the most common side effects of medications are often presented to patients, but this does not always include all of a drug’s potential secondary effects. Patients can’t make a fully informed decision unless the drug’s full profile is shared.
- Daniel J. Elliott, M.D., MSCE, FACP, medical director of Quality Partners and the Quality Partners Accountable Care Organization and a Research Scholar in the Value Institutem, discussed areas of improvement in communication with patients. He noted the challenge of explaining relative and absolute risk when describing medical options to patients. Both are important, but unless options are boiled down to something easy to explain, it is hard to incorporate these concepts into everyday practice.
- Bettina Tweardy Riveros, Esq., chief health equity officer, spoke about ways to empower Delawareans to take more control of their health through positive food choices. She observed that The Food Trust, a non-profit that helps make affordable nutritious food accessible to everyone, is working in Delaware communities to encourage the development of healthy food retail, expand the variety of food offerings and provide consumers with information to support healthy decisions.
Participants thanked Dr. Welch for his timely and nuanced presentation. They also noted that Christiana Care is well-positioned to strike a balance in favor of high-value care as Delaware’s leading medical provider, and is already having a positive impact by advocating lifestyles that advance the overall health of our neighbors.