What Doctors Don't Know - problems with the health care system

Washington Monthly, Dec, 1998 by Michael L. Millenson

HMOs aren't the only thing wrong with American Medicine

In Edgar Allan Poe's "The purloined Letter," the protagonists overlook the crucial clue that is sitting right in plain sight: a letter left casually on a desk. Today, a similar nearwillful blindness prevails among those who present the managed care industry as the leading threat to the quality of American medicine. Implicitly, this view defines high-quality care as consisting of immediate access to treatment. While that is obviously important, the critics ignore a separate issue whose equal significance should be glaringly obvious: What happens to the patient once he or she actually reaches the doctor or hospital?

It would be nice if good medical care simply consisted of preferring the physician's judgment over that of "insurance company accountants," as President Clinton put it in his 1998 State of the Union address. Indeed, the argument that the public is faced with a choice between medical decisions made by "good" doctors or "bad" bureaucrats (albeit private-sector bureaucrats) has been sounded by everyone from anti-managed care politicians to (surprise) indignant representatives of various physician organizations. Preserving physician freedom is presented as the way to "preserve" high-quality care; any other path leads inexorably to ruin.

Unfortunately for the health of patients, this story line is a gross oversimplification. There's no question that the business ethic of some health plans can dangerously distort medical decision-making and has sometimes done so. Yet the larger truth about our health-care system is at once more complicated and much more unsettling.

From ulcers to urinary tract infections, tonsils to organ transplants, back pain to breast cancer, asthma to arteriosclerosis, scores of thousands of patients are dying or being injured every year because the best scientific information on how to care for them is not being put into practice by physicians. If one counts the lives lost to preventable medical mistakes, the toll jumps even higher.

In the scientific literature, the struggle to put medical theory into practice goes by the genteel term "evidence-based medicine" Kenneth I. Shine, president of the Institute of Medicine, phrases the problem this way: "If we asked the question of whether physicians have based their practice on scientific principles," he says, "it is clear that the profession has been sorely lacking."

Put in Clintonian campaign terms, however, the problem is easy for a layperson to understand: "It's the doctors' decisions, stupid."

What Doctors Don't Do

Most patients would be surprised to know what their doctors don't know--or don't put into practice. Even the best-trained doctors go about their work with an astonishingly shallow base of knowledge concerning the link between what they do and how it affects a patient's health. For instance, more than half of all medical treatments, and perhaps as many as 85 percent, have never been validated by clinical trials. But even when there is scientific evidence about what works best, large numbers of doctors don't apply those findings to actual patient care.

A prime example of the latter problem is the treatment of ulcers, a common and painful condition that will afflict an estimated 25 million Americans at some point in their life. Back in 1988, the prestigious British journal The Lancet published the results of a clinical trial that showed that most ulcers were actually caused by a bacteria called H. pylori. Patients didn't have to spend their lives taking anti-ulcer medications to control acidic secretions; the bacteria could be eradicated and the ulcer cured.

A study replicating this research appeared in a major American journal in 1991. A consensus panel from the National Institutes of Health endorsed the anti-bacteria ulcer treatment in 1994. Yet today, half of all U.S. doctors still aren't testing their ulcer patients for H. pylori and prescribing the right therapy, according to the federal Centers for Disease Control and Prevention. Managed-care financial incentives have nothing to do with this problem. Indeed, if anything they should work in the opposite direction--it's cheaper to cure a patient than to keep paying for maintenance drugs.

But to truly understand the consequences of failing to apply evidence to practice, one need only look at treatment of heart disease, the number one killer of both men and women in the United States. Heart disease is common, and it is expensive (total health care costs for cardiovascular disease are more than $150 billion annually). To listen to the managed-care debate, one might think the most pressing problem in cardiac care is getting people directly to the hospital emergency room without waiting for pre-approval from their health plan. (And forget for a moment that only 1 of every 9 visits to the emergency room for chest pain results in a confirmed heart attack.) The medical literature, however, paints a very different story than the one heard on the nightly news. It's a tale of wasted money and of unnecessary patient deaths and complications that has nothing to do with health plans. To give just a few examples: