Tuesday, August 27, 2013

Conservative Medicine: Why am I the best person to write it?

In a recent New York Times editorial about exorbitant healthcare costs, Dartmouth professor H. Gilbert Welch (the author of Overdiagnosed: Making People Sick in the Pursuit of Health) asserted: "Medical care in America could use a dose of moral outrage." For all our hand-wringing about unsavory business practices in medicine, Dr. Welch explained, health care professionals have done shamefully little to counteract the interests that value profits over patients. His stance was subsequently supported by a JAMA survey showing that most physicians didn't feel it was their responsibility to contain medical costs.

I was reminded of Dr. Welch's editorial when reading a well-intentioned e-mail that advised me to tone down the "emotion" and "heat" in writings critical of providers of direct-to-consumer screening tests. Really? If companies were going around selling bargain-priced chemotherapy to healthy people at churches and community centers without advising potential customers that these therapies were not recommended for the general population and could be harmful, we wouldn't be gently chastising them in the editorial pages of access-restricted academic journals. No, there would be class-action lawsuits and high-profile investigations. Consumer-protection groups would be clamoring for regulators to shut these businesses down. Providers of unnecessary and potentially harmful screening tests (physicians included), on the other hand, get a pass. Diagnosis: insufficient outrage.

I felt similarly as an employee at the Agency for Healthcare Research and Quality in the demoralizing aftermath of the cancellation of the U.S. Preventive Services Task Force's November 2010 meeting. We were intentionally interrupting the work of the Task Force, and preventing millions of men and their clinicians from receiving their assessment that prostate cancer screening was harmful to their health, so that the President's political party could perhaps hold on to a few more Congressional seats in the midterm elections? Really?

Why am I the best person to write Conservative Medicine? It's not only because I'm a family physician with a public health degree who has spent my career examining the evidence on clinical preventive services. Though I may not write as eloquently as journalist and health policy expert Shannon Brownlee, or summon the gravitas of the American Cancer Society's chief medical officer Otis Brawley, I am passionate (and, occasionally, appropriately outraged) about reducing overdiagnosis and overtreament, exposing political interference in screening guidelines, and ensuring that people who come to me for health care are more likely to be helped than harmed by the encounter.


This is the fourth in a series of brainstorming posts about a book that I plan to write titled Conservative Medicine.