The dark side to the noble medical profession.

        The dark side to the noble medical profession.

                              Dr KS Dhillon

Introduction                 

In recent years there have been articles published in malaysian newspapers about the lack of ‘voice of the doctor and his patients’ [1]. Some doctors in Malaysia are urging all ‘doctors and their patients to empower themselves’ so that their voice can be heard. The doctors are lamenting that their rights and the rights of their patients are gradually been ‘eroded’ by ‘the big business of medicine’. Some doctors believe that Malaysian laws and regulations stifle ‘the practice, the art and the humanity’ of their work. The Managed Care Organizations (MCOs) and the Third Party Payment System (TPPS) have been accused of changing the landscape ‘with their single-minded pursuit of profit’ [1]. The MCOs and TPPS have been accused of ‘unilateral denial of payment for honest work done’ and of creating administrative hurdles which divide the doctors and their patients. There have been calls for the creation of a Royal Commission on Healthcare in Malaysia to address these issues [1].
This begs the question whether there is any other side to the story?

The origin of ‘Managed care’ organizations (MCOs)

The Congressional Committee on Interstate and Foreign Commerce in the United States held hearings on unnecessary surgery in 1974. McCarthy et al (2) presented important evidence which indicated that about 17.6% of recommendations for surgery could not be confirmed by the surgical second opinion program (SSOP) which was introduced specifically to reduce the rate of unnecessary surgery. The Congressional Subcommittee on Oversight and Investigations estimated that in the USA there were 2.4 million unnecessary operations performed yearly at a cost of $3.9 billion. These unnecessary surgery resulted in 11,900 deaths [3]. This information aroused the attention of payers who were feeling the burden of accelerating health care costs. Their objective was to reduce cost by at least 15-20%. The commercial insurance companies introduced preprocedural review programs for operations which were generally believed to be overutilized [4]. In the 1970s "Managed care" came into existence which questioned doctors decisions. The aim of managed care was to reduce days of hospitalization and the use of expensive services. The government of the day gave subsidies for the development of health maintenance organizations (HMOs) and the government also encouraged enrollment of Medicare patients in the HMOs.
Initially significant reductions in hospital stay and utilization of particular procedures was seen. However over the years the health care cost continued to rise at 2 to 3 times the inflation rate. The attempts at cost controls however did not affect the quality of care. Inappropriate use of a variety of services continued and without doubt unnecessary surgery is still with us [4].
What is unnecessary medical care and how rampant is the problem?

Unnecessary/Low Value medical care

Some investigators use the term unnecessary medical care but the majority prefer to use the term low value medical care. Low value medical care is defined as a service with little or no benefit or a service where the risk of harm outweighs any potential benefit. The risk is sometimes directly from the service and sometimes indirectly where the service will lead to extra tests and procedures which will provide little or no benefit to the patient but it may contain risks. Low value medical care also increases health care spending without providing benefit to the patients. In recent years several investigators have studied low value medical care.
Schwartz et al [5] studied a random 5% of the 2008–2009 Medicare beneficiaries claims data to analyze the extent of low value medical services provided to Medicare patients. They found that in 2009, Medicare spent at least $1.9 billion on 26 types of tests and procedures which offered  few or no health benefits to patients. They analyzed the data of 1.3 million Medicare patients and found that at least one in four patients received one of these ‘low value’ services.
When a narrower definition of low value services was used, 25 percent of patients received at least one of the 26 wasteful services costing  $1.9 billion. On the other hand when a wider definition was used 42 percent of patients received at least one of the 26 wasteful services costing $8.4 billion.
Among the hundreds of health care services know to provide little or no benefits to patients only 26 procedures were analyzed in this study. In this study six service categories were analyzed which included ‘low-value cancer screening; low-value diagnostic and preventive testing; low-value preoperative testing; low-value imaging; low-value cardiovascular testing and procedures; and other low-value surgical procedures’ [5]. The list of 26 types of tests and procedures which offered few or no health benefits to patients that were analyzed included:

• Cancer screening for patients with chronic kidney disease (CKD) receiving dialysis
• Cervical cancer screening for women over age 65
• Colorectal cancer screening for adults older than age 85 years
• Prostate-specific antigen (PSA) testing for men over age 75
• Bone mineral density testing at frequent intervals 
• Homocysteine testing for cardiovascular disease
• Hypercoagulability testing for patients with deep vein thrombosis
• Parathyroid hormone (PTH) measurement for patients  with stage 1-3 CKD
• Preoperative chest radiography 
• Preoperative echocardiography
• Preoperative pulmonary function testing (PFT)
• Preoperative stress testing
• Computed tomography (CT) of the sinuses for uncomplicated acute rhinosinusitis 
• Head imaging in the evaluation of syncope 
• Head imaging for uncomplicated headache
• Electroencephalogram for headaches
• Back imaging for patients with non-specific low back pain
• Screening for carotid artery disease in asymptomatic adults
• Screening for carotid artery disease for syncope
• Stress testing for stable coronary disease
• Percutaneous coronary intervention with balloon angioplasty or stent placement  for stable coronary disease
• Renal artery angioplasty or stenting
• Carotid endarterectomy in asymptomatic patients
• Inferior vena cava filters for the prevention of pulmonary embolism
• Vertebroplasty or kyphoplasty for osteoporotic vertebral fractures
• Arthroscopic surgery for knee osteoarthritis

Their findings appear to be consistent with the believe that wasteful practices are pervasive in the US healthcare system.The authors believed that this was just the tip of the iceberg and that the such practices were much more common. They were also surprised that these wasteful services were so prevalent in the United States [6].
Elshaug et al [7]  reviewed a total of 5209 articles from the literature and they identified 156 potentially ineffective and/or unsafe medical services which are being provided to patients. The authors believe that low-value services have to be identified and low-value care has to be reduced so that the limited resources can be diverted to ‘more beneficial or cost-effective services, thus maximising health gain’ [7].
Chassin et al [8] randomly sampled Medicare beneficiaries who had coronary angiography, carotid endarterectomy, and upper gastrointestinal tract endoscopy in 1981 to study the appropriateness of the use of these procedures. They did a detailed review of the medical records and found significant levels of inappropriate use of these procedures. Inappropriate care was seen in 17% of cases for coronary angiography, 32% for carotid endarterectomy, and 17% for upper gastrointestinal tract endoscopy.

Patient safety and unnecessary surgery

“There are many forces coming together to harm or even to kill the patients---their physician should not be one of them”
                                                       Arnold S. Relman, MD (1923-2014)
                                                       Editor Emeritus
                                                       The New England Journal of medicine
Medical errors and surgical complications remains a major problem in medicine due to ‘lack of physician-driven initiatives aimed at recognizing, preventing and mitigating’ these problems [9]. It is disheartening to know that it is ‘significantly safer to board a commercial airplane, a spacecraft, or a nuclear submarine, than to be admitted to a U.S. hospital’ [9]. Medical errors rank as the 3rd leading cause of death, after heart disease and cancer, in the United States [10].
Medical error has been defined as an unintended act of either omission or commission, an act which does not achieve its intended outcome, an error of execution, an error of planning or a deviation from a process of care which would prevent harm to the patient [10]. One of the easiest way to reduce errors, complications and death would be by avoiding unnecessary surgery.
Unnecessary surgery has been defined as surgery which is not indicated or needed and is not in the patients best interest. The scientific community has been aware of unnecessary surgery since the 1950s when Dr. Paul Hawley, the Director of the American College of Surgeons (ACS), said that “the public would be shocked if it knew the amount of unnecessary surgery performed (…)” [11].
Due to space constraints only some examples of unnecessary surgery in orthopaedics are analysed and listed below.

Spine surgery

Gamache [12] in 2012 reviewed over a 14-month period, 155 patients who presented to his clinic for a second opinion and found that 69 (44.5%) of the patients did not need the spine surgery that was recommended to them by other spine surgeons.
Epstein NC [13] reviewed 437 patients with cervical or lumbar complaints who presented to the neurosurgical services over a 20-month period. Two hundred and fifty four (58.1%) patients come for first opinions and 183 (41.9%) patients come in for second opinions. The author found that in 111 (60.7%) patients the surgery recommended by the previous surgeon was  “unnecessary”, in 61 (33.3%) patients “wrong” surgery was advised and only in 11 (6%) of the patients the “right” operation was advised. A “wrong” operation included operations that were overly extensive (multiple levels), or the approach (anterior or posterior approach) to the spine was wrong.
Arts et al. [14] in study involving 82 patients who underwent additional spinal fusions for failed back surgery found that 65% of the patients had unsuccessful outcomes, which the authors classified as “unnecessary” spinal operations.
There have been several clinical trials which showed that spinal fusion for back pain is no better than conservative treatment [15,16]. Despite such evidence the spinal fusion rates in USA continue to dramatically increase [17].
Besides the spine, the other example where increasing rates of unnecessary surgeries are carried out is the knee.

Knee surgery

Arthroscopic partial meniscectomy

Arthroscopic partial meniscectomy is probably the most commonly performed surgical procedure in the world [18]. In the United States, more than 700,000 arthroscopic partial meniscectomies are carried out every year despite very good evidence (level 1) that arthroscopic partial meniscectomy in patients with degenerative meniscal tears is no better than sham surgery [19].

Arthroscopic debridement of the knee

Arthroscopic debridement of the knee joint for osteoarthritis is another operation that is commonly performed despite the presence of high level (level 1) clinical evidence that it provides no benefit to the patient [20,21].

Knee replacement

Riddle et al [22] studied the appropriateness of knee replacement in 205 patients. They found that the knee replacement was an appropriate procedure in 44% of the patients. It was inappropriate in 34.3% of the patients and in 21.7% of the patients the appropriateness was inconclusive. The study showed that about a third of the patient had inappropriate or unnecessary knee replacement.

Shoulder surgery

Arthroscopic subacromial decompression of the shoulder for subacromial shoulder pain is a commonly perform operation. In England the number of patients undergoing subacromial decompression increased 7 times from 2,523 in 2000 to 21,355 in 2010 [23]. In the past there have been controversial reports of the effectiveness of this surgical procedure and its value in the treatment of subacromial pain was uncertain. However in 2017 Beard et al published the outcome of a multicentre placebo controlled trial which evaluated the effectiveness of arthroscopic subacromial decompression for subacromial shoulder pain [24]. They divided the patients into three groups, one group had arthroscopic decompression, the other only arthroscopy without decompression and the third group had no treatment. They found that the two surgical groups had slightly better outcome as compared to no treatment group but the difference was of no clinical importance. The slightly better outcome was probably due to placebo effect because the arthroscopy group had no surgical treatment.
The authors questioned the value of this operation and were of the opinion that this information must be shared with the patients who present with subacromial pain.
Even for the treatment of atraumatic tears of the rotator cuff there is no good evidence that surgery is better than conservative treatment. Recently there have been two prospective randomized studies which compared surgical and conservative treatments for rotator cuff tears and they found that there was no clinically significant difference in outcome between the two groups [25,26].

Removal of orthopaedic implants

Implant removal after fracture union is one of the most common elective orthopaedic procedure. A Finnish study showed that  implant removal constituted about 30% of all planned orthopaedic operations and 15% of all operations performed in their department [27].
A review of literature shows that deep seated stable implants are usually asymptomatic and most authors recommend that they should be left in situ even in children. Removal of implants is not as innocuous as is often believed. Besides anaesthesia related complications there are surgery related complications in 3% to over 40% of the patients. Implant removal is also associated with increased cost and time off work. In patients who complain of pain around the site of the implant, the actual cause of the pain is often not known and it could be due to effect of the injury rather than the implant itself. In symptomatic patients removal of implants resolve the symptoms in only about 50 % of the patients [28].
There is no scientific evidence to support a routine removal of  deep seated orthopaedic implants after fracture union though it is a common practice in many hospitals. Essentially, routine removal of asymptomatic deep seated implants after fracture union can be classed as another example of unnecessary surgery which is quite rampant.
There are many other examples of unwarranted procedures which are frequently carried out such as tonsillectomy, appendectomy, CABG, hemorrhoidectomy, herniorrhaphy, prostatectomy, carotid endarterectomy,   hysterectomy and cholecystectomy [29].

Why do surgeons continue to perform unnecessary surgery?

The often asked question is, how can a procedure which is contraindicated by research be so common? Stahel et al [30] have framed the question very well, when they asked “Why would a reasonable surgeon consider performing unneeded surgical procedures?” They have come up with two answers from the surgeon’s perspective.
1. Surgeons perform surgery because they have been trained
to do so and that they have always being doing it that way and do not know any better. In German phycology it known as “Funktionslust” [31].
2. The other reason is that the surgeons are ‘incentivized to perform surgical procedures, either for financial gain, renown, or both’ [30].
It is obvious that it would be difficult to get people to do the right thing when they’re paid to do the wrong thing. Doctors are in a powerful position because of information asymmetry. Doctors know much more about  medical treatment than patients do, hence doctors can recommend care which is of little or no value to enhance their incomes, partly out of habit and partly because doctors incorrectly believe in it. Unfortunately many doctors have stopped being doctors and have become businessmen.
Besides the financial aspects, “availability heuristic,” also play a role. This term was coined by Nobel laureate psychologists Amos Tversky and Daniel Kahneman. It simply means that it is human instinct to base an important decision on an example which is dramatic and easy to recall even if that example is irrelevant or incredibly rare.
There is an avalanche of unnecessary medical care which is harming patients physically as well as financially. Is there something that can be done about it?

Second Surgical Opinion Programs (SSOP)

Second surgical opinion programs were first introduced in the USA in 1974 specifically to reduce the rate of unnecessary surgery. Medicare and Medicaid programs strongly recommended the use of SSOP. By 1984 private health insurers also began to offer second opinion programs.
However over the years enthusiasm for SSOPs  cooled as more and more payers found that saving from this programs was not relevant and in some cases it cost more than the savings [29].
 After the failure of SSOP to reduce the rate of unnecessary surgery, many believed that the introduction of practice guidelines may be of value.

Practice Guidelines

There is a lot of high level scientific evidence available in literature to guide treatment of patients appropriately. The challenge is to get doctors to assess this information and effectively use the information. The development of medical practice guidelines was an attempt to overcome this challenge. Now there are excellent practice guidelines easily available online from various professional specialty societies. The challenge now is to get doctors to treat their patients based on the best evidence available in these guidelines.
To date, however, there is no evidence that these guidelines have been effective in reducing the numbers of unnecessary surgeries.

Review of health care benefits

Another way to reduce unnecessary low value medical care would be for the health insurers to stop paying for services which have been found to be of no value to the patients. The Australian government is taking steps in this direction by reviewing the Medicare Benefits Schedule to remove ineffective medical services from the schedule so that taxpayers do not have to pay for these services. The money thus saved can be more effectively used to fund more effective care.

Choosing Wisely

Choosing Wisely is an initiative of the ABIM Foundation which by advancing medical professionalism hopes to improve health care. Choosing wisely is one of ABIM Foundation’s most famous initiative. They help to promote conversation between patients and their doctors so that the patient can chose and get medical care which is supported by evidence, free from harm and is truly necessary. The various American specialist societies have provided recommendations, for the patients and the doctors, about what should not be done in the management of various medical conditions [32].
This initiative is relatively new and only time will tell if it is effective in reducing low value medical care.

Conclusion

The problem with medical practice around the world appears to revolve around the doctors themselves rather than the MCOs and the TPPS. These organisations are in the business of reducing the cost of medical care by eliminating unnecessary low value medical care. There appears to be no need for a Royal Commission on Healthcare in Malaysia. Low value medical care is not going to reduce in the near future despite the efforts of organization such as ‘Choosing Wisely’. It is the responsibility of the doctors and their societies to overcome the problem of unnecessary medical care and eliminate any negative perception the public may have of the noble profession.

References

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