How to Avoid Avoidable Care–by George Lundberg

Below, a  guest-post by Dr. George Lundberg, Editor-at-Large of MedPageToday; Editor in Chief of Collabrx; President and Board Chair of the Lundberg Institute.  (Full disclosure: I am a member of the Lundberg Institute’s Board)

What Lundberg says is not meant to be news.  Today, physicians tend to agree that many of the tests that patients undergo are unnecessary. Three years ago, one hospitalist shared a story on HealthBeat, describing how he warned his residents about over-testing His hospital may not have been happy about his disclosure: tests boost revenues.

But in some cases, we have solid medical evidence showing that for certain patients, these tests do more harm than good– though vested interests may try to bury that evidence. (See Dr. Hoffman’s post below.)

Yet doctors continue to order the tests– why?  

George Lundberg brings a unique perspective to this problem. Drawing on his wealth of experience, both as a practitioner and as a teacher, he puts it in a historical context.  For 40 years, he has asked physicians why they perform so many tests. The frankness of their responses is matched only by Lundberg’s own candor as he diagnoses the excesses in our medical system . 

How to Avoid Avoidable Care 

George Lundberg

Why do physicians order laboratory tests?  The traditional reasons are: diagnosis 37%, monitoring 33%, screening 32%, previous abnormal result 12%, prognosis 7%, education 2%, and medicolegal 1%.

In  order to confirm these data, I began to ask the same question of many groups of clinical and laboratory workers over three continents in the 1970s, ‘80s and ‘90s during  Socratic teaching sessions on how to use the clinical laboratory correctly. And I began to get very different answers.  

I was told that physicians order laboratory tests to: confirm a clinical opinion; establish a baseline;  complete a database;  curiosity; insecurity; public relations; documentation; peer pressure; patient pressure; pressure from recent literature; question of accuracy of prior result; unavailability of prior result; personal education; research; personal reassurance; a need to show to an attending physician; hospital policy; state legal requirement; concern for liability; CYA’ personal or hospital profits, fraud and kickbacks;  hunting or fishing expeditions; frustration at nothing better to do (don’t know what’s wrong with this patient, better get some lab tests); to buy time (maybe by the time the lab tests come back I will have some better ideas what is wrong with this patient); simple availability; and ease of doing.

When I was editor-in chief of JAMA I introduced a new series called “Toward Optimal Laboratory Use” by observing that: “The huge variety and volume of available laboratory tests confronts the physician with a major dilemma: What tests should be ordered on what patients? When, how, how often, at what cost, grouped or individually, and in what sequence? What is the interpretation of the results and what steps should be taken?  . . . Standards have not been established, but are urgently needed.

I wrote those words in 1975.

Today, these questions remain largely unanswered. Outcomes credited to performing or not performing screening or diagnostic tests still are largely unknown although millions of such tests are performed on Americans each year

In 1989, shortly after he became the Secretary of Health and Human Services, I asked Dr Louis Sullivan how much medical care was unnecessary. He said that he thought that between 30 and 40% of medical care was inappropriate or unnecessary. Many people cite similar numbers in 2012.

 Looking at the reasons lab tests (and imaging is likely similar) are ordered, it is easy to see how a person who is “not sick” transitions through the “worried well” into a lifelong “patient.”  Better not to do un-indicated fishing expeditions to begin with.

It is not that nobody cares about this. There has been a recent deluge of at least 15 American books on the topic of overtreatment or unnecessary care: 

2000;   Severed Trust: Why American Medicine Hasn’t Been Fixed. Basic Books. Lundberg, GD;

2002;   Overkill: How Our Nation’s Abuse of Antibiotics and Other Germ Killers is Hurting Your Health and What You Can Do About it. Rodale. Thompson KM;

2003;   Epidemic of Care: A Call for Safer, Better, and More Accountable Health Care. Jossey-Bass. Halvorson GC and Isham GJ;

2005;   Hope or Hype: The Obsession with Medical Advances and the High Cost of False Promises. AMACOM. Deyo RA and Patrick DL;

2005:   The Health Care Mess: How We Got into It and what it will take to Get Out. Harvard University Press. Richmond JB and Fein R;

2006:   The Trust Crisis in Healthcare: Causes, Consequences, and Cures”. Oxford. Shore DA;

2006:   Money Driven Medicine: the Real Reason Health Care Costs so Much”. Harper Collins. Mahar M;

2006:   Money Driven Medicine: Tests and Treatments that don’t Work Cundiff DK;

2007:   Overtreated: Why too Much Medicine is making us Sicker and Poorer. Bloomsbury USA. Brownlee S;

2008:   Too Much Medicine: A Doctor’s Prescription for Better and More Affordable Health Care Paragon House. Gottfried D;

2008:   Hippocrates Shadow: What Doctors Don’t Know, Don’t Tell You, and How Truth Can Repair the Patient-Doctor Breach Scribner.  Newman DH;

2008:   Do Not Resuscitate: Why the Health Insurance Industry is Dying and How We Must Replace it. Common Courage Press. Geyman J;

2011:   Rethinking Aging: Growing Old and Living Well in an Overtreated Society. UNC Press. Hadler NM

2011:   Overdiagnosed: Making People Sick in the Pursuit of Health Beacon. Welch HG, Schwartz LM, Woloshin S.

2011:   How We Do Harm: A Doctor Breaks Ranks About Being Sick in America St Martin’s Press. Brawley OW.

Alas, Shakespeare foretold the effects of all this concern while writing MacBeth in approximately 1605: “it is a tale told by an idiot, full of sound and fury. Signifying nothing.”

Nobel Peace Prize recipient Bernard Lown MD, when recently asked if he was an optimist or a pessimist replied that he was both: a pessimist about the past because it cannot be changed; and an optimist about the future because it can be changed.

 Physicians Hold the Key

In 2012, one almost must take an optimistic view on avoiding avoidable care, because as a country and as a profession, we simply must do a better job of acting out our professionalism. Physicians hold the key. “Doctors orders” dictate as much as 75% of all medical costs. Physicians can fix the problem if they begin to exert their will power.

Virtually every time I address this topic in lectures, some physician comes up to me afterwards and tells me that he wants to do the right thing but that authorities, such as hospitals, tell him not to because they need the revenue.  

Around the world, medical care is generally about health. In modern America, medical care is mostly about money and it is about jobs.

Still this may change, because it must. We are heading for a wall.

Could it be that there is now a movement sizable enough to make real change in this hemorrhage of money on unnecessary care? To “bend the cost curve”? To ascend to a “tipping point”? I don’t know, but there are at least glimmers of hope. The “Choosing Wisely” movement that sprang up inside organized medicine got off the ground in 2012.And around 150 medical leaders assembled in Cambridge MA on April 24-26, 2012 to try.

The conference called “Avoiding Avoidable Care” was organized by Vikas Saini MD and Shannon Brownlee under the auspices of the Bernard Lown Foundation, with support from many other organizations, such as the Institute of Medicine and the Robert Wood Johnson Foundation.  If you are interested in this topic, and you certainly ought to be, it is worth your time to click here  to study what has been done and to follow the movement as it evolves.

It is easy to feel discouraged. But I believe that we must not be disheartened. We simply must fix this problem.




15 thoughts on “How to Avoid Avoidable Care–by George Lundberg

  1. Lundberg wrote:
    “Physicians Hold the Key
    In 2012, one almost must take an optimistic view on avoiding avoidable care, because as a country and as a profession, we simply must do a better job of acting out our professionalism. Physicians hold the key. “Doctors orders” dictate as much as 75% of all medical costs. Physicians can fix the problem if they begin to exert their will power.”
    I doubt the conservative push for consumer directed healthcare will lead to this, not with the fear and emotion of illness and with the info asymmetry that the providers have. I must say that if providers want or have to do the right thing, that they could get together and define (guidance) and limit what is done for certain situations. More of a top down monopsony (single payer) approach will eventually have to be instituted for fairness, sustainability, and to control what has gone wrong under unfettered FFS system up to now??

  2. Re: NG’s comment:: What consumer-directed healthcare has led to so far is poor decision-making – like postponing needed colonoscopies because of the out-of-pocket deductible cost to patients covered by these “more skin in the game” plans. This reflects the “info asymmetry” you mention and will only contain spending in the short-term while likely driving up spending longer-term as more advanced disease needs to be treated at higher cost.

    Re: Dr. Lundberg’s article, it’s true that “Physicians hold the key”, but so far they’ve been using it lock patients out of truly informed decision-making. CT scans, for example, have increased more than three-fold since 1993, and 43% of surveyed doctors admit to ordering them in clinically unnecessary circumstances. The surge in cardiologist-owned CT scanners has undoubtedly played a major role in this phenomenon despite no evidence of benefit for patients.

    Indeed, it’s instead led to the growth in PCIs for stable angina cases where the risk of causing a heart attack was estimated by Mayo Clinic researchers – in a study published last year in The New England Journal of Medicine – at 5-30% of cases.
    This, in addition to the estimated 29,000 cancers caused every year by CT scans, about a third of them unneeded.

    I’d love to share the optimistic view that this will somehow change because it has to, but there’s little evidence to support such optimism. Instead, the evidence all points to a continuing decline in medical ethics in America that permits these ill-advised, and often unsavory, practices to exist in the first place. This is the tipping point I worry about – and it doesn’t need to be a majority of doctors to achieve it.

    We may already be there.

  3. NG–
    In some specialites doctors are likely to get together and discuss what constitutes overtreatment.
    In others speciaities, that won’t happen.
    It seems that the urologists, for instance,
    are digging their heels in on PSA testing)see theJully 9 post right below this one.)
    Primary care physicians, on the other hand, are the
    doctors who normally recommend PSA testing to their patients, and today, more and more of them
    have reservations. At the very least, most will (I hope) tell their patients that the Preventive Services Task Force recommends against PSA testing and why.
    Then, the question is: will patients listen? Or will
    they just shop for another doctor who will give them
    whatever they think they need?
    Finally, will insuers and Medicare continue to pay for treatments that medical science says don’t work?
    Right now, they will continue to pay, because most Americans are not yet ready to accept the fact that something many doctors have been doing for years just doesn’t save lives.. In other words, they’re not ready to accept the fact that medicine is an imperfect, evolving science– always open to revision.
    But over time, I think we’ll see a change in our medical cutlure–both among doctors and among patients–as they come to understand what evidence-based medicine means.

  4. John Lynch– I agree about consumer-driven health care.
    (What we need is patient-centered healthcare.)
    I’m not as pessimistic as you are about reducing overtreatment. The fact is that we only have so much money, and really can’t spend a significantly larger share of GDP on healthcare han we do now.

    Some people suggest that in the not-too-distant future, heathcare wil eat up 20% of GDP. But the truth is that resources are finite (On Wall Street, there is a saying: “What can’t happen won’t.” I think that applies here.
    In that sense, our health care isystem s headindg for a wall. The only way we can afford so much overtreatment is if we “tier” healthcare– overtreating the wealthiest 10% or 20% (killing some of them in the processs) while undertreating the rest of the population.

    But there seems to be a national consensus that we want universal coverage, with everyone getting what the Affordable Care Act calls “Essential Benefits.”

    This means we have to reduce the overtreatment, and the ACA provides ways to do that. For one, it gives the Secretary of HHS the power to reduce fees for “overvalued services” (and increase fees for undervallued services.) This
    means reducing what Medicare pays for certain tests.
    Medicare has already done this by reducing fees for tests done by doctors in their offices using equipment that they bought themsleves. Research shows that when
    a doctor makes that investment– and needs to pay it off– he does many more tests.
    By reducing fees, Medicare is now discouraging the investment …
    Physician-owned hospitals also lead to over-treatment, and under the ACA,no more
    physician-owned hosptials will be created.
    Private insurers are more than happy to follow Medicare in reducing fees– as long as Medicare goes first.
    In addition, the ACA sets out to change HOW we pay for care, moving away from
    fee-for-service (which encourages “doing more”) to lump sum payments, with
    health care providers sharing in the savings if they manage to achieve better outcomes at a lower cost. (These lump sum payments also encourage providers to work together to make more efficient use of evidence-based medicine. No one gets the bonus unless they, as a group, succeed in achieving those better outcomes for less.
    Yesterday, CMS announced that 89 more of these “Accountable Care Organizations” have been created–with doctors (or doctors and hospitals) banding together to accept these lump sum payments.

    This will all take time. Health care reform is a process,not an event. But
    assuming Obama is re-elected, the process wil move forward. (Even if the ACA is repealed, much is already happening on the ground that cannot be undone.

    Not all physicians wil cooperate. There are dinosaurs out there (not to mention greedy dinosaurs). But over time, they will retire.(Some will retire early because they don’t like reform.)
    Some physicians also recognize that we need to change the way we educate
    medical students. “Order a battery of tests” is not the best response when presented with a problem. Taking a history– and listening carefully to what the patient has to say– is usually the best first step.
    Finally,as I said to NG, there is growing awareness in some professional societies that physicians need to think about the larger picture, and realize that if we waste money providing ineffective care for some patients, we won’t have the money to give another patient needed care. These doctors are explaining to their patients that just because their brother-in-law had an MRI doesn’t mean that they need one too.

    • Hi Maggie,

      I love your optimism, I truly do. I just don’t share it. Here’s why:

      1. ACOs are an improvement, primarily in coordination of care that accounts for so many medical errors today. But they’re not necessarily cost-savers. Established ones in Massachusetts – operating in the only state with near-universal health insurance – are among the state’s most expensive providers.

      Furthermore, the lump sum payments you describe can be manipulated by increasing the disease severity of each group’s patient panel. This is done by ordering more tests and procedures to create more diagnoses and a higher severity score for the group.

      It’s the willingness of the medical profession to engage in such gamesmanship – and I guarantee you they will – that’s so disheartening because it reveals the underlying decay in medical ethics in this country.

      2. The flip side of this is that many patients will be victimized by medical under-treatment, much as most are victimized by over-treatment in our fee-for-service system. And it’s not just the older doctors who may choose to retire who engage in such me-first practices.

      Witness the fact that 98% of medical school graduates are choosing medical specialties over primary care – the exact opposite of what we need with our aging population with chronic diseases. Our current imbalance in physician supply will only worsen, meaning more patients will get so-called “primary care” from ill-equipped specialists who perform more procedures on them for the same conditions compared to primary care doctors (see above re: diagnosis-padding benefit of doing so).

      3. Finally, the notion of a “wall” or “cliff” is an imaginary construct with no basis in reality. There’s nothing to stop our medical spending from climbing past 20% of GDP. And there are plenty of scapegoats to blame when it does – mainly an aging population and global leadership in obesity that drives so many chronic diseases.

      The ACA will help mitigate each of these, but let’s be realistic. The Independent Payment Advisory Board envisioned under the ACA for hospitals doesn’t even kick in until 2020.

      The bottom line is there’s only so much third parties like the government and insurance companies can do to influence physician behavior. Yes, there’ll be the occasional nudge from some professional societies to change their ways, but you just have to witness the Urological Society backlash against the USPSTF’s recent recommendation against routine PSA testing for men to realize what an uphill battle that will be.

      Several years have passed since the Orthopedic Surgical Society condemned arthroscopic surgery of arthritic knees as useless, and yet over a million a year are still performed in the US. This is powerful testimony to the extent to which greed has overtaken the medical profession.

      The best solution, in my book, is a massive patient education effort to better equip consumers to avoid being further victimized by whatever financial incentives emerge to drive their doctors’ treatment recommendations. A tall order, I know, but no taller than expecting to change the moral compass of a profession that has largely lost its way.

      If that sound cynical, you haven’t been listening. It’s the practices I’m describing – and I doubt you’ll refute them – that are cynical. And they’re our ongoing reality – ACA or no ACA.

    • Maggie-
      “Patient-centered care” is the latest focus group tested GOP buzzword for what they want to do to replace “Obamacare”.

  5. Anybody who does not fully understand the key issues that have polluted medical care, may achieve great visceral and intellectual clarity, after contracting a very serious illness.
    It is no coincidence that while we rank 37th in the world for quality of care (NEJM, Jan 2010), our medical business (drug companies, insurance companies, doctors, lawyers, politicians, lobbyists, etc.) is NUMBER 1. Cannot have them both. Labs (chemical, tissue and imaging) are huge business.
    Focus is on the bottom line and if quality of care must be sacrificed for shareholders/stakeholders, then why not? Who is stopping them? Is this not the mission of the grim, chief executive and his/her minions, whose equity values apparently eclipse most other things in life?
    For example:
    Look at the incomes:
    Some insider transactions:
    How about that balance sheet?:

    Pretty solid, eh? Go ahead and do this for any medical business whose records are in the public domain; same picture. Try Labcorp, Quest Diagnostics, etc., etc.

  6. John lynch wrote:
    The best solution, in my book, is a massive patient education effort to better equip consumers to avoid being further victimized by whatever financial incentives emerge to drive their doctors’ treatment recommendations
    Maybe pushing the old Christian scientist view would cut down utilization and costs! Seriously though, where is it written that humans must have tons of medical care and drugs to survive well. Public health including proper sanitation may be most of the key. I often wonder just how much we all benefit from this obsession with interventional medical care??

  7. @John Lynch

    I don’t know what you are talking about—since i had athroscopic surgery my knee has been like new. In addition, it was much cheaper than a knee replacemnt.

  8. John–
    All doctors are not alike. There are regional differences, generational
    differences, and different individuals have different values.
    Certainly, for some, maximizing their income is a top priority.
    For others, money simply isn’t the key to self-respect.
    I know a fair number of doctors who are not money-driven.
    For instance, when I started seeing a new eye doctor about 1 1/2 years ago,
    she suggested that perhaps I didn’t have glaucoma after all. (About 25 years ago I was diagnosed with glaucoma and have been using eye drops and undergoing tests ever since.) See this post:
    She suggested that I stop using the eye drops for two months, and come back and see her. We continued the experiment –and she turned out to be right!
    This means that I need to see her only once a year, not every 4 months to have the pressure on my eyes checked.
    What about the original diagnosis? Probably an honest mistake. The problem is that after that, no one questioned it.
    But she stepped outside of the box and asked herself: “If this woman has had
    glaucoma for 25 years, why isn’t it worse?(It’s a progressive disease.) Other doctors simply assumed “the eye drops are working!– great”
    I know a fair number of doctors who are actively involved in the movement to
    reduce spending and improve quality–some at Dartmouth, some other places.
    These days, a growing number of doctors and hospitals participate in “shared decision-making–which means giving patients all of the information about
    risks and benefits when making a decision about elective surgery or tests.
    Research shows that when patients engaged in “shared decision making” (there is a protocol with decision-making aids in the form of videos, pamphlets etc.) they
    are much more likely to decide not to go ahead with the treatment.
    So doctors who follow the “shared decision-making” program are reducing the number of surgeries and tests that they do … Nevertheless many doctors embrace the program.
    There also are regional differences: in some parts of the country, doctors charge more and earn more. Those who are most interested in money are more likely to practice in those places. Some people pick specialities that are not terribly lucrative (pediatrics is a good example.) There is a generational difference: doctors who went to med school in the ’90s realized that “managed care” means that insurers were clamping down on spending. They also realized that they coud make more money in the financial sector. Still,they went to med school. (By contrast those who went to med school at the beginning of the 1980s had very high expectations regarding income. Physicians earnings had been going up steadily, since the late 60s.) Finally, for most women money is not the key to self-respect. Like everyone, they enjoy what money can buy, but they don’t need to earn $1 million to feel
    content. Being thin, being loved are more important. Many women doctors work
    shorter hours because they want to have more time with family. (This is also true of
    some younger male doctors.)
    My point is simply that your generalizations may reflect where you live, or the
    doctors you have known.

    Finally, on specific points:
    We know that ACOs can deliver better care for less. Places like Mayo run what are
    essentially ACOs and if you compare two very simiiar patients –one treated at Mayo, one treated at UCLA(just one example) you find that stays are shorter at Mayo, care is better co-ordinated, there are fewer complications, outcomes are better,and the final bill that Medicare pays is lower.
    We’re just beginning to set up ACOs all over the country. It will take 4 or 5 years to see how they are doing, but the concept is very sound.
    Med students don’t choose primary care because: other doctors (including their teachers) look down on primary care (“a terrible waste of a good mind”; real men become surgeons, etc.) In addition, working conditions for doctors training in primary care and practicing primary care are poor– not enough support (unless they are part of a large organization).
    On walls & cliffs– yes, these are metaphors, but if you follow the economy you know that our economy in the midst of a major recession/depression. The spending and borrowing of the past 30 years (which includes spending on health care, borrowing to build ever-larger and more resort-like hospitals) has taken us to a point where we are heading over a cliff. Most of us are going to be tightening our belts for at least another 8 years.,

  9. Ruth–

    Yes, the U.S. medical industry has been hugely profitable– see my book MOney-Driven Medicine: The Real Reason Health Care Costs So Much.
    . Anyone involved in testing, imaging, medical devices etc. has been doing very well.
    Pharma is not as profitable as it was– too many generics coming to market and the pipeline of new drugs has been drying up.
    Insurance also has not been as profitable– as premiums rise, more and more people cannot afford insurance. So they have fewer customers. Moreover, the underlying cost of care (what insurers pay out to doctors, hosptials, for devices, etc.) has been rising just as fast as they can hike premiums.
    And, under health reform, insurers are going to have a much harder time making money. (Increasingly, they’ll have to cover “essential benefits” that many policies don’t now cover.When covering large groups they’ll have to pay out 85% of premiums for medical care–or refund customers. They won’t be able to keep more than 15% for administrative costs,salaries, profits, etc. Finally, they won’t be able to turn down customers suffering from pre-existing conditions–or charge them more.)
    Many for-profit private sector insuers wil get out of the business.Others wil have to find a new business model, hooking up with Accountable Care Organizations and working wtih provides to try to keep patients healthy, and costs down…
    But you are right, our health care system is largely money-driven. We are the only developed country in the world that decided to let healthcare become a largely
    unregulated for-profit enterprise.
    This, however, wil be changing.
    Over the next 10 years, I expect we’ll see the FDA getting tougher as it regulates the
    drug & device industry. Medicare is going to be shaving payments to hospitals (reducing inflation increases by 1% a year). And under the ACA, the Secretary of HHS has the power to cut the fees Medicare pays for “overvalued services.”

  10. NG & John, Marc

    NG & John–
    I totally agree that patient education is essential. Both doctors and patients will need to change how they think about medical care. As patients become aware that
    “more care” is not necessarily “better care” they will seek out like-minded
    doctors. Med school education also will have to change.
    But again, this will take time. I would hope to see a real culture shift over the next 10 years—though the change will happen sooner in some parts of the country than in others.

    Marc– I believe you. Conservatives wil use any catchy phrase that they can find, even if they don’t understand (or bother to think about) what it means.
    But they didn’t “coin” patient-centered medicine. It’s something that the reserachers at Dartmouth and former Medicare director Don Berwick have talked about for
    a long, long time.

    The key to the phrase is that the patient is just that– a sick person who needs help. He is not a savvy consumer. He is not a bargain-hunter. He and the seller are not vying with each other to see who can make a better deal. In other
    markets “caveat emptor “appies. But healthcare is not like any other market, and for heathcare to work, the doctor-patient relationshp must be based on trust as they work together toward single goal– comfort & cure–,all the
    time putting the patient’s interests first.

  11. It is very interesting that some of the reasons listed to do unnecessary lab tests include curiosity, insecurity, frustration at nothing better to do since it is unknown what is wrong with the patient, and buying time to think on what could be wrong with the patient. Working in a teaching hospital, I feel that much of the testing we do are unnecessary! Lactic acids every 6 hours do not change that much! This is just one of the many orders I feel are unnecessary. However, as a nurse, I also feel that it is my duty to be proactive as the patient’s advocate and as an asset to the company in keeping down costs to question the physicians on some of the orders that could be avoided or to inquire why we are doing such tests. I can also offer options or my opinion without penalty. Yes, there is still much to be done about this in the healthcare realm, but I believe that is where your nurses can help and we do most of the time! On the other hand, there are times that testing needs to be taken further and physicians refuse! Case in point, a friend of mine took her 2 year old to the doctor multiple times over a large lump on the child’s neck and all the physicians constantly reassured her it was a lymph node and would prescribe an antibiotic. The spot kept enlarging to the point she went to LeBonheur Children’s Hospital here in Memphis and demanded they do a CT scan because something was not right. And indeed the mother was right and it was a cancerous tumor on her 2 year old’s neck. This is clear evidence that physicians do not always listen and do the right thing because they think they are right, not the patient.

  12. What is necessary for a patient to opt out of tests that he previously believed were necessary? A good doctor/patient relationship based upon the physician treating the patient as an individual rather than as part of a group. With all the emphasis by government, HMO’s, etc. on cost reduction it appears as if the physician is more responsible to a third party than to the patient. That seems to inhibit what many are trying to promote. All the parties involved have been tainted because of the breakup of this relationship and the third party relationships.