How much medical care do we want in our lives? H. Gilbert Welch poses this question in his excellent op-ed piece for the LA Times entitled, “The Medicalization of Life” and tells us that the answer will be vitally important for reining in the spiraling cost of health care.
We’ve written a lot about cutting out the waste and over-treatment that is inherently part of our profit-driven health care system. The culprits are clear: Too many scans, too many diagnostic tests, too much surgery and too many prescriptions for expensive new drugs. But despite increasing evidence of where cuts can be made, we’ve always assumed that Americans help drive health care spending with their constant demand for newer and more advanced treatments and technologies.
Welch, professor of medicine at the Dartmouth Institute of Health Policy & Clinical Practice, is asking us to take a far more critical view of these advances and the relative risks and benefits they have to offer. Author of the book, “Should I Be Tested for Cancer,” he is part of a growing movement that encourages “just saying No” to routine tests, treatments and surgeries that have little benefit and may even cause harm—and saying “yes” to watchful waiting, lifestyle changes and in the end of life, palliative care.
In his op-ed, Welch highlights two points in life when medical care can be the most intensive and intrusive: birth and death. Of birth, he says;
“Two of the most common tests preformed on pregnant American women are obstetrical ultrasound and electronic fetal monitoring. After reviewing experimental studies involving more than 27,000 women, the Cochrane Review — an independent, international collaboration that summarizes evidence for medical procedures — found that routine late-pregnancy ultrasound ‘does not confer benefit on mother or baby.’
“But it does do a good job of scaring expectant parents.” The scans pick up minor anatomical abnormalities that can, in rare instances, signal a serious genetic problem like Down syndrome. This leads to anxiety for parents and further testing and interventions for the fetus—even though, says Welch, “minor anatomical abnormalities are about 30 times more common than the genetic disorders they have been associated with.”
Routine fetal monitoring also fits into Welch’s view of the over-medicalization of birth. In their latest clinical guidelines, the American College of Obstetricians and Gynecologists (ACOG) notes that routine use of electronic fetal monitoring grew from 45% in 1980 to 85% in 2002. Despite that increase, fetal mortality and the incidence of cerebral palsy have not decreased. In fact, the false positive rate in predicting cerebral palsy with fetal monitoring is “greater than 99%” according to ACOG—meaning that only one or two out of 1,000 fetuses with “nonreassuring” monitor readings will actually develop cerebral palsy. Most of them will end up delivered through C-sections or with forceps. And although fetal monitoring can sometimes predict seizures, Welch notes that 100 extra women will undergo C-sections to avoid just one seizure.
“The increase in fetal monitoring is part of the explanation for why the beginning of life now involves major surgery one-third of the time,” he says.
The medicalization of the end of life has been well-documented. Spending on the last year of life makes up one-third of all Medicare expenses and dying patients routinely see 10 doctors or more during their last six months of life. They undergo countless tests, surgeries and other treatments—often to end up dying in the ICU instead of at home in peace.
To answer Welch’s question about how much medical care we want in our lives, it’s first important to lay out the risks and benefits. Evidence is accumulating that some of the tests and treatments we once considered beneficial are now questionable in many cases: MRIs for back pain, prostate cancer screening, yearly mammograms under 50, cholesterol-lowering drugs and diabetes treatments—just to name a few. In order to make our choices we must have better evidence-based information and unbiased guidance from practitioners.
“Medicalization is the process of turning more people into patients. It encourages more of us to be anxious about our health and undermines our confidence in our own bodies. It leads people to have too much treatment — and some of them are harmed by it.
And it's big part of the reason why medical care costs so much.”