What to Do About the Overtreatment Epidemic
What follows is not the column I intended to write. I originally planned to complete a piece about another topic, but then I found myself unexpectedly on an outpatient-surgery table.
Let me cut to the chase: I have nothing to worry about. A couple of weeks ago my dermatologist biopsied a small mole on my thigh that I’ve had for as long as I can remember. It looked subtly different from my last exam and turned out to be a dysplastic nevus with clear margins—essentially a pigmented skin lesion that exists somewhere in the gray zone between a benign mole and melanoma.
Now, if you’re like most people I know, you read the word “melanoma” and all you can think about is a form of life-threatening cancer. You can’t consider the possibility that this mole is possibly one step removed from completely benign.
My dermatologist is just like you. She referred my case to a dermatologic surgeon for a second excision (taking a larger and deeper border around the original biopsy) before she even spoke with me. In fact, she never told me the outcome of the biopsy. Instead her resident gave me the results—clearly assuming I would simply listen and then move forward with the treatment recommendation.
But it turns out I’m more curious than the average patient and decided to first read the research before acting on her advice.
Researchers who followed 33 melanoma-prone families for 25 years found the annual transformation rate of any single nevus into melanoma ranged from less than 1 in 200,000 for both men and women younger than 40 to about 1 in 33,000 for men over 60. In addition, the lifetime risk of any selected nevus transforming into melanoma by age 80 (for a 20-year-old) was about 0.03 percent for men and 0.009 percent for women.
In other words, the risks were extremely low that my nevus would ever become malignant melanoma. And, since I religiously have regular skin exams, any additional skin changes would be caught in the early stages.
Yet, I still found myself on that outpatient-surgery table.
Why? Every person I conversed with about next steps answered with the same catchphrase: “Better to be safe than sorry.” This included several physicians, friends in the medical field and a well-respected HR leader.
I couldn’t find one person who would consider the objective research I shared. Nor did they weigh the risks associated with the second excision, including slow-healing ulcer, bleeding, pain, infection, permanent visible scar, depressed scar, numbness, recurrence and the possibility of additional surgery.
Despite all the above, here’s what continues to bother me: I met my surgeon already somewhat prepped for surgery. He reviewed my case with me and said the research indicated this procedure wasn’t necessary—exactly what I’d been trying to discuss with anyone I trusted. Yet, even though he had strong misgivings, he believed we should respect my dermatologist’s opinion.
You may be wondering why this well-informed patient didn’t protest. And so am I. Maybe it is because it’s somewhat challenging to take a strong stand when you literally are speaking with a person of authority when you’re half-dressed. Perhaps I was simply worn down from over a week of arguing. Regardless, I caved in.
We continued to talk during the procedure and there came one moment, right after the scalpel sliced into my thigh, when both of us realized we shouldn’t be doing this. But now there was no going back.
So, I sit here writing this column with 16 sutures and an ice bag on my lap. And I’m not allowed to engage in any physical activity for two weeks until my suture line is well-healed.
I share my personal experience with you because I have yet to come up with even one policy or procedure that could have gotten my dermatologist to consider more than one possibility, or my surgeon to call and question my dermatologist.
We have efforts like Choosing Wisely and the Task Force on Low-Value Care, but these platforms are only as helpful as the information contained within and the doctors’ willingness to discuss and apply the recommendations.
My surgeon sent me a copy of his surgical notes. As I read through them, something caught my attention. Twice, my surgeon referenced using the World Health Organization’s surgical safety Time-Out procedures. This included confirming my name and date of birth along with the site, side and surgical tray prior to administering anesthesia. Then, a second Time-Out took place before the incision when I confirmed my name and date of birth.
Here’s what I realized. My surgeon should have shared a Time-Out with my referring dermatologist—especially since he did not agree with the need for this surgery. You could argue that he didn’t know my full medical history, but you would be mistaken. It was clear he’d read my entire record. It was also evident that he didn’t want to challenge another physician’s opinion.
If we are going to address overtreatment and the associated medical costs, we can’t simply shift more costs onto our employees in the hope they will question how they spend their healthcare dollars. Patients cannot easily discern the difference between overtreatment and undertreatment.
A 2017 research study published in PLOS One on overtreatment in the U.S. indicated that, on average, physicians believed 20.6 percent of all medical care was unnecessary, including 22 percent of prescriptions, 24.9 percent of diagnostic tests and 11.1 percent of procedures. Of the doctors studied, 27 percent perceived that at least 30 percent to 45 percent of overall medical care is unnecessary.
Almost 85 percent of the surveyed physicians said the reason for overtreatment was fear of malpractice suits, but that fear is probably exaggerated, according to the authors. Only 2 percent to 3 percent of patients pursue litigation, and paid claims have declined sharply in recent decades.
Nearly 60 percent of doctors said patients demand unnecessary treatment. A smaller number (38 percent) thought that limited access to medical records led to the problem. And more than 70 percent of doctors conceded that physicians are more likely to perform unnecessary procedures when they profit from them, while only 9.2 percent said that their own financial security was a factor.
Doctors offered several recommendations to stem overtreatment, including training medical residents on appropriateness criteria, providing easy access to patients’ medical records, developing more practice guidelines and minimizing fee-for-service bonus pay (while increasing base salaries).
I will add a final recommendation. We have to encourage open discourse among physicians—and find a way to reward them for it. Otherwise, every day, employees like me will find themselves on surgical tables when safer and less-costly options exist.