The woman's wheeze was a head-turner, audible from across the emergency department. Along with a hacking cough, the musical, whistling sound prompted her to leave the children asleep with her sister one night and seek relief at the E.R.
Inhaled medicines were able to quiet her lungs, and with a clear chest X-ray and easy breathing restored, the diagnosis was simple: acute bronchitis.
While diagnosing bronchitis, a common respiratory infection, is often easy, treating the condition is more difficult. Medicines may calm the symptoms, but the only cure is time. Most notably, antibiotics, though commonly prescribed, are no better than a placebo for bronchitis. Yet discussing this can be a bit of a minefield for physicians, particularly when patients are used to antibiotics for such infections. So when I sat down to talk to my patient, I was surprised when she cut me off.
"If it's O.K. with you" she said, wiping her nose with a tissue, "I'd like to avoid antibiotics, with all those side effects."
An hour earlier I had cared for a violinist who struck his head (but saved his instrument) during a fall. After a neurologic examination was normal and I had sutured a small cut, he and I discussed the possibility of a CT scan to detect rare hidden injuries. We also discussed the alternative: Spend the evening with a friend and come back if symptoms appear. He chose to skip the scan.
See a trend here? So does Dr. Michael Barry, president of the Informed Medical Decisions Foundation, a nonprofit group that promotes sound medical thinking. "People are more receptive to conversations about medical interventions having both pros and cons" says Dr. Barry. "Traditionally, newer and more aggressive interventions were often assumed to be better." But there are hints of a shift, he says: "When patients are fully informed, they tend to be more conservative."
After decades of presuming that more health care leads to better health, public consciousness may be moving toward a leaner view.
Today, a group of nine medical specialty boards is recommending that doctors perform 45 common tests and procedures less often, and is urging patients to question these services if they are offered. The move is the latest by the medical community to acknowledge that many tests and procedures are performed unnecessarily, leading to excessive costs, false positives, additional testing and even harm to patients. By some estimates, unnecessary treatment constitutes one third of medical spending in the United States.
Dr. Barry, whose editorial on shared decision making was published last month in The New England Journal of Medicine, believes patients are ready to hear the message. He cites popular books like "Overtreated," by Shannon Brownlee, and "Overdiagnosed: Making People Sick in the Pursuit of Health," by H. Gilbert Welch. These are among a slew of books in recent years written by health experts on the dangers of the "more is better" attitude about health care.
Dr. Barry also points to news reports that may also be shifting attitudes. In just the past year, medical headlines have covered record-setting fines paid by pharmaceutical companies, the overuse of potentially carcinogenic medical radiation, medical device recalls and the rise of prescription drug deaths(which now outnumber illicit drug deaths). Even once-sacred interventions like screening for cancer are under scrutiny, with a better understanding of both limited benefits and growing harms. That randomized trials of prostate specific antigen (PSA) testing, for instance, had shown little or no lifesaving benefit was hardly noticed until last year, when the United States Preventive Services Task Force drew attention to sexual and urinary problems and prostate biopsy complications, all common fallout from positive PSA results.
Emerging research supports the trend: The Cochrane Collaboration, a leading medical review group, last month published the results of a review of more than 20,000 patients in studies of "decision aids," communication tools meant to prepare people for treatments by explaining potential benefits, harms and uncertainties. The studies showed that patients using decision aids more often declined interventions like surgery and cancer screening, choosing more conservative options instead. Patients also reported better communication, fewer conflicts and a better understanding of risks.
This month, physicians and experts from around the country will convene in Boston for "Avoiding Avoidable Care," the first major medical conference to focus on the perils of unnecessary and unhelpful medical care. Dr. Vikas Saini, president of the Lown Cardiovascular Research Foundation, who with Ms. Brownlee, the author, organized the conference, described it as a response to growing scientific and social consciousness. "It's the zeitgeist," he says. "People from all around, including Shannon and I, felt isolated without a way to connect and grow these ideas. There is no 'Journal of Overtreatment' to bring these concepts and people together."
The movement toward a more restrained view of medical care raises an obvious question: Could improved communication, informed patients and increasing health literacy help to slim down a bloated system — and improve American health? As a physician planning to attend the Boston conference, I am hopeful.
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