COVID has meant less health care. What does that mean for our health?
“Doc, I don’t want to go for that echocardiogram, I’m afraid I’ll get COVID if I go into the hospital.”
It’s a common complaint from my patients - and I’m far from alone. Patients all over the country are cancelling tests that they’ve planned or simply not showing up for ones that they’ve scheduled.
About half of all adults in America have postponed medical care due to concerns about COVID-19. As a result of this loss of revenue, hospitals are hemorrhaging money, medical practices are closing, and people are losing their jobs. Federal bailouts for hospitals and health systems have totaled in the tens of billions.
And even though this has fixed some of the financial shortfalls the systems are facing, individual doctors and many hospital employees are going to feel the financial belt tightening effects for years.
The financial fallout from COVID has illuminated a few longstanding problems in our healthcare system:
We perform a huge amount of unnecessary medical care that doesn’t do much to make patients feel better or live longer
Financial incentives for hospital systems are driven by short term concerns - procedures, visits, medications, and testing - rather than long term outcomes
Hospital business plans are based on finding patients with good insurance and providing “elective” care to them
As a result, even though half of all American adults have postponed care, only about 11% report that missing care made their health worse.
The latter two of these problems - the financial incentives in the system and the need for hospitals to optimize their “patient mix” - I’ll write about at a later time, but I wanted to focus this newsletter on the first problem: unnecessary medical care.
Why do we perform so much pointless medical care?
Before I got into the healthcare system, I don’t think this I appreciated how much of what doctors do is simply dumb and pointless.
I would divide unnecessary medical care driven by physician decisions into a handful of buckets:
Decisions that are driven by concerns of missing something or being sued
Things that we do because that’s how it’s always been done
Things that we do because we think they work even though the evidence says that they don’t
Treatment plans that are started because “we need to do something”
Let’s take a look at each one in turn.
Fear of missing something
Doctors do all kinds of tests because we’re afraid that we’re going to miss something. Although fears of medical malpractice cost the system tons of money, it only amounts to about 3% of all healthcare expenditures.
But I actually think most doctors are more worried about missing a dangerous diagnosis in a vulnerable patient than they are about practicing CYA medicine.
When you report chest pain or trouble breathing, you get a whole bunch of different tests done - chest X-ray, nuclear stress test, echocardiogram, CT scan of the chest - not so much because the doctor is worried about being sued, but because no one wants to miss the rare patient who has a life threatening pulmonary embolism or critical coronary artery disease.
Of course we do too many tests on patients who have a low probability of disease. The evidence is clear on this. But doctors remember the times we screwed up and missed something, not the CT scans that we dumbly ordered.
That’s why the Choosing Wisely campaign was started - as a way of systematically identifying low yield medical testing and treatments to help doctors waste less money.
Things that we do because that’s how it’s always been done
“Because that’s how we’ve always done it” is probably the dumbest answer to the question of “Why?” that exists. But welcome to the world that we live in.
The best example of this that I can think of is preoperative testing and evaluation. I see a ton of patients in my office and in the hospital who are coming in for a “preoperative cardiovascular evaluation.”
I think that preop medicine is by far the dumbest thing that I do. We know from extensive study that preoperative evaluations are overused, wasteful, and are more likely to make outcomes worse than to make them better.
That doesn’t stop patients from coming into my office because the ophthalmologist wanted them to see a cardiologist before cataract surgery or the surgical team from consulting me at midnight to see a patient before hip surgery to treat an unstable fracture.
Things that we do even though the evidence says it doesn’t work
The medical literature documents tons of examples of ways that our care is wasteful and useless.
Fake surgery is as good as real surgery for some knee problems
When cardiologists are away at national meetings, there’s some evidence to suggest patients with heart attacks do better
Antidepressants prescribed to millions have real side effects and questionable real benefits
The threshold that we use to adopt new treatments or technologies must be higher in medicine than it is in other industries because of the asymmetry in knowledge between practitioner and patient.
The low bar that we use to accept a treatment into practice leads to an unacceptable amount of medical reversal that wastes money, makes patients worse off, and undermines trust in the healthcare system.
“We need to do something”
Doctors are frequently perpetrators of the Politician’s Fallacy:
We must do something
This is something
Therefore, we must do this.
When a patient comes to you with a complaint, it’s much easier to prescribe a medication than not to prescribe one. People want an answer, not a reason why your possible interventions are pointless.
This is part of why antibiotics are so overprescribed - when you go to the doctor with symptoms of a viral illness, you want medication and not the reassurance that it will go away on its own after a few days.
You can extend this fallacious reasoning to things like annual stress tests or screening CT scans for lung cancer. There are examples in every field of how we do pointless things because a visit to the doctor feels like it should end with a new prescription or a new test.
The end result is that a lot of what doctors do can be a waste of time and money for both the patient and the physician. Sometimes these things even lead to worse health outcomes.
I think that COVID has taught us about minimizing the amount of nonsense that we do to focus on the most important things, but I fear that as we move past the pandemic, we’ll be back to our wasteful ways once again.
PS: If you’re enjoying my newsletter, please share via email and on social media and encourage your friends and family to sign up!