This Won’t Hurt a Bit
When the White House and Congress were struggling last year to keep the cost of health-care reform from exploding, they got most of the industry to ante up. Pharma agreed to give up $80 billion in revenue over the next decade, hospitals kicked in $155 billion in foregone Medicare and Medicaid payments, and medical-device makers grudgingly agreed to a $20 billion tax. But one big player refused to put any money on the table: doctors. The American Medical Association pledged to support health-care reform only if its members’ incomes didn’t take a hit.
That doctors demanded protection for their wallets strikes Howard Brody, a family physician at the University of Texas Medical Branch, as "ethically questionable," and not only because he thinks doctors have a moral obligation to help get the nation’s health-care bill under control. The bigger problem is that "doctors rip off the system with inappropriate care," says Brody. An estimated one fifth to one third of U.S. health-care costs, at least $500 billion a year, goes toward tests and treatments that do not benefit patients—routine CT scans in the ER, antibiotics for colds, Pap tests for women who do not have a cervix, and …
What comes after the ellipsis is the question of the hour. Brody recently proposed, in The New England Journal of Medicine, that every medical specialty identify five procedures—diagnostic or therapeutic—that are done a lot and cost a lot but provide no benefits to some or all of the patients who receive them. Five is just a suggestion, high enough to be meaningful but low enough to exclude procedures in which the science is still open to debate, such as annual mammograms for women under 50. "I’m pretty convinced that each specialty could come up with 15 or 20, but in calling for five I think we can find uncontroversial ones," says Brody. It’s not just about saving money, either. Any time a doctor performs a procedure, there is the risk of medical error and side effects, such as an elevated risk of cancer from CT scans. Unnecessary care kills 30,000 Americans every year, estimates Dr. Elliott Fisher of Dartmouth Medical School—and that figure includes only Medicare patients.
Medical groups have not exactly beaten a path to Brody’s door, so NEWSWEEK contacted several to see if they would play along. Reactions ranged from "we do no unnecessary care" (dermatology) to "only five?!" (emergency medicine). Allen Lichter, CEO of the American Society of Clinical Oncology, nominates what he calls "nth-line therapy"—the third or fourth or fifth chemotherapy drug for a patient whose cancer has not been felled by the first or second. "I don’t know what n should be," he says. "But at some point chemotherapy has an extremely low chance of extending life and a high chance of shortening life due to toxicity."
Experts in internal medicine are already well along in identifying items for Brody’s list. "I hate to say it, but it’s true: doctors sometimes do things that do not benefit patients and can even be harmful," says Stephen Smith of Brown University medical school, who is spearheading the effort. Nominations, all from physicians, include antibiotics for upper-respiratory infections (the drugs kill bacteria, not the viruses that cause colds), Pap tests for women under 21 ("solid research shows that they find things that lead to unnecessary interventions but would clear up on their own," says Smith), and me-too drugs that are no more effective than older versions (anything other than diuretics for first-line treatment of high blood pressure).
High-tech tests are also in Smith’s crosshairs. For coronary calcium scans, he says, "there is no evidence they lead to better outcomes. In low-risk patients, high coronary-artery calcification still means the patient is at low risk for heart disease and nothing needs to be done other than the usual ’heart healthy’ behaviors. In a high-risk patient, aggressive efforts at reducing risk factors need to be undertaken regardless of the coronary-artery calcification." Similarly, thyroid testing in a patient with no symptoms "rarely yields an abnormal result," Smith says, and so "is not worth doing" on a symptom-free patient. Smith’s team will "field test" these and other nominees this spring by asking hundreds of doctors if they agree. Eventually, docs who pledge to avoid unhelpful procedures might display some sort of emblem.
词句笔记：
ante up:下注付款
toxicity:n. 毒性，毒效
spearhead:vt. 做先锋，在前面带头做先锋
crosshairs:(瞄准镜)十字准线，交叉丝
field test:vt. 对 ... 作现场试验
