Less is More

Los Angeles County Hospital has been one of the largest public hospitals in the country for decades. It’s a big, unionized hospital. In perpetual deficit (just like the great state of California itself). With public employees constantly making demands for more wages and lifetime benefits that it is now evident that the hospital and taxpayers could never possibly afford.

So these public employees, ostensibly performing critical jobs, regularly went on strike. Which seems like a tremendous danger to public health. So I was initially surprised back in the 1980’s when studies showed the exact opposite.

Whenever the hospital closed down due to strikes, the death rate in Los Angeles County actually decreased!

But it’s really not such a surprise. Particularly when you begin to realize just how much of medicine is dangerous, unnecessary, and downright counter-productive. Granted, this example is “old news” by now. But more and more evidence emerges all the time that, for many people, less medical care may be better for your health.

Just three months ago, nine physician groups around the country initiated a campaign called “Choosing Wisely.” Which removed nearly 50 tests and procedures from their inventory of doctor’s orders. All of them deemed useless, counter-productive, redundant, or potentially dangerous.

And here in Boston, the much admired Massachusetts General Hospital (MGH) recently informed its doctors that they were ordering more potentially dangerous x-rays than their colleagues at less famous hospitals. MGH suggested to their doctors that, since they are among the nation’s best, they could—and should—do more with less.

But this movement is nothing new. Dr. Bernard Lown first began developing the concept of what he now calls “Avoidable Care” 60 years ago. Here are four of his basic tenets with my own additions:

  1. In the real world, most of the problems that bring someone to a doctor are minor. And the vast majority of them are healed simply by the passage of time. This is the basic theory behind Hippocratic medicine. (Which was the norm for nearly 2,000 years.) The ability of the body to heal itself. In fact, one of my own tenants for so-called “alternative” medicine is that self-healing is the basis of all healing.
  2. Just a carefully taken history and physical exam identify the underlying condition in the overwhelming majority of patients. Without the need for invasive, expensive, high-tech tests of any kind. I remember working in the former British Malaya in the 1970’s. There was no modern medical technology. But British-trained physicians could look at a patient from across the room and have a “working diagnosis” by the time they reached the bedside. And most of the time they were right! They only needed the history and physical to confirm it.
  3. Much of the information doctors rely on is epidemiological and statistical. But statistical fact is not the same as individual truth. Statistical data, regardless of how “comprehensive,” may not be relevant for the individual patient. This is one reason why today’s “evidence-based” medicine trend is being called “junk science” by some. It does not account for personal differences. Or the fact that not only is each person different, but different in a unique way. Individuality is another important lesson from so-called “alternative” medicine.
  4. The more time invested by the doctor at the outset, the more effective and less costly the treatment. The lower the number of referrals to super “sub-specialists.” And the fewer requests for expensive, potentially dangerous technologic procedures. And, ultimately, the more satisfied the patient.

Dr. Lown’s opposition to a lot of standard medical practice was in part provoked by the growing prevalence of overtreatment. To him, using excessive interventions as a first resort, instead of a last resort, seemed to be a bastard child born of the mother of technology and the absent father of market medicine. (Aided and abetted, of course, by our favorite “uncle,” Sam. Who continues to funnel huge taxpayer subsidies into the kind of research and practice that is bankrupting us. And completely ignoring legitimate alternatives that would represent true “health care reform.”)

When Dr. Lown started 60 years ago, this kind of overtreatment was just a trickle. But over time it became a flood. And it’s now a tsunami threatening not only the viability of our healthcare system, but of our national economy and society.

One of Dr. Lown’s landmark findings regarding overtreatment involved what has long been the most common medical problem in America—heart disease. Although Dr. Lown first published these results in 1952, his conclusions weren’t widely accepted until a decade ago.

In the meantime, keep the idea of “Avoidable Care” in mind when you go to the doctor. And before your next physical exam, be sure to review the list of tests and procedures included in the “Choosing Wisely” campaign. (You can read the complete list here.)

You may save yourself much more than a hefty insurance co-pay.