This difference is apparent when you read Atul Gawande try to muddle through conceptual landscapes which are plowed and planted by physicians, endocrinologists and oncologists in particular, and he gets swallowed up in sink holes he simply does not know how to avoid.
He does not distinguish between waste in medical practice which occurs because doctors have decided to rape the system by buying medical machines (MRI's, CAT scans, what have you) and various profit centers (rehab facilities, etc) and then pumping every patient through the door in the direction of these profit centers, between these sleazy if not illegal forms of waste and the "waste" which occurs because doctors do not have crystal balls to tell them which patients with "cancer" will get into trouble and who will not.
Gawande takes full credit for shining the sunlight on the nefarious doctors of McAllen, Texas, who were sending every patient for the most expensive tests because they profited directly from owning the facilities to which those patients were sent. In the case of that sort of avarice, the role of sunlight is indisputable.
But then Dr. Gawande spins off into something entirely different. He claims all our efforts at diminishing deaths from breast cancer and thyroid cancer have been worth nothing, that mammograms are diagnostic overkill and that surgery for thyroid cancer does nothing to benefit the patient. Even carotid artery surgery to prevent stroke does not live up to Dr. Gawande's expectations. His mantra seems to be if the patient has no symptoms and is not currently bothered by his or her cancer, or has not yet had a stroke, then it is not worth treating to prevent bad things from happening. One wonders what he thinks of treating hypertension to prevent stroke.
The fact is, there are plenty of studies to suggest breast cancer death rates are falling and falling more among women who get mammograms and less among those who do not. In the care of thyroid cancer, the problem is about 1400 people die from thyroid cancer out of the tens of thousands every year who are diagnosed with it and we do not have technology which distinguishes between the cells we call "thyroid cancer" which act more like warts from those which metastasized and kill people, which look no different from the indolent variety.
Gawande has so little insight into how medical care is delivered (as opposed to surgical care) he insists that primary care providers are the solution to over use of expensive tests, which, in fact could not be further from the truth.
He is clearly under the thrall of Dr. H. Gilbert Welch, the Dartmouth "expert in overdiagnosis" and "centers for excellence" like the Geisinger Medical Center, with which Walmart has contracted to see patients with back pain and other complaints. Dr. Gawande believes the Walmart approach results in less "unnecessary" effort, when in fact one wonders whether it simply is a way for Walmart to reduce costs and Geisinger to increase its own income. He is long on anecdote and short on data when it comes to the "centers of excellence."
The fact is, there once was a time when you had to be a neurologist to order a CT or MRI of the head, the exams were so expensive and the machines so over worked, but now every physician's assistant and nurse practitioner has only to click a box on her EMR and the deed is done. Dr. Gawande mentions a patient he saw who had been sent for an MRI of her neck after a fine needle aspiration had demonstrated thyroid cancer--clearly a worthless test. But who does he think orders the lion's share of these worthless tests? Certainly not the company WellMed, which has paid physicians to avoid ordering expensive tests by paying them to spend more time with patients to avoid ordering such tests. "Step by step...his team [was] replacing unnecessary care with care that people needed."
Oh, you have no idea, Dr. Gawande. Truly, honestly and plainly not.
What I see every day is not what Dr. Gawande wants to believe: He believes humble is always best, so the NP or PA will take the time to listen to the patient and not order expensive tests or consultations. In fact, those "physician extenders" or whatever you want to call them are the mot likely to order tests which add little to the decision and simply add cost. The whole system of certifying practitioners plays a role in this very complicated miasma: Anyone who passes his boards in whatever is as good as anyone else in the eyes of the powers that be, but the fact is, what I see is people who have trained in what I can only snobbishly refer to as, "less selective" training programs tend to order every exam in the book because they have never had the discussion with really insightful professors about the nuances of diagnosis which constitutes "good training." These folks are "certified" but not well trained, and they order extravagantly.
Dr. Gawande ends his piece with a vignette--he is very strong on anecdote--about a young woman who had microcarcinoma of the thyroid, which current consensus suggests does not require complete removal of the thyroid, but because she feared dying from thyroid cancer, he went ahead and did what she wanted.
To be fair, he is caught in a modern bind: In the age of the patient being part of the team, of not allowing the doctor to be "paternalistic" and dictating to the patient what needs be done, of involving the patient in significant decisions, he went ahead and took his directions from her and did "unnecessary surgery."
Heaven forbid, we listen to the patient.
But he did what he criticizes others for doing--he acted in defiance of the statistics to do what the patient wanted.
I am about to fly off to a week long conference where I will sit in conference rooms listening to pundits like Michael Tuttle of Memorial Sloan Kettering analyze difficult cases of thyroid cancer and I'll hear Ian Hay from Mayo Clinic rail about over treating microcarcinomas and late recurring lymph node metastases and if the past is any guide, by the end of the day, my head will be swimming because, when it comes down to individual cases, there is always something to make the decision tough.
When it comes to "unnecessary" tests and treatment done by entrepreneur doctors like those in Texas, the solutions are easy and administrative. Sunshine really is the best disinfectant for these sorts. But when it comes to the well meaning practitioner who is not motivated by profit, but who is simply not well enough trained and versed in current thinking to know when to order what test, the solutions are more complicated.
And even the best trained, most up to date practitioner will order unnecessary tests because the technology is limited. When I send a patient to surgery because her fine needle aspiration biopsy showed "thyroid cancer" but once the gland is removed and the whole lump is examined it turns out to be benign, that was unnecessary surgery. It was unnecessary because the patient did not have the disease we feared she had but we did not have any better way of knowing that, short of surgery.
What we really need is better technology when it comes to malignant disease. What we've had until very recently is the light microscope doctors were using since the late nineteenth century. Cells were defined as cancer, for the most part, by their appearance under the light microscope. But some nasty looking characters turned out to be pretty harmless and some, which looked no more dangerous, ravaged patients. We've known for some time what we really need is genetic analysis to predict which cancer cells will behave aggressively. Now we have some of those, but the reliability of these tests is still being evaluated and if we use them, Dr. Gawande and Dr. Welch from Dartmouth will accuse us of running up the bill, piling on and doing "unnecessary" tests.
Dr. Gawande is a certified "genius" (a MacArthur grant recipient) and he publishes in one of the best journals extant in this country, The New Yorker. And still, he gets it wrong and the New Yorker aides and abets the crime. The New England Journal of Medicine would have sent Dr. Gawande's article to a "reviewer" or "referee" who would, assuredly, have rejected it. Had it been published, there would have been extensive letters to the editor in a follow up issue with Dr. Gawande's responses. In the age of connectivity, there would have been a real discussion. Sadly, we do not have that when medical topics are discussed in the world outside the rigors of academia.
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