Ezra, I'm with you on the effectiveness. There's plenty of expensive (and painful) procedures that have been proven to not work. Some kinds of back surgery especially. The New Yorker had a great article on that a while back.

It's best to leave the placebo deal out of it.

I know it seems like patients always demand something, surgery or pills or potions or whatnot. When none of those will work, what doctors need is the time to explain the truth, and the time to show a little basic human compassion.

I think that is the main premise in overtreated. People demand medicine that not only is harmful but expensive coupled with the financial incentives doctors have to overtreat sickness and you have the system we have now.

I'm a social worker and I work with a lot of doctors. I see 3 things driving unnecessary care.

First, they feel like they have to do something when they have a patient in front of them asking for help. Often there is nothing that they can do, or they can not get the right services for the patient (say, substance abuse treatment), so they prescribe a psychotropic and the patient and the doctor feel like something was done, even if it's of no value. There's also a way in which these practices have become a substitute for a real relationship between the patient and doctor.

Second, like all professional disciplines, they tend to overestimate the effectiveness of the tools of their profession. As you suggest, better research on outcomes would help, but there will always be resistance among physicians in this area.

Third, I'm not an expert on malpractice, but I suspect that physicians overestimate their chances of being sued. Their fear of malpractice is very real and, particularly in psychiatry and even more so in emergency settings, plays a powerful role in their decision making. As illogical as it sounds, providing dubious treatment is often a risk management strategy.

"if a hypochondriac walks into a doctor's office"

ezra, what do you mean exactly,
by a hypochondriac?
what about,
"an ounce of prevention is worth a pound of cure."
first, my only knowledge of health care is what i have learned through my "hypochondria...."
but in defense of hypochondriacs, what are we, anyway?
in some ways, i wonder whether the preventive aspects of maintaining one's health, due to hypochondriacal concerns, doesnt lead to greater cost efficiency down the road.
for instance, a hypochondriac may go to the doctor sooner to have an unusual or disturbing symptom checked out, than someone who pays little attention or remains in denial, and waits to the point that a potential situation has worsened or bloomed into a crisis.
have any studies ever been done on that?
second, nowadays, how can one not be a hypochondriac? and what does that actually mean?
does it mean that when you experience a new or strange symptom, you are concerned/anxious/panicky????
perhaps, a moderate amount of hypochondria serves people well.
also, people are more knowledgeable, (i think) nowadays....and with the advent of the internet, even the most casual symptom can be an indication of looming or impending disaster.
perhaps, " a hypochondriac," is actually a more cost-effective and "attuned" and health-conscious patient in the longrun, in terms of prevention and follow-through.

final word,
may all "hypochondriacs" find courage and peace in a world of mysterious microbes, suffering and adversity.:-)

epitaph of a hypochondriac:
"i told you i was sick."
:-)

The homeopathic principle, which is like cures like, stands. Does not matter whether the "remedy" is in the form of a literal "sugar pill" coated with with the homeopathic medicine of a specific substance, or whether it is life constantly "giving" us similar challenges to heal our underlying state (what REALLY needs to be cured). This principle is universal - it not only applies to people and animals, but to countries as well.

Real "sugar pills" have healed many patients over the last 200 years!

but in defense of hypochondriacs, what are we, anyway?

Generally, they are people with very few friends because no one wants to spend time with someone who is constantly talking about their real or perceived health problems.

a hypochondriac may go to the doctor sooner to have an unusual or disturbing symptom checked out, than someone who pays little attention or remains in denial, and waits to the point that a potential situation has worsened or bloomed into a crisis.
have any studies ever been done on that?

The hypochondriac who wants the be evaluated for brain cancer every time he gets a headache likely has no better health outcome than the person who doesn't see a doctor until he has a seizure.

perhaps, " a hypochondriac," is actually a more cost-effective and "attuned" and health-conscious patient in the longrun, in terms of prevention and follow-through.

People who constantly believe themselves to be sick tend to live less active, vibrant lives because they are worried that their these things will exacerbate their sickness.

The homeopathic principle, which is like cures like, stands.

It is not that the placebo effect proves to homeopathic principle, it is that homeopathic principles are actually just expressions of the placebo effect.

Ezra,
Thank you for this. I don't really see the connection between your earlier post and this one, but I'm glad you're taking a firm stand against giving patients placebo treatment.

Regarding the issue of rationing and cost-effectiveness, I have three suggestions. First, doctors (and I'll be one in May) should be on salary or capitated. Second, within this salary/set income model, there should be financial incentives for spending more time with patients, period. Hopefully this would allow doctors to better explain the benefits and costs of treatment options to their patients. Third, I think eventually we should end up with a tiered system of co-payments. Treatments that are well-proven and cheap should be nearly free. Treatments that are well-proven and expensive should still be pretty cheap. Treatments that are less-proven should cost significantly more. And treatments with poor evidence should be really expensive. The new NIH-like Institute for Clinical Effectiveness that Obama should create would help make these calls.

Figuring out how to treat hypochondriacs will be a real test of whatever medical system follows the current one. My understanding is that the European approach is to slightly undertreat everyone, which helps the problem not evolve.

There are basically three kinds of hypochondriacs:
-attention seekers
-people with mental health issues
-people who are acutely sensitive to their bodily sensations and functions.

There are programs that are trying to sort out how to deal with this. I know one of the Medical Centers in Boston was requiring that people with a certain number of tests that had nothing show up divert into a special program. The people were given ridiculously thorough medical exams to make sure nothing was actually wrong, and then they tried to figure out what was really happening.

Electronic medical records with one record per person will help immensely. A psychology prof told us that the huge, huge gap in mental health treatment (but also medical) is the self reported medical history. The doctor basically has to believe what the patient is telling them. With a lifetime medical history following you, that problem is lessened.

Another issue is that we have to give up on treating all "in the mind" problems as "crazy." As we are learning more about how the brain controls the body, and how that control can go haywire, we need to respect it a bit more. Some of that will be giving people short term Cognitive Behavioral Therapy before continuing on to more drastic mental health treatments. But the sense that mental health treatments for physical ailments are "denying" that the problem exists is one that has to go.

There was a really good article in the New Yorker a few years back on fibromyalgia that brought up a lot of these issues. A CBT therapy helped a lot of patients, but when one of the patients in a highly medical treatment program, lots of expensive treatments, mediocre results, was offered the therapy, she refused, saying that she would not see anyone who did not see her condition as a real, physical problem. That's what is going to need to be dealt with.

"the hypochondriac who wants to be evaluated for brain cancer everytime he gets a headache likely has no better outcome than the person who doesnt see a doctor..."

first of all, this is quite an extreme , though, i am sure, not uncommon situation.
i have never seen a study on a "hyponchondriacal" profile of patients, but since they are deeply concerned about health issues, that might make them better informed and more health-conscious patients, in general.
"hypochondriacal" can be a misused word for someone who worries about lumps, small infections turning into bigger ones, lingering coughs....and a host of other worrisome symptoms where early treatment can stave off costly, later treatments and interventions some of the time.
it seems to me that "hypochondriacal" patients would be more inclined to practice early detection and care and preventive medicine by virtue of awareness and concern.
second, i would guess that when most hypochondriacal patients go to the doctor with a headache, a regular office visit is "usually" enough to allay fears with a general exam, or to determine if it could be tension, sinus,vertico, allergies,etc.
i wonder if a study has been done about overly concerned patients, to determine if those who check out their symptoms quickly, can cause a reduction in the cost of treatment because of early detection, which makes the treatment and cost less than it would be for what might be otherwise ignored or overlooked, and then turn into a situation that requires more expensive treatment, or something even advancing to become catastrophic.
i think that would be an interesting question to examine.

also,

"hypochondriac" is a demeaning term.

unfortunately, people who suffer from illnesses like fibromyalgia, allergies or other autoimmune issues and mysterious illnesses like lyme disease are often referred to as hypochondriacs, when in fact, the cause of their suffering may be undetermined, but actually very "real."
i think that all patients need to be "listened" to.
when people are concerned about something and are feeling pain, (also children), i think it is always a good idea to pay attention, and not to unequivocally "write them off" as "hypochondriacal, attention seeking or having emotional issues."
i think people "know" what they are feeling.
an excellent book to read on this subject is called,"the heart speaks"...
written by the cardiologist, dr. jennifer guarneri, the director of scripps hospital of integrative medicine, on the need to "listen" to what a patient is saying and feeling.
healing the body, heart and soul is very interconnected, and all of the very best and most compassionate doctors know that in building rapport with patients , diagnosing them and helping them to feel better.:-)
compassion and understanding need to be part of universalized health care too.:-)

So if guidelines were released encouraging doctors to be more judicious in prescribing those treatments, would that be "rationing?"

No, but it would be perceived as a kind of limitation that didn't somehow exist previously, and it speaks to the need to explain, more fully, to a larger segment of the public, what the situation with health care is now, and why "rationing" is not a big change from what already happens.

Or is it what we expect our health care system to be doing already?

The problem with this question is... who's we? We who know the need for reform? Or we, the public, who have outsized expectations of the healthcare system? The question of what "we" expect from healthcare is key... but I think often "we" isn't defined broadly enough.

Would people be surprised to know that all the incentives in the system point towards prescribing more treatments?

Yes. Just as they would be surprised to know that things they think are important - seeing a doctor, getting a test, having a surgery... are not necessarily the best practices for a particular condition. Just as they are surprised to discover that hospitals, often, are not patient friendy or structured to deal well with individual needs and expectations. I have more friends than I can cunt on two hands who have had to get care, or get care for loved ones for serious issues - including other healthcare professionals - who are stunned to discover how things actually work. And always, always, I remember that when talking to people who have not experienced those issues. Because many people just don't know. And we're not telling them.

interesting topic, not sure what I think, but people may want to listen to this July 2008 Krugman podcast on healthcare, "Krugman: Americans’ Unhealthy Spending". After Krugman speaks, there's also an interesting presentation by Elisabeth Ryden Benjamin, mostly on health care polling.

http://www1.cuny.edu/portal_ur/news/radio/podcast/lecture_148.mp3

One of the points Krugman makes relevant to this post is that while people talk about too many doctors visits, too many diagonistic tests, that's not really where the money is. Another point he makes is that the VA system is currently doing the best job of controlling costs, not sure they do it by saying "No tests for you! Come back one year!"

Another thing I was wondering about in health care is if you want to bring down costs, you probably want to increase the supply of doctors, and increase capacity in other ways. But doctors, among others, won't like this. So how about some sort of bargain giving extra help to doctors in terms of cheaper med school bills, etc. in return for increasing the number of doctors?

Thank you for this. I don't really see the connection between your earlier post and this one, but I'm glad you're taking a firm stand against giving patients placebo treatment.

Yeah, this pretty much says it all. Nice walkback from a silly post. Your earlier post clearly did suggest treating placebo was exactly what you meant, hence your conclusion:

There are ethical issues, of course. But still. Interesting.

If you didn't actually mean that doctors shouldn't prescribe placebo, then there aren't any ethical issues. Again, silly post but we could use a little more than a politican-like walkback that "this isn't what you really meant." It was a mistake, it happens in the 24/7 world of blogging, have the chutzpah to admit it.

This new post ends up focusing on the traditional role of placebo, i.e. if something doesn't work better than placebo, then it doesn't work. That isn't about "value"-- that's standard clinical science. So I don't think this is what Orszag is saying either. Perhaps you should stop guessing and actually find out. (My sense of the presentation is that his takehome message is that there is much more to health than traditional medical interventions, and placebo effects are evidence of that. I think the conclusion is that we need more behavioral research on what drives health outcomes and adjust our lives accordingly.)

This discussion neglects the benefits of "the placebo effect," which are striking, amply documented, and which doctors allow for rather than dismiss.

When you are given a placebo in, say, a trial for a new anti-depressant, what you are actually receiving is a dose of care and hope -- not just a sugar pill. No one -- like a physician -- potentially able to help you get a more livable outcome has said, "Well, there's a monkey on your back and you'll just have to carry it." No, they've set out to help you and taken time to care for you, to be a witness to your pain. The power of an alliance with an authority who intends to help you, an authority in whom you've placed hope and trust, is in itself healing -- otherwise a shaman couldn't perform effective treatment, ever. This is why a good doctor will use the placebo effect in his shamanistic capacity -- it's good medicine.

Ethical dilemmas abound here, with reference to who decides how to treat or whether to treat when health care is by any other name rationed, but not the ones this discussion cites. Few doctors would be truly comfortable showing that graphic to a patient who had read a certain surgery could help his back pain and declining to authorize it. A doctor might say, "In my judgment you won't get the relief you need with that surgery. I'd like to try something that will lay you up less and work at least as well."

There may indeed soon be a new paradigm for the placebo effect. If so, actuaries ought to become familiar with its real history.

i have never seen a study on a "hyponchondriacal" profile of patients, but since they are deeply concerned about health issues, that might make them better informed and more health-conscious patients, in general.

There are certain situations in which being an informed patient is a good thing once you have been diagnosed, but the truth is that if you have a small but persistent problem or minor irritation, and you google the symptoms to find out what's wrong, you will be confronted with any number of bad things and worst-case scenarios. If you have an active imagination or are a bit on the paranoid side, which is what pretty much defines hypochondriacs, this will cause you a lot of unneeded and unwarranted worry.

What Elatia outlines sounds like the fact that a lot of people are pretty lonely and need someone who cares and has expertise in treating their problems. It may make te case for people having a "primary care physician" that they consult with regularly. I always viewed having regular consultation with a physician as something reserved for someone unfortunate to have a chronic illness that needed regular monitoring and care, but it may be that even those without serious, chronic conditions can benefit from regular monitoring of their health by a professional, if only to prevent their worries about their health from spiraling out of control and turning into requests for medical interventions that don't ultimately help.

The issue is complicated by the fact that we currently have staggeringly little data on the efficacy of most treatments. Experts estimate between 15% and 50% of care is wasted. Problem is, we don't always know which care is the wasteful care.

But sometimes we do. Most data suggests that angioplasties, for instance, are frequently unnecessary. Same with lumbar back surgeries.

Really? Would you care to link to scientific research to back up those sweeping assertions, Ezra. And I'm talking about valid, peer-reviewed research, not some Heritage Foundation bunk.

Drat. Formatting errors. The paragraph "But sometimes...." is also in italics, quoted from Ezra'a post.

You have to be practice for a very short time to understand that the minute you relegate that chest pain to the hypochondriac ...incoming with
That:
They die on the doorstep ..out.

Every patient is new everytime..
In an ideal world.
It's hard, that, tho'. In practice.

But you knew that.

"a small but persistent problem or minor irritation"

from the patient's perspective, it is an interesting question.., "when does one decide to go to the doctor?"
for some people, the answer may be often, and for others, the answer would be never...and everything in between, from "give it another day, to a temperature two degrees higher."
i have been with elderly people in the midst of a heart attack, who refuse to call an ambulance.
and how many mothers, not wanting to call a doctor at two in the morning, agonize over a baby with croup or high fever, half dressed,wondering when the scales tip, to run out to the emergency room in the middle of the night.
and then, there is the small infection that one nurses, thinking, "this is too small an issue for a doctor..." and then, one day, almost magically, it turns into a staph infection....
people trust their intuition about going to see the doctor, or going to the emergency room.sometimes, they are right and sometimes wrong.
i wonder if a study was done to track the medical expenses over a period of time, of people who go too often to a dr. or those who wait too long to go, what you would find.
what is unbearably painful or terrifying for one person, may be completely tolerable for another.
in terms of what you said about loneliness contributing to general fear, it would be interesting to know if people who live alone make more trips to the doctor....
working on a crisis hotline, i can say for sure that when people are ill and alone at night, they are often terrified and can barely make it through the night to see their doctor.
when they speak with someone, their anxiety levels calm down and often, they can deal much better with their condition and sometimes even go to sleep.
in fact, there are chronically ill, "frequent callers" who call the line almost every single night, to talk with someone so they can finally fall asleep.

is that "hypochondriacal," or is that just being human?

Ezra if you weren’t so fundamentally opposed to doing research and such a partisan hack you would know what you described is exactly what HMOs did. Some HMOs took it to far but those cases where a VERY small percentage of care.

You could never muster the honesty to admit Congress tried this already and failed miserably. Mainly Ted Kennedy.

Rationing, no matter how you define it, is going to be hated. Everyone that is honest about HC expenditures will admit it is the main requirement to spare our system but no one wants to be the bad guy.

That's why Ted Kennedy wrote the first HMO bill. That's why they subsidized them so heavily and that is why they made it a FEDERAL LAW employers offer HMOs.

Congress would control the purse strings and make the rules while the evil HMOs took all the blame. It was a progressive cowards way to reform.

The problem is the politicians had no spine. As soon as the HMOs did what they where supposed to and ration out unneeded care people complained. As soon as people complained politicians feel over each other to offer solutions.

Like most politically contrived solutions we where left with the worst parts and none of the benefits. Now we have HMOs that can't ration care. We have the hurdles and headaches and all that is wrong with HMOs but none of the benefits. It's one thing if your forced to have an HMO but it's only costing your family $5000 a year. TO have an HMO and pay $12,000 just sucks. We would all be better off where we where 30 years ago before Teddy got the stupid notion that he knew what was best and we should all be in HMOs.

For people that actually know Healthcare your pure comic relief. Typing away like the informed lil expert with all your thoughts and ideas…not only are they not original, as they have already been tried, but they where tried and failed miserably. You’ll rail against the evils of managed care then turn around and propose the exact programs that made them evil.

Did you know restaurants try to sell you more food then you need, and food that isn’t in your best health? Did you know mechanics will try to sell you services your car/bike don’t need? When ever you ask someone for advice it will always be tainted by their best interest. Are you really so naïve as to think you can make healthcare the exception? People are ripped off in everything we do. It’s the desire to not get ripped off of our money or assets that makes us actively try to minimize these losses. As long as you blindly believe your magic slippers will protect you from this with no effort of your own we will continue to be over treated and treated inappropriately. Only when it is the patients dollar on the line will the bad questions drop and providers be forced to provide good answers.

You can close your eyes now and drift back to your imaginary land where people don’t over consume free services and don’t repeatedly make bad decisions when there is no perceived effect.

You could never muster the honesty to admit Congress tried this already and failed miserably. Mainly Ted Kennedy.

Rationing, no matter how you define it, is going to be hated. Everyone that is honest about HC expenditures will admit it is the main requirement to spare our system but no one wants to be the bad guy.

That's why Ted Kennedy wrote the first HMO bill. That's why they subsidised them so heavily and that is why they made it a FEDERAL LAW employers offer HMOs.

Congress would control the purse strings and make the rules while the evil HMOs took all the blame. It was a progressive cowards way to reform.

The problem is the politicians had no spine. As soon as the HMOs did what they where supposed to and ration out unneeded care people complained. As soon as people complained politicians feel over each other to offer solutions.

Like most politically contrived solutions we where left with the worst parts and none of the benefits. Now we have HMOs that can't ration care. We have the hurdles and headaches and all that is wrong with HMOs but none of the benefits. It's one thing if your forced to have an HMO but it's only costing your family $5000 a year. TO have an HMO and pay $12,000 just sucks. We would all be better off where we where 30 years ago before Teddy got the stupid notion that he knew what was best and we should all be in HMOs.

For people that actually know Healthcare your pure comic releif.

Of course we're a nation of hypochondriacs. For perhaps 2 decades fussing about "health and wellness" has been fashionable. Instead of viewing the obsessive interest physical complaints as a disgusting characteristic of whining old women who have nothing better to do it's become a status symbol. You are just nobody unless you have allergies or a bad back. This sort of behavior is weak, sickening and disgusting.