MOVIE: Knock (1951): Foreshadowing Medicalization

A first for Less is More!

No, we are not making a movie. It's the first "pop culture" feature of the problem of medicalization, where healthy people get labeled as sick.

Those of you who know I speak a bit of rusty, fragmented french will be aware of the page of French-language resources [français] on this site. I would love for the entire site to be better organized and to have the whole thing translated. But with a budget consisting of the coins I find in my couch, that is unlikely to happen soon.

In the meantime, I am proud to tell you about this french film.

"Dr Knock," is a french comedy film from 1951 in which a physician who, in need of work, convinces an entire healthy village that they are all ill so that he can treat them. Originally a play in 1923 by Jules Romains, called Knock ou le Triomphe de la médecine (The triumph of medicine), this film had some kind of foreshadowing!

Theatre 625 (BBC) did an English adaptation in 1966 but I have not been able to find a video of it.

 The full film is available (legally, I believe) on YouTube. French speakers, enjoy!

Source: https://www.youtube.com/watch?v=OVBnhTEoiv...

I love Healthcare Triage! VIDEO: Malpractice, Healthcare Costs, and Tort Reform

Dr Aaron Carroll (@aaronecarroll) & Co. are amazing!

Healthcare Triage (@HCTriage) has a YouTube channel that hosts a range of videos, most of which pertain to the "Less is More in Medicine" movement. The Less is More blog has featured their work before, 1) when Healthcare Triage did a video about Choosing Wisely, and 2) when Dr Carroll wrote Why Survival Rate Is Not the Best Way to Judge Cancer Spending for Upshot in the NY Times. In early June, they posted another great video, busting some major medico-legal myths.

One of the main excuses physicians make for ordering too many tests and treatments is that they have to practice defensive medicine. You must 'cover your ass' (CYA) to ensure nothing is missed, lest you face a horrible lawsuit. Physicians pay a ransom to malpractice insurance in order to help protect their reputation (and earnings) should a case come forward.

Many frivolous lawsuits exist and a lot of poor care is not legally pursued. Physicians think that tort reform will solve everything. Not so. Watch the video to learn more:

Source: https://www.youtube.com/watch?v=sK-E_d1MGt...

Celebrity Medical Advice: Mark Cuban says "more is better" in Health Care

Twitter is a wonderful place to share ideas, learn quick tidbits, and to get a sense of the 'zeitgeist.'

Unfortunately, many people use it as a platform to share their crazy opinions and famous people are able to propagate all kinds of medically questionable myths (read Hoffman SJ and Tan C in BMJ re: following celebrities' medical advice). The Jenny McCarthy- and Gwyneth Paltrow-types persuade others with obvious contravention of science. However, the subversion of the process of medicine can also be subtle. 
 

BEWARE it may make you shudder to read it:

If you can afford to have your blood tested for everything available, do it quarterly so you have a baseline of your own personal health . . . 

a big failing of medicine = we wait till we are sick to have our blood tested and compare the results to “comparable demographics

- Mark Cuban (@mcuban)

Fortunately, before Mark Cuban (billionaire entrepreneur) could get too far with his "more is better" evangelism, Charles Ornstein (Pulitzer-Prize winning journalist, @charlesornstein) challenged him. Too bad that challenging people often makes them dig their heels in deeper.

Did the evidence provided sway Cuban? See the play-by-play on Forbes.

Source: http://www.forbes.com/sites/dandiamond/201...

The Preventative Visit and Choosing Wisely

The preventive health visit is not synonymous with an 'annual physical'

I always felt lost when asked to do a general exam on a healthy person. Every physician performed it differently. Do we check for breast masses? Feel the thyroid? Look at the tongue and mouth for squamous cell carcinomas? Check the belly for a pulsatile mass? Listen for a murmur? Heck it would take hours to go over every mole and mucosa, to palpate every bump and move each joint. So what were we doing?

The American Choosing Wisely campaign, in the list of Society of General Internal Medicine suggestions, recommended in 2013 that physicians stop “performing routine general health checks for asymptomatic adults." (see some backing data)

Many were outraged by this, and a similar decision in Ontario by the provincial government to de-list the annual physical exam, such that physicians would no longer be paid to provide this service to patients who don't require it. The concern was mainly that very important preventative health and screening measures would no longer be undertaken.

 Prevention is essential. Not sure about the "quality" of the helmets here, but even the dog is at least trying to being careful.

Prevention is essential. Not sure about the "quality" of the helmets here, but even the dog is at least trying to being careful.

But, a preventative health visit is not the same thing as an annual physical. For example, we've got decent evidence that pap tests are important screening tools for cervical cancer, and have changed our guidelines to use them less frequently. And we are not suggesting dispensing with this. However, recent studies have shown that the pelvic exam (feeling the uterus and ovaries, essentially) really is not essential and many organizations are beginning to recommend against this practice. We had been doing pelvic exams out of "tradition" for the longest time - how much else is driven by tradition?

I come back time and time again to the Milstein paper from Health Affairs, Why Behavioral And Environmental Interventions Are Needed To Improve Health At Lower Cost. We know that prevention is key, but we don't know how, when, or where to deliver it. Dispensing lifestyle advice in the office probably doesn't work (eg. GP advice is ineffective in improving metabolic outcomes in high risk patients). Clearly we need something different to achieve a persuasive, meaningful impact.

A colleague recently sent me an article, from the American Journal of Preventative Medicine (access required - ePub ahead of print, Jul 2014),  which addresses concerns with the way our push for efficiency and appropriateness may be drawing attention away from the real issue of prevention. Wong, Gaster, and Dugdale write:

. . . the Choosing Wisely Campaign sends the wrong message at a time when prevention remains more important than ever, and as the data supporting it grow more complex and more nuanced. The preventive health visit has and will continue to evolve . . . The preventive health visit currently remains an effective tool for increasing adherence to evidence-based service guidelines. This is no time for us to abandon it.

I would personally need to learn a lot more about what "effective" is meant to construe in the above sentences before agreeing wholeheartedly. I don't disagree that we need to spend a lot more effort looking at prevention, but I don't think Choosing Wisely contravenes that effort. 

 

What do you think?

Why NOT? Common concerns with the Less is More approach

Overtreatment: When Less Is More In Medicine

Dr. David Liu on Better Health posts a reaction in support of the Associated Press article, Overtreated: More Medical Care Isn't Always Better. He tackles one of the biggest challenges to the Less is More movement - that although we know that we should be doing less of the interventions that have poor evidence (or evidence of harm) behind them, it seems impossible at times to convince the public of this fact.

You would think the public would be happier that they would be poked and prodded less as scientific evidence shows that it is safe to do so. We should want the healthcare system to be in the mindset of continual learning and not mired in old traditions just because that is the way it was always done.

Yet despite this reality, some people view this as rationing of medical care or the beginning of socialized medicine.

It’s not. It’s the time of rational medicine. Doctors need to lead the change and get away from the hype and more to the science. That is what patients really want.

Read more on Better Health.