Friday, May 7, 2010

Overuse, underuse, misuse and the physicians' obligation to patients

During the 1998 Institute of Medicine (IOM) Roundtable on Quality, experts in the field categorized medical error into one or more of three areas: underuse, overuse, or misuse. Much discussion and research has focused on the topic of underuse (barriers to access of care, especially to preventive care), misuse (avoiding hospital-acquired infections, etc.) and others over the topic of overuse (provision of tests and interventions that have no clinical benefit and while still having associated risk).

Research by The RAND Corporation quantified some of the overuse: 20-40 percent of some surgical procedures are performed on patients who cannot, on scientific grounds, be expected to benefit from them (Leape et al. 1991). - From Don Berwick's Eisenberg lecture, April 2005

The national debates over healthcare reform have once again brought to the fore this 3rd cause for medical error - particularly due to its financial implications.
According to the American College of Physicians (ACP) 2009 policy paper, Controlling Health Care Costs While Promoting the Best Possible Health Outcomes, the Congressional Budget Office estimates that 5% of the American gross domestic product (roughly $700 billion per year) is spent on medical tests and proceduresthat do not improve health outcomes. (Introduction to interview with Steven Weinberger, MD, FACP - on Medscape)

Despite increased attention on the topic - it continues to be extremely heated, including now infamous phrases such as "Death Panels." Overuse at the end-of-life becomes a particularly contentious issue, partly because what one person calls overuse, another may consider appropriate. We know that practice standards regarding use of tests and interventions for the very same circumstance vary widely not only between countries, but also between and within states.

I for one, look forwards to seeing what ACP brings forward with regards to evidence-based recommendations to address this question. In my practice in palliative care, it has not been uncommon for me to be called to address questions of intensity of care - not only from the patient's perspective, but through conflicting points of view between the physicians caring for patients. One very personal story for me was when I was called to another state, to the bedside of a dear friend who had been in a horrific car-on-bicycle accident. He on his regular 50 mile Sunday bike ride when a car swerved ever-so-slightly and hit him head-on. He was rushed to hospital with massive head and chest injuries. He had bilateral brain contusions and bleeds. After a couple of weeks of giving it their all, there was clear conflict between clinicians information being shard with families:
  • One physician pointed to the small improvements each day: the wounds were healing, his face less swollen, cardiac function improving. His honest perspective was that he was getting better, and could continue to improve to leave the hospital. This physician treasured life over all else. In the words of Dr. Epstein's article referred to by Dr. Levy in his blog "Running a hospital:"
    "The Role of the Physician in the Preservation of Life." Q J Med 2007; 100:585–589.

    We physicians belong to an ancient profession, standing apart from all others in its primary concern and respect for human life and its enmity to death. And in the long run, that attitude of the profession may be as important to society as any miracle that modern technical medicine can perform.
    That, however, what he missed was meaning of the next part of Dr. Epstein's speech -
    The fact is that for all our talk and our science, we do only a little. Life cannot be prolonged indefinitely, and death comes at last. But the little we can do has an importance that transcends the patient, for it carries a message to all our patients and to the world: Human beings are important.
  • The other physician saw a very different picture: a young man, an athlete and artist who would never return to his previous vigorous self and should he survive this hospitalization (a big if) would likely remain on life-support for his remaining years would definitely always be completely dependent for all activities of daily living, unable to carry on a conversation. He saw the ongoing aggressive life-sustaining interventions as possible overuse, given the dismal outcome.

Harm from overuse is not merely harm to the patient and family (providing risky or painful procedures that have little to no benefit - principle of beneficence and non-maleficense) society (cost, burden - from the principle of justice), but also may harm staff: physicians, nurses, other caregivers. In some settings: test after test, procedure following procedure in a patient with progressive end-stage disease who remains minimally interactive but winces to the interventions. One physician ordering this, while others are the ones doing it, protesting as they do, questioning the rationale and the harm with perceived little-to-no benefit, as nurses pick up the pieces. Nurses, resident physicians, and attending physicians have spoken to me of their sense of struggle, their inclination to avoid patients to whom they are "forced" to provide care they see as not having benefit but instead harm. For the ordering physician, the drive may indeed be patient preference, or perhaps that personal and professional commitment to valuing life and fighting of its enemy - i.e. death.

In our field we weave through cultures of medicine and preferences of patients, families and even clinicians that represent a wide range of perspectives, even on the value of prognosticating stating that maybe this patient will be the one to beat the odds and question the role of epidemiology of prognostication or EBM in prognosis. (Thank you Drew for your review of the article on Prognosis in the Neuro ICU.)

One of our roles as the palliative care clinician or team-member, is to navigate in this world of uncertainty. To support families struggling as they see the patient slowly, ever-so-slowly die as more and more is done to prevent or slow down the death per their request, while supporting the healthcare team who struggles with the procedures that seem to have little to offer, while supporting and watching with the physician who is also doing all he or she can to keep this person, their patient alive - as he or she believes we can clinicians are called to do.

I think physicians fall in all areas of believe around these topics - influenced, of course, by personal values and education. I remember when I was a medical student meeting another med student at a wedding. On his way to the wedding he had seen a massive accident with multiple deaths. He told me that there he met our shared enemy - death. At that moment, I began to believe that there are two general places where people fall - on one end of the extreme: death the enemy, on the other, suffering the enemy. At risk of influencing this readership, I will share that in my mind, I believe that our call as physicians (and nurses, and all in healthcare field) is to prevent premature or preventable death, but the primary role - as Eric Cassell so eloquently wrote in numerous articles, is to alleviate suffering - in all its manifestations.

Particularly in our field of palliative medicine, we walk on this ledge of uncertainty, of differing opinion and values, lending strength and comfort to any who suffer due to the illness and complications of treatment. We are also called to lend our expertise in preventing medical error - whether overtreatment, undertreatment, or mistreatment - in the time of life when patients, their families, and their clinicians often most struggle with defining what this means. Even when we personally may disagree with the choices made, our role is to lend strength, to practice non-abandonement, and - as Dr. Epstein was known to do - to "fluff the pillows" for patients and even to colleagues whether .