Re: The Placebo Effect


Saturday, January 5, 2008
Health
By JAMES BARRON; JAMES BARRON IS A NEW YORK TIMES REPORTER.
Published: April 16, 1989
LEAD: ONE CASE HISTORY:

ONE CASE HISTORY:

Recurrent dizziness. Patient is terrified that he might be having a
heart attack. Doctor had ordered a 24-hour ambulatory
electrocardiogram, taken with a small portable device that keeps track
of the heartbeat. When the patient returned to the office the next day
for evaluation, the electrocardiogram showed dramatic fluctuations of
the heartbeat: 130 beats a minute during activity, only 40 beats a
minute when the patient ia asleep. During the time he's been
monitored, the patient has not experienced any dizziness. THE DOCTOR
RECOMMENDATION:

''You need a pacemaker.''

A pacemaker is, in fact, implanted the next day and the patient
becomes a statistic: one of millions of Americans who have undergone
unnecessary elective surgery - nonemergency procedures performed as
alternatives to more conservative treatment. In recent years,
researchers have called into question the need for hundreds of
thousands of operations, including pacemaker implants, coronary bypass
surgery, hysterectomies and Caesarean section, to name only a few
procedures that seem to be performed too frequently. A review team
headed by Dr. Allan M. Greenspan of Albert Einstein Medical Center in
Philadelphia estimated that 20 percent of pacemaker operations may be
unnecessary, including the one done on the man with the fluctuating
heartbeat. Dr. Greenspan maintains that the fluctuations were normal,
and that the patient's dizziness had nothing to do with his heart.

The surgery rate in the United States grew more than twice as fast as
the population between 1979 and 1987. By most accounts, it's the
highest in the world. For example, studies cited by Lynn Payer in her
recent book, ''Medicine and Culture,'' show that American women are
two to three times more likely to undergo a hysterectomy than women in
England. Heart patients here are six times more likely to have a
coronary bypass. Yet our more aggressive style of medicine doesn't buy
us longer lives: According to the World Health Organization, life
expectancy is about the same in the United States as in Western
Europe, and Americans are somewhat more likely to die of heart disease
than people living in England.

Despite the dramatic increase in surgery, experts can't say precisely
how much of it is unnecessary. Only in recent years have researchers
begun to review hospital records to document the problem, and they
have been hampered by a lack of consensus among doctors concerning the
proper indications for various operations. In addition, records on
surgical procedures vary from hospital to hospital, making it
difficult for researchers to conduct large studies assessing the
appropriateness of operations.

Another way to document the extent of unnecessary surgery is to follow
patients who have undergone operations like coronary bypass and
compare them with patients who have been treated with more
conservative approaches, such as drug therapy. So far, however,
studies have been done for only a limited number of procedures. As a
result, doctors who recommend an operation over drugs often have ''a
basic lack of knowledge of which works better,'' says John E.
Wennberg, an epidemiologist at Dartmouth Medical School.

Even so, evidence is accumulating that unnecessary surgery is a
widespread problem. In Dr. Greenspan's study, specialists reviewed the
charts of 380 patients who had received pacemakers at 30 hospitals in
the Philadelphia area. One-fifth of those implants were judged to be
totally unnecessary. One reason was that some physicians had failed to
evaluate patients' symptoms correctly, even at university hospitals
with sophisticated diagnostic equipment.

The continuing increase in the number of coronary bypass operations
performed each year has also come under scrutiny. Dr. Thomas B.
Graboys, a cardiologist at Harvard Medical School, estimates that as
many as 350,000 bypass procedures will be performed this year - nearly
twice as many as in 1983. ''Doctors and their patients tend to view
heart disease as a plumbing problem,'' he says. Their attitude is that
damaged coronary arteries are like corroded pipes -they simply must be
replaced. But a major study published by Dr. Graboys in 1987 suggests
that this aggressive approach is often unwarranted.

Eighty-eight patients who had been advised by their doctors to undergo
coronary bypass surgery received second opinions from specialists
working under Dr. Graboys. The bypass operations had been recommended
on the basis of a diagnostic test called cardiac catheterization,
which had found blockages in the patients' coronary arteries. The
specialists judged that, despite the blockages, 74 of the patients
could be effectively managed with drugs instead of surgery. Most of
them took the specialists' advice, and two and a half years after the
study began, none of them had died.

A skyrocketing rate of diagnostic cardiac catheterizations is partly
to blame for the upsurge in bypass operations, says Dr. Graboys. In
this procedure, a catheter is inserted through the skin near the elbow
or in the groin area and threaded through blood vessels into the
coronary arteries. A dye is injected through the catheter, and X-rays
are then taken of the coronary arteries in order to find blockages.
According to Dr. Graboys, 800,000 cardiac catheterizations were
performed in 1987; by the end of this year, the number may exceed a
million. A study he is now working on suggests that even these
procedures - which are often done when patients complain of chest
pains or when there are abnormal EKG or stress-test results -are
frequently unnecessary. When the specialists working under Dr. Graboys
gave second opinions to 150 patients whose doctors had recommended
cardiac catheterization, they found that the diagnostic procedure was
unnecessary in a majority of cases. According to the specialists, the
patients were medically stable and their condition could be controlled
by life-style changes or medication.

Balloon angioplasty, a procedure in which a tiny balloon is inflated
inside a coronary artery to flatten a blockage, has also come in for
criticism. A study published in March by scientists at the National
Heart, Lung and Blood Institute in Bethesda, Md., suggested that 40
percent of the angioplasty procedures performed on heart attack
patients may be unnecessary.

Of course, the heart isn't the only part of the body vulnerable to
unnecessary surgical tampering. In 1988, the Rand Corporation, a
research organization in Santa Monica, Calif., completed a study of
1,302 Medicare patients who had undergone carotid endarterectomies -an
operation in which blockages in the neck arteries supplying blood to
the brain are removed. A panel of physicians found that 32 percent of
the operations were unjustified.

Dr. Wennberg at Dartmouth recently helped conduct a study that
followed the cases of 263 men who had undergone surgery to repair
enlarged prostates. Many doctors recommend this surgery to prevent
more serious problems, such as kidney damage, that can shorten a
person's life. But Dr. Wennberg found that because of postoperative
complications, the surgery actually caused a slight decrease in life
expectancy.

Where a person lives can affect the chances of being operated on
unnecessarily. For example, according to a 1985 report by the Senate
Special Committee on Aging, hysterectomies are performed 80 percent
more often in the South than in the Northeast. Within the state of
Massachusetts, the rate of hernia repair surgery varies by as much as
380 percent, while pacemaker surgery varies by as much as 1,250
percent. And, in a study by Dr. Wennberg, carotid endarterectomies
were found to be twice as common in Boston as in New Haven. Meanwhile,
people in New Haven were twice as likely to undergo bypass surgery as
people in Boston.

According to Dr. Wennberg, these geographical variations, or
''surgical signatures,'' are seen year in and year out and are
independent of rates of illness. There appears to be a correlation
between the number of surgeons in a particular area and the number of
operations, with more surgeons generally resulting in more operations.
The variations may also be indicative of differences in prevailing
medical wisdom. In any case, they clearly suggest that something other
than hard medical data often underlies the judgment of surgeons.

UNNECESSARY SURGERY means unnecessary risk of complications and even
death. In testimony before a Senate subcommittee in 1985, Dr. Wennberg
estimated that 5,000 deaths could be avoided each year if all doctors
used the most conservative indications for doing prostate surgery.
Unnecessary surgery also comes at great financial cost - and not just
the cost of the operations themselves. Unnecessary surgery usually
means unnecessary tests, drugs and hospitalization. No one knows for
sure what the bill is, but even back in the mid-1970's, Congress
concluded that it was unacceptably high. A House investigation found
that in 1975, 2 million unjustified operations had been performed in
the Medicaid and Medicare programs - at a cost of $4 billion.

Experts cite a glut of surgeons as one of the major causes of needless
operations. According to Dr. Eugene G. McCarthy, director of the
Health Benefits Research Center at New York Hospital-Cornell Medical
Center, the Federal Government began to help finance medical education
in the 1960's to counter what was then a shortage of doctors. One of
the results was a 30 percent increase in the number of surgeons.

The fear of malpractice lawsuits is prompting many surgeons to perform
operations they might otherwise pass up. Arthur L. Caplan, director of
the Center for Biomedical Ethics at the University of Minnesota, says
that in the past 20 years, rulings in malpractice cases have changed
the way doctors are judged in court. Legal standards of reasonable
medical care were once based on the judgment of physicians in the
community. ''Today, juries make their own judgments based on what a
reasonable patient would want done,'' says Caplan. ''Generally
speaking, in our society doing something is preferred to doing
nothing.'' A doctor being sued for malpractice stands a better chance
of winning the case if he tried an operation and failed than if he
recommended more conservative treatment. As a result, the approach of
many surgeons is, '' 'When in doubt, take it out,' '' he says.

The lack of studies on the effectiveness of many surgical procedures
gives malpractice lawyers a potent weapon in court. ''Malpractice
litigation flourishes in this information vacuum, because no one knows
what legal standard of reasonableness to apply,'' Caplan says.

Ironically, improvements in medical care are also contributing to the
problem of unnecessary surgery. Many operations are done more quickly
and easily these days. For example, a lumpectomy, a 20-minute
procedure in which a breast tumor is removed, is now often done as an
alternative to a radical mastectomy, an operation that can take up to
three hours in which the entire breast is removed. Kidney stones and
polyps in the colon can now be eliminated without surgery. Many
surgeons find themselves spending fewer hours in the operating room
and collecting fewer or smaller fees, says Dr. Anthony P. Monaco, a
professor of surgery at Harvard Medical School. As a result, some of
them recommend surgery to their patients when a conservative method
might be equally effective.

Hospitals are hurting, too, because operations for such relatively
common conditions as cataracts are increasingly being done on an
outpatient basis or in doctors' offices. Consequently, surgeons are
being pressured by their hospitals to schedule big-ticket procedures
to fill the empty beds.

According to Caplan, the reimbursement policies of many health
insurance plans inadvertently encourage surgeons to operate
unnecessarily. In recent years, Medicare and some private insurance
companies have placed limits on the amounts they will pay for
particular operations. A cap on payments for procedures that are
highly profitable for hospitals as well as doctors, such as coronary
bypass operations, reduces profitability but doesn't eliminate it.
This may encourage surgeons to do more of these operations to make up
for the decreased profits.

Sometimes patients must share the blame for unnecessary surgery.
''It's very easy for the doctor to be lured by a patient's demand for
a quick fix,'' says Dr. Peter D. McCann, an assistant professor of
orthopedic surgery at Columbia University's College of Physicians &
Surgeons. This is particularly true of weekend athletes who are
injured and want to make a rapid comeback. A common source of shoulder
pain, for example, can be problems with the rotator cuff, a group of
tendons and muscles that helps stabilize the shoulder joint. Patients
who elect physical therapy may find the results every bit as
satisfactory as those who insist on surgery.

ONE OF THE BEST ways to curb unnecessary surgery is to require that
all patients get second medical opinions. ''We surmise that doctors
who are subject to the review of their peers are less inclined to
prescribe unnecessary surgery,'' says Dr. McCarthy.

The first second-opinion program in the country, insti-tuted by New
York Hospital-Cornell Medical Center in 1972, required that patients
consult a second physician before undergoing elective surgery. Since
then, second-opinion programs for both hospitals and insurance plans
have multiplied. Virtually all insurance plans in New York State
require second opinions for elective surgery, according to Dr.
McCarthy. If a patient fails to get a second opinion, his insurance
company will typically reimburse him for less than 50 percent of the
cost of the operation.

Such mandatory programs have been established in other states as well,
and they have had a substantial impact. The hysterectomy rate in New
York State is only a third of what it is in states where few or no
second-opinion programs exist, says Dr. McCarthy. And, according to
the 1985 report of the Senate Special Committee on Aging, back-surgery
rates in the Wisconsin Medicaid program plummeted 36 percent when
second opinions began to be required.

Attitudes don't change overnight, but Dr. Greenspan, who did the
pacemaker study, says that ''many doctors have become aware that they
must abide by a more stringent set of rules. And many patients are now
aware that they must ask questions and get second opinions.'' As a
result, rates of increase for some surgical procedures may have
peaked, he says, and the rate of pacemaker implants is actually
starting to come down. Thanks to a growing awareness that carotid
endarterectomies are often unnecessary, fewer of these procedures are
being performed today than in the past.

But much more still needs to be done. In testimony before the Senate
Finance Committee's subcommittee on health last year, Dr. Wennberg
pointed out that the Government requires extensive studies to evaluate
new drugs, yet surgical procedures rarely get the same scrutiny.
''This double standard for truth in clinical medicine compromises the
rationality of medical decisions,'' he said. And it threatens the
health of both the national economy and countless patients. Dr.
Wennberg is pushing for Federal funding of a program to measure the
effectiveness of a large number of surgical procedures.

But perhaps the best guardians against unnecessary operations are
patients themselves. If a doctor recommends that you have surgery,
don't hesitate to get a second opinion. Get as much information from
both doctors as you can, and explore carefully all the alternatives to
surgery. Ask whether drug therapy or changes in diet and exercise have
proved effective for your condition. You should also ask the doctors
specifically what they think an operation could accomplish: a cure, or
simply relief from symptoms? Is a relapse likely? What are the
possible complications of surgery and what are the chances that they
will occur? Have any studies been done about the procedure, and what
do they say?

In the end, it's up to you to decide what's necessary. For example,
Dr. Graboys says it's reasonable for heart patients who are extremely
anxious about their condition to choose bypass surgery even if drug
therapy would be sufficient treatment. If, on the other hand, you
value medical care that is as noninvasive as possible, it behooves you
to find a physician who shares your philosophy. Collaborating with
your doctor in making the decision whether to operate or not is
probably the best way to avoid becoming another statistic in the
annals of unnecessary surgery.




Copyright 2008 The New York Times Company
.

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