Why Do Doctors Overtreat? For Many, It’s What They’re Trained To Do

The habit of ordering unneeded tests and treatments drive up medical costs. It’s a pattern doctors often learn in medical school and residency.

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When family physician Jenna Fox signed on for a year-long advanced obstetrics fellowship after her residency to learn to deliver babies, she knew she’d need to practice as many cesarean sections as possible.

The problem was, she also knew C-sections aren’t always good for patients. Many women’s health experts argue they’re often unnecessary and increase health risks for mom and baby. Doctors are working to decrease high C-section rates in hospitals around the country. Fox and her colleagues on the labor and delivery floor at the University of Rochester try hard to prevent them, particularly primary C-sections, when a woman needs one for her first baby.

“I want to avoid primary C-sections. But also in this one year of my life I want all the primary C-sections in the world,” Fox says. “It’s me feeling conflicted, internally, all day, every day.”

During her fellowship, she says, the more C-sections she does, the better prepared she’ll be to practice independently.

Medical education is built on the assumption that the more procedures or treatments doctors see and do, the more competent they’ll be when they’re independent. It can feel tempting to do more rather than less.

But excessive medical tests and treatments can have financial and personal costs. They contribute to this country’s rising health care spending and subject patients to anxiety and the risks of extraneous procedures. A group of medical educators thinks this epidemic of overtreatment, as they call it, starts with the habits that doctors develop during training — habits they’re hoping to break with new approaches to medical education.

There’s some evidence that the patterns we learn in residency are hardwired for the rest of our careers. In a 2014 JAMA study, for example, doctors who trained in regions where patients underwent more tests and procedures went on to practice independently in a similarly aggressive style.

Academic medicine is often criticized for its emphasis on an overly thorough workup for ordinary problems. In the name of learning how to practice medicine, young physicians may be tempted to order lots of tests, a trial-and-error approach with real implications for patients.

Early in my own training as a family physician, I remember ordering a colonoscopy for a young man with mild rectal bleeding. I rationalized the risks of the procedure — bowel perforation, complications from anesthesia — because it would put both me and the patient at ease to know his symptoms weren’t caused by something dangerous. As Fox puts it: “We like to be reassured. We feel much better when we think a situation is terrible and find that’s everything is awesome rather than the other way around.”

But more isn’t always better. It’s not news that health care costs in the U.S. are out of control: we spend more on health care, per capita, than any other developed country.

Unnecessary tests and treatments may contribute to high costs. According to a 2010 estimate from the Institute of Medicine (now known as the Health and Medicine Division of the National Academies of Sciences, Engineering, and Medicine), we could reduce many of our medical interventions by 30 percent without sacrificing quality of care.

There can be a disconnect between that abstract fact, however, and deciding how to take care of an individual patient.

“Nobody went to medical school to treat the GDP,” says Christopher Moriates, a physician and dean at Dell Medical School in Austin, Texas, who designs medical school curricula to teach appropriate use of tests.

Instead, medical educators are focusing on a different argument in an effort to teach judicious use of tests and treatments: the human costs of overtreatment.

Order enough medical tests, and they’ll inevitably yield abnormal results. Doctors then may feel obligated to treat those abnormalities — even if the patient would have lived a healthy life without knowing about them.

“It’s totally natural to think more information is just going to be better,” says Moriates. “Eventually it leads to patients feeling less well than they actually are, if you uncover things that are meaningless but abnormal.”

Take my patient with the rectal bleeding. After my overzealous workup, I talked through his case with a more experienced doctor. He told me what I now know from more clinical experience: The patient’s bleeding was almost certainly caused by hemorrhoids, and watching and waiting for a few weeks would have been safe and helped the patient avoid an invasive procedure.

Moriates and other medical educators are exploring ways to teach this concept early in medical education, as I was lucky to experience. They want to help medical students and residents curb these habits before they become ingrained.

One area that seems to have some promise? Harnessing doctors’ competitive spirit and showing them how they compare to their peers.

Internist and Columbia assistant professor Joshua Geleris published a study in 2018, for example, that examined the sheer number of tests that internal medicine residents ordered during the 2016-2017 academic year at a New York residency program. Geleris and his co-authors didn’t distinguish between tests ordered on different types of patients, since all residents spend equal time in intensive care units and regular hospital floors.

What they found, Geleris says, is that some residents ordered seven to eight times more tests than their peers. It’s hard to say what number of tests is the right one, Geleris adds, but the variability is concerning.

“They’re just trying to get their work done and make sure the attending is happy the next day,” he says.

At Johns Hopkins Hospital in Baltimore, Md., a group of professors is working to provide similar data to their residents in real time, with the hope that it might encourage doctors to think more carefully about what tests are truly necessary.

Johns Hopkins radiologist Pamela Johnson, an associate professor who teaches residents about appropriate use of tests, says she and her colleagues give out personalized reports that show how individual doctors compare to their peers. She’s currently studying whether or not these reports are effective in reducing the number of CT scans ordered to check for blood clots in the lungs. There are clear guidelines for when a CT scan is the right test to check for clots, she says, but they’re often ignored, in part, because doctors are afraid of missing a life-threatening diagnosis.

“The best way to avoid a diagnostic error is to avoid an unnecessary test,” Johnson says.

This kind of peer pressure may be helpful for fully trained doctors, too.

Internist Adam Cifu, a professor at the Pritzker School of Medicine in Chicago who has written about medical overuse, recalls a meeting several years ago with an infectious disease physician charged with decreasing unnecessary antibiotic use in the hospital. That physician told Cifu he was one of his department’s worst offenders when it came to using broad-spectrum antibiotics for ordinary urinary tract infections. Knowing that he was over-treating compared to his colleagues, Cifu says, made him rein in his prescribing almost immediately.

“We’re all ridiculously obsessive high achievers,” Cifu says. “Seeing that I’m not in the 90th percentile or above kills me.”

Medical school professors are hoping to further harness this competitive spirit when it comes to teaching students and residents to test and treat responsibly. Johns Hopkins associate professor Lenny Feldman, a physician who works with Johnson to develop educational tools, says he’s hopeful these “report cards” will help normalize more judicious ordering of tests.

“We have to break the cycle somewhere,” Feldman says.

Mara Gordon is a family physician in Washington, D.C., and a health and media fellow at NPR and Georgetown University School of Medicine.

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If Rock Stars Weren’t Rock Stars

House musician Jonathan Coulton leads a music parody game alongside host Ophira Eisenberg on Ask Me Another at the Bell House in Brooklyn, New York.

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Get out those guitars: It’s music parody time in a word game where the names of famous musical acts are mashed up with regular-people occupations.

Heard on Retta: Tweet Yo’ Self.

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Hockey Fact Bag With Retta

Jonathan Coulton and Ophira Eisenberg play a round of Fact Bag with Retta, on Ask Me Another at the Bell House in Brooklyn, New York.

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It’s the Stanley Cup of public radio bags: Fact Bag. In this hockey-themed edition, Los Angeles Kings fan and Good Girls star Retta joins Ophira Eisenberg and Jonathan Coulton to discuss three NHL trivia questions, one for each period in a regulation game. Will they guess the answers, or will they be sent to the penalty box?

Heard on Retta: Tweet Yo’ Self.

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Guidance: Today’s Foul Language

In a tweet this morning, the president uses the word “bullshit” to characterize some of the “statements made in the ‘Report’ about me.”

As with yesterday’s guidance about an F-bomb, our position is that we’re not going to say the word on the air. If we do refer to the line, we can say he called some of the statements “B.S.,” but should make clear that he used the actual word.

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Silicon Valley Has Its Tech Campuses. Now It Wants A Monument

A tourist takes a selfie at Google’s sculpture garden in Mountain View, Calif.

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As much as Silicon Valley is an actual place, it has no official borders or capital. It’s a nickname, not a name on a map. But now there might be a monument about its glory.

The San Jose City Council approved a design competition for a landmark that would symbolize the tech industry’s power and influence. There isn’t a single architectural icon to represent Silicon Valley, like the Hollywood sign or the Empire State Building.

Apple Park’s visitor center has a store, cafe and roof with views of the main building for the public.

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Tourists line up to take photographs in front of Facebook’s “like” sign, which has become a landmark in Silicon Valley.

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However, Silicon Valley has long been physically defined first by its modest, unremarkable suburban office parks. Then, in the past few years, tech giants began erecting grandiose campuses designed by superstar architects. These buildings, such as Apple’s new headquarters and Frank Gehry’s addition to Facebook, can be seen as corporate monuments. They convey a sense of permanence and establishment, instead of the fluidity and flexibility that defined startup culture.

Tourists use augmented reality to explore Apple’s visitor center.

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“This is what rich and powerful people have done throughout history. Louis XIV built Versailles. The pope built St. Peter’s. The pharaohs built the pyramids,” said Louise Mozingo, a professor of landscape architecture and environmental planning at UC Berkeley who studies corporate landscapes. “And at this moment, the really rich and powerful are the technology companies.”

That’s what tourists already travel for. They want to see where their apps and devices are dreamed up.

Tourists shop and snap photographs at the Googleplex in Mountain View, Calif.

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“There’s an energy and a spirit here,” said Le Zhang, who runs a startup. “I want to show my friends who are visiting how Silicon Valley was built and what a success story looks like.”

He and his friend, who works at Apple in China, rode their bikes to notable tech sites. They went from Steve Jobs’ childhood home, where he and Steve Wozniak put together the first Apple computers inside the garage, to the HP Garage located on a residential street in downtown Palo Alto. A handful of tourists were already snapping pictures of where classmates Bill Hewlett and Dave Packard started their company 80 years ago.

Bella Chen takes a photograph of the iconic garage where HP started in Palo Alto 80 years ago.

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The Computer History Museum in Mountain View explores “the history of computing and its ongoing impact on society.”

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“It’s good to pay respect to these histories,” Zhang said, “but in the end, we need to make our own, make our own stories.” I joked that in a few years people will want to see the house he rents in Menlo Park. “I definitely hope so,” he said and laughed. Coming here is more a pilgrimage than a typical vacation.

People wait in line at the “like” sign outside Facebook’s headquarters. They eat and shop at Apple’s multimillion-dollar visitor center. They play in Google’s colorful candy land with sculptures of the Android mascot.

Top: Google’s colorful corporate fleet of bikes take employees — and tourists — around its many buildings. Tourists come to Silicon Valley to explore tech campuses, such as Google’s (left), and to see where it all began, like the garage where Steve Jobs and Steve Wozniak put together the first Apple computers.

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Then, they post about it on social media. On Instagram, @ravikiran_kondoju captioned a photo at Google with #CantImagineLifeWithoutGoogle and @meredithwild posted a photo of herself at the Apple campus with the caption “This tech nerd is very happy!” and #oneinfiniteloop.

Access to these campuses lets visitors satiate their obsession with technology. “People are in awe of an industry that’s so ubiquitous in our lives,” said photographer James Tensuan, who grew up in Mountain View and documents tech culture.

Apple Park is a private campus, but the company built a visitors center for the public.

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But these slivers of public space on the campuses can feel like a facade. Instagram user @tobiblond captioned his picture at the Facebook thumbs-up sign: “Finally found all my data.” The openness and friendliness convey a sense of false transparency at a time when Silicon Valley is under intense scrutiny.

The animosity for how smartphones, social networks and monopolistic policies undermine society is growing, so it’s not surprising that the industry is trying to immortalize its legacy in the landscape of Silicon Valley.

A man takes a photograph of a Google street sign at its headquarters in Mountain View.

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Samantha Clark is a writer and photo editor based in Washington, D.C. Follow her on Instagram @samanthabrandyclark.

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A Promising Anti-HIV Drug Poses A Dilemma

The anti-HIV drug dolutegravir is effective — but may carry a risk for pregnant women.



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If you live in a wealthy country, you have choices about your medical care.

Let’s say you’re a young woman who is HIV positive and find out there’s a new treatment that’s much better for your long-term health. But there’s a potential problem: If you get pregnant, the drug could cause a serious birth defect in your baby.

In the U.S., Europe and other wealthy areas, a doctor will explain the benefits and the risks. If you choose the new drug, the doctor will prescribe birth control. If you want to get pregnant, the doctor will guide you through a period of taking the old drug, then get you back on the better drug when it no longer could endanger the fetus.

Now, say you live in a poor country. There aren’t enough doctors and nurses to explain the risks and benefits of the new drug to every patient. Your country may not have the resources to keep supplies of two different drugs on the shelves. And there is no consistent access to effective birth control.

So what will those poor countries do in this kind of situation? Some will offer the new, better drug only to men and to women beyond child-bearing years. Some won’t offer the new drug at all. Many younger women will get the second-best treatment for AIDS simply because they’re of child-bearing age.

That’s the dilemma faced by many countries which don’t have the resources to offer patients the same choices that people in rich countries have. The problem was explored in a new study released this month in the Annals of Internal Medicine.

Unexpected Finding

The new study was a response to a surprising result from a clinical trial comparing two AIDS treatments. Between November 2016 and May 2018, 426 HIV-positive pregnant women in Botswana were given a new drug designed to treat their symptoms and help prevent HIV transmission to the baby and to the women’s sex partners. First reports from the clinical trial published in June 2018 in the Lancet showed that the new drug was, indeed, more effective than the old drug with fewer side effects.

But as time went by and more babies were born, the researchers became alarmed about the drug’s impact. Among the group of women who took the new drug during the period that they conceived the child, four of them gave birth to infants with severe brain defects. In a flash, a promising international AIDS treatment strategy that was on the verge of being rolled out in sub-Saharan African countries was thrust into a world of uncertainty.

The new study estimated what could happen if millions of poor HIV-positive African women of child-bearing age were given the new, more effective drug. How many babies might be harmed? On the other hand, if the more effective drug were withheld, how many adult women would suffer health consequences? It has become a complicated equation, calling attention to a larger problem: How do very poor countries balance the health of women with the health of the babies they might bear?

At first, a clinical trial found no apparent danger from the new drug, according to a Lancet study looking at births to HIV-infected women in Botswana from 2014 through September 2017. The 6,322 women in the study were receiving two different AIDS treatment drugs. The first reported results of the study showed no difference in birth defects among babies born to women who were taking a new HIV-treatment drug called dolutegravir compared to those taking an older treatment drug called efavirenz.

That was good news. The price of the new drug, thanks to negotiations by international organizations, had just been dropped to an affordable level. In September 2017, the Bill and Melinda Gates and the Clinton Foundations had worked with dolutegravir’s manufacturer to provide the drug to developing countries for less than $75 a year per patient — a fraction of its cost in wealthy nations. Several sub-Saharan nations started making plans to provide it for their HIV-positive populations, says Dr. Caitlin Dugdale, lead author of the new study and infectious disease specialist and researcher at Massachusetts General Hospital.

(Editor’s note: The Gates Foundation is a funder of NPR and this blog.)

Dolutegravir has been the first-line treatment for HIV in the U.S. and Europe since 2014. Like efavirenz, the pill is taken just once a day. But the newer drug is even is more effective, has fewer side effects like lethargy and is less likely to stop working if people occasionally forget to take their pills, Dugdale says.

With the newly negotiated price reduction “we could provide incredible care for AIDS patients in resource-poor countries,” says Dr. Rochelle Walensky, infectious disease specialist and senior author of the study. “There was this massive effort to make [dolutegravir] available around the world.”

Stopping Distribution … But Not Everywhere

But just then, in May 2018, the bad news about possible birth defects hit, bringing the roll-out efforts in many poor countries to a halt.

The four babies whose mothers took dolutegravir were born with part or most of their brain missing – and they died as a result. It was a small risk—about 0.9 percent—but the risk was far greater than the 0.1 percent risk of such a brain defect among the women taking the older drug.

The numbers are small, and more research is needed to determine if the fatal brain defects were the result of dolutegravir or if they were caused by some other factor like inadequate folic acid.

“This is a signal, not a finding,” says Dr. Anne Drapkin Lyerly, an OB-GYN and professor of bioethics at the University of North Carolina at Chapel Hill. “We don’t really know if [dolutegravir] is a risk.”

Until more is known, the hope in the global health community around this new, improved AIDS treatment fell. “There was this screeching halt to efforts to supply dolutegravir,” says Walensky. “There was fear.”

And the fear was specific to using the new drug in poor countries. Dolutegravir is still widely used in wealthy countries with enough doctors and good access to birth control.

Healthgap, an international agency that advocates for access to life-sustaining HIV drugs, put out a report in November 2018, noting that some 70 low- and middle-income countries are re-evaluating their plans to roll out the new drug.

Trying To Predict The Future

As poor countries began to put the brakes on plans to roll out dolutegravir, researchers got busy. Walensky, Dugdale and others developed a mathematical model projecting health outcomes for 3.1 million South African HIV-positive women of child-bearing age and their children over the next five years. They believed it was crucial to give policymakers in poor countries the best possible estimation of the health consequences to both adults and babies if women were given — or if they were denied — access to the new drug. They compared outcomes assuming different possible policies. What would happen if all HIV-infected women took the newer, more effective drug, dolutegravir? And what would happen to their children if the drug does in fact cause the defects? How did that compare to a scenario where all those women took the currently available drug, efavirenz?

What they found were difficult trade-offs. The newer drug would save thousands of women’s lives and halt the spread of HIV to tens of thousands people—but at the cost of fatal brain defects in a few thousand infants.

But, of course, not all women of child-bearing age want to become pregnant. And it would be indefensible if poor countries developed policies that would give all women the older, less effective drug because they might get pregnant, says Daniel Wikler, professor of ethics and population health at Harvard’s T. H. Chan School of Public Health. “That would mean that some women are going to die because they’re at risk for pregnancy,” he says, even if they have no plans to become pregnant.

A Call For Equality

Women are making it clear that they want control over their options for treatment, says Dugdale. At the July, 2018, meeting of the International AIDS Conference, she met 39 women with HIV from AfroCAB (African Community Advisory Board), a network of community HIV treatment advocates. “These women were passionate about this topic,” she says. “And they were well-informed.” They know that it’s likely that older men, not women of child-bearing age, are the people making decisions about which drug treatment will be available in their countries, Dugdale said.

They wrote a statement at the AIDS conference that said, in part: “We believe in our ability to make decisions about our reproductive health, including when to have children and what medications are best for us.” And they asked for improved access to birth control.

In other words, they want the same right to choose their treatment and their destiny as women in wealthy countries.

Susan Brink is a freelance writer who covers health and medicine. She is the author of The Fourth Trimester, and co-author of A Change of Heart.

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House Judiciary Chairman Jerry Nadler Subpoenas Full Mueller Report

House Judiciary Committee Chairman Jerry Nadler has said, “This committee requires the full report and the underlying materials because it is our job — not the attorney general’s — to determine whether or not President Trump has abused his office.”

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The House Judiciary Committee issued a subpoena on Friday to the Justice Department demanding access to the full work product of special counsel Robert Mueller, including grand jury testimony and other material not made public.

Chairman Jerry Nadler, D-N.Y., said he wants everything by May 1.

“I am open to working with the department to reach a reasonable accommodation for access to these materials. However I cannot accept any proposal which leaves most of Congress in the dark, as they grapple with their duties of legislation, oversight and constitutional accountability,” Nadler said in a statement.

Attorney General William Barr has offered key congressional leaders access to a version of the report with less redaction, and DOJ laid out a process for a dozen top Hill leaders from both parties, as well as select staff, to see that version of the report in secure reading rooms over the next couple of weeks.

The demand for the full report and underlying evidence to be seen by the full House Judiciary Committee goes beyond that.

Continued Nadler

“My committee needs and is entitled to the full version of the report and the underlying evidence consistent with past practice. The redactions appear to be significant. We have so far seen none of the actual evidence that the special counsel developed to make this case. Even the redacted version of the report outlines serious instances of wrongdoing by President Trump and some of his closest associates. It now falls to Congress to determine the full scope of that alleged misconduct and to decide what steps we must take going forward.”

The move followed weeks’ worth of tensions between Nadler and Barr, who has said he is prohibited by laws, regulations and longstanding department practice from revealing some of the underlying evidence in the report on Russian interference in the 2016 election.

Barr had agreed to negotiate with Nadler and the chairman of the Senate Judiciary Committee, Lindsey Graham, R-S.C., about giving them more information than had been included in the redacted version of Mueller’s report provided to Congress and the public on Thursday.

Those talks didn’t move far enough or fast enough for Nadler, who announced that he was formally serving the subpoena on Barr and DOJ that his committee authorized him to use, if necessary, on April 3.

The next phase of the duel appears likely to take place before a judge.

Barr told Congress that he didn’t believe the exceptions to revealing grand jury material applied in the case of Nadler’s demand. The Federal Rules of Criminal Procedure do have some exceptions to grand jury secrecy — but not one for Congress to access it, he said.

“The chairman of the Judiciary Committee is free to go to court if he feels one of those exceptions is applicable,” Barr told Congress.

The attorney general also responded wryly when asked by Republicans on a Senate Appropriations Committee panel if he was concerned that giving grand jury material to Congress would increase the chances that it might find its way into the open press.

“I mean, that’s been known to happen,” said Sen. John Kennedy, R-La.

“Yes, occasionally,” Barr agreed — but the integrity of the grand jury system depends upon the people involved knowing that the work will remain protected, he said.

Attorney general or advocate for White House?

Democrats argue they can’t trust Barr to represent honestly what Mueller has developed.

Barr began arguing even before he was nominated to become attorney general that Mueller’s investigation of obstruction was legally flawed, Democrats observe — and thus they need to see all of what Mueller discovered and not view it through any filter created by Barr.

Nadler also has made clear that he believes Congress must keep its own counsel on the major questions facing the country about Trump’s conduct.

Just because Barr has concluded that Trump won’t face prosecution for the actions he has taken doesn’t mean that Congress shouldn’t assess them for its own purposes, Nadler argued.

“This committee requires the full report and the underlying materials because it is our job — not the attorney general’s — to determine whether or not President Trump has abused his office,” Nadler said.

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