Less Health Care is Better, Not More

by Jeffrey Dach MD

A shocking "medical heresy" was quietly stated in a mainstream medical journal last week.(1)   Less health care is better than more health care.  Dr. Deborah Grady's editorial in the May 10 Archives of Internal Medicine throws a giant egg on the face of mainstream medicine.  It is generally assumed and expected that health care offers some benefit to our health.  Yet, Dr Grady points out that when health outcomes are actually studied, the data shows that more health care leads to worse outcomes. (2,3)  This revelation isn't new, and is actually old news, like a worn and familiar piece of clothing.  The real news story is that this "medical heresy" somehow eluded censorship by the editorial board and appeared in print in a mainstream medical journal.  Are mainstream doctors getting fed up?  Is this the opening salvo of a medical revolution? 

Above Left image: Courtesy of Deborah Grady MD

Examples of Harmful Medical Care

Dr Grady cites specific examples of treatments that result in harm, with adverse effects outweighing the benefits.  The first example is synthetic "monster" hormone therapy used by the mainstream medical system, which was found to cause cancer and heart disease in the famous 2002 Women's Health Initiative study. (4)   It seems incredible, but true.  The mainstream medical system used Synthetic "monster" hormones for years until the WHI (Women's Health Initiative) study finally convinced millions of women to switch to safer and more effective bioidentical human hormones.  My previous articles on the safety and importance of bioidentical hormones discusses this at length. (5)(6)

Dr. Grady's second example is the discredited practice of arthroscopic surgery for osteoarthritis.  Millions of these useless procedures were performed in the late 90's until it was abandoned after randomized trials showed no benefit.(7) My previous article on the power of the placebo discussed this.(8)

Left Image: Egg Sunny Side Up Courtesy of Wikimedia Commons
 
A third example is the case of SSRI antidepressant drugs which have little benefit for patients with mild to moderate depression.  The benefits of SSRI drugs are equivalent to placebo pills.(9)  Dr. Grady points out that in cases of mild depression, the known adverse effects of SSRI antidepressants clearly outweigh the benefits.  My previous article on SSRI antidepressants  discussed this.(10)

A Fourth example is screening mammography.   "The adverse effects of mammography—false-positive findings, biopsies, anxiety, and overdiagnosis and treatment of latent cancers may overwhelm the benefit." (11)  My previous article on screening mammography  discussed this.(12)

Dr Grady's final example is the over-use and misuse of antacid drugs called proton pump inhibitors (PPI's), which have serious adverse effects of increased rates of fractures, Clostridium difficile infection, and increased risk of pneumonia. (13-18) I discussed the harms and benefits of acid blocker drugs in a previous article . (19)

Reducing Medical Care Opposed as "Rationing"

Dr Grady reminds us that the term "rationing" is frequently misused and abused in health care debates.  In politics, those who want more health care oppose those who propose less health care.  Less health care is called "rationing",  a term originating in the wartime practice of rationing food, fuel and other scarce goods, and services, and may not apply to over use of health services which causes harm rather than benefit.

Above left image: President Obama Signs the Health Care Reform Bill, courtesy of Wikimedia Commons.

A False Hope - Bone Marrow Transplantation for Breast Cancer

A perfect example of misuse of the term "rationing' is the discredited bone marrow transplantation for breast cancer.  Starting in the 1980's, thousands of procedures were done costing up to 400,000 dollars each.  While many women stricken with advanced illness clamored for the "lifesaving" procedure, their health insurance companies balked at paying for an experimental and unproven treatment.  A media and legal campaign ensued claiming the insurance companies were cruel tyrants withholding or "rationing" a "lifesaving" treatment.  After a couple of decades of harming thousands of severely ill women, medical studies were eventually done, and these showed the procedure had no merit, causing it to be discredited and abandoned.  Clearly, the term "health care rationing" is misused when applied to a sham procedure that causes more harm than good.

This incredible story of bone marrow transplantation for breast cancer can be found in an excellent article by Nicholas Gonzalez MD, and also in a book which documents the story called False Hope. (20-22)

More Examples: Drugs that Don't Work

The misguided use of the term "health care rationing"  applies to blockbuster drugs developed over the last few decades that are in fact, Bad Drugs.  These patented drugs are expensive, yet have marginal effectiveness, and horrendous adverse side effects.  In spite of this, thanks to drug company advertising, the television viewing audience clamors for these "lifesaving drugs", complaining that high cost and lack of insurance coverage amounts to "health care rationing".  An excellent book on this topic entitled, Drugs that Don't Work, Natural Therapies that Do, is available from Dr. David Brownstein.(25)

Solution: Less Health Care

When the health care system is dominated and corrupted by huge corporations that place profit over people, the end result is a health care system that produces more harm than good. Hence, the sage old doctor's advice Doing Nothing is frequently the best treatment plan, and one offered by my medical school advisor, Dr Neil Kurtzman, as the title for his first book.(23) 

Of course, the real solution involves liberating the practice of medicine from the shackles of corporate and government control.  Athough somewhat draconian, an excellent first step would be the elimination of the entire health insurance industry.   Don't hold your breath, as this is unlikely to happen any time soon, judging by the recent "health care reform" signed into law by President Obama.  This latest "health care reform" effort amounts to a giant government subsidy for the health insurance industry with very little in return.  Above Left Image: Courtesy of Neil Kurtzamn MD

Credit and Thanks to Deborah Grady MD for much of the material for this article. (24)

Links and References
(1) http://archinte.ama-assn.org/cgi/content/full/170/9/749
Less Is More, How Less Health Care Can Result in Better Health
Deborah Grady, MD, MPH; Rita F. Redberg, MD, MSc,  Editor
Arch Intern Med. 2010;170(9):749-750.

(2) http://www.annals.org/content/138/4/288.abstract
Fisher ES, Wennberg DE, Stukel TA, Gottlieb DJ, Lucas FL, Pinder EL. The implications of regional variations in Medicare spending, part 2: health outcomes and satisfaction with care. Ann Intern Med. 2003;138(4):288-298.

(3) http://www.annals.org/content/138/4/273.abstract
Fisher ES, Wennberg DE, Stukel TA, Gottlieb DJ, Lucas FL, Pinder EL. The implications of regional variations in Medicare spending, part 1: the content, quality, and accessibility of care. Ann Intern Med. 2003;138(4):273-287.

(4)http://jama.ama-assn.org/cgi/content/abstract/288/3/321
Rossouw JE, Anderson GL, Prentice RL; et al, Writing Group for the Women's Health Initiative Investigators. Risks and benefits of estrogen plus progestin in healthy postmenopausal women: principal results from the Women's Health Initiative randomized controlled trial. JAMA. 2002;288(3):321-333. 

(5) http://jeffreydach.com/2008/06/27/the-safety-of-bioidentical-hormones-by-jeffrey-dach-md.aspx 
The safety of bioidentical Hormones by Jeffrey Dach MD

(6) http://www.drdach.com/BioIdentical_Hormones.html
The Importance of bio-identical Hormones by Jeffrey Dach MD

(7) http://content.nejm.org/cgi/content/abstract/347/2/81
Moseley JB, O'Malley K, Petersen NJ; et al. A controlled trial of arthroscopic surgery for osteoarthritis of the knee. N Engl J Med. 2002;347(2):81-88.

(8) http://jeffreydach.com/2007/05/22/the-power-of-the-placebo--by-jeffrey-dach-md.aspx
The Power of the Placebo by Jeffrey Dach MD

(9) http://jama.ama-assn.org/cgi/content/abstract/303/1/47
Fournier JC, DeRubeis RJ, Hollon SD; et al. Antidepressant drug effects and depression severity: a patient-level meta-analysis. JAMA. 2010;303(1):47-53.
 
(10)
http://jeffreydach.com/2010/01/21/jama-says-ssri-antidepressants-are-placebos-by-jeffrey-dach-md.aspx 
Antidepressants Found to Be No Better Than Placebo.

(11) http://jama.ama-assn.org/cgi/content/full/303/2/164
Woloshin S, Schwartz LM. The benefits and harms of mammography screening: understanding the trade-offs. JAMA. 2010;303(2):164-165.

(12)
http://jeffreydach.com/2009/11/17/mammogram-guideline-reversal-by-jeffrey-dach-md.aspx
Mammogram Guideline Reversal by Jeffrey Dach MD

(13) http://archinte.ama-assn.org/cgi/content/abstract/170/9/765
9. Gray SL, LaCroix AZ, Larson J; et al. Proton pump inhibitor use, hip fracture, and change in bone mineral density in postmenopausal women: results from the Women's Health Initiative. Arch Intern Med. 2010;170(9):765-771. FREE FULL TEXT 

(14) http://archinte.ama-assn.org/cgi/content/abstract/170/9/784
10. Howell MD, Novack V, Grgurich P; et al. Iatrogenic gastric acid suppression and the risk of nosocomial Clostridium difficile infection. Arch Intern Med. 2010;170(9):784-790. FREE FULL TEXT 

(15) http://archinte.ama-assn.org/cgi/content/abstract/170/9/772
11. Linsky A, Gupta K, Lawler EV, Fonda JR, Hermos JA. Proton pump inhibitors and risk for recurrent Clostridium difficile infection. Arch Intern Med. 2010;170(9):772-778. FREE FULL TEXT 

(16) http://www.annals.org/content/149/6/391.abstract
12. Sarkar M, Hennessy S, Yang Y-X. Proton-pump inhibitor use and the risk for community-acquired pneumonia. Ann Intern Med. 2008;149(6):391-398.  

(17)http://jama.ama-assn.org/cgi/content/abstract/301/20/2120
13. Herzig SJ, Howell MD, Ngo LH, Marcantonio ER. Acid suppressive medication use and the risk for hospital acquired pneumonia. JAMA. 2009;301(20):2120-2128. 

(18) http://archinte.ama-assn.org/cgi/content/full/170/9/747
14. Katz MH. Failing the acid test: benefits of proton pump inhibitors may not justify the risks for many users. Arch Intern Med. 2010;170(9):747-748. 

(19) http://jeffreydach.com/2009/09/14/heartburn-and-acid-blockers-by-jeffrey-dach-md.aspx  Heartburn and Acid Blockers by Jeffrey Dach MD

Bone Marrow Transplant for Breast Cancer

(20) http://www.dr-gonzalez.com/bias.htm
Academic Bias and Fraud: The cases of bone marrow transplantation for breast cancer, and HIV-nevirapine By Nicholas J. Gonzalez, M.D.

(21) http://www.amazon.com/False-Hope-Marrow-Transplantation-Breast/dp/0195187768
False Hope: Bone Marrow Transplantation for Breast Cancer [Hardcover]
Richard A. Rettig (Author), Peter D. Jacobson (Author), Cynthia M. Farquhar M.D. (Author), Wade M. Aubry M.D. (Author)

(22) http://www.jcojournal.org/cgi/content/full/26/1/11
Journal of Clinical Oncology, Vol 26, No 1 (January 1), 2008: pp. 11-12
EDITORIAL A Dramatic Story of Hope and Reality Edward A. Stadtmauer

(23) http://medicine-opera.com/doing-nothing-reviews/
Neil A Kurtzman MD is the Grover E Murray Professor and University Distinguished Professor, Department of Internal Medicine at Texas Tech University Health Sciences Center in Lubbock. He has combined careers in clinical medicine, education, basic research, and administration for more than 30 years. Dr Kurtzman was my research advisor in medical school.

(24) http://whcrc.ucsf.edu/people/bios/grady_deborah.html
Deborah Grady, MD, MPH is Professor of Medicine, Associate Dean for Clinical and Translational Research and Director of the UCSF Women's Health Clinical Research Center. Dr. Grady is an international expert on menopause and the risks and benefits of postmenopausal hormone therapy. Dr. Grady has trained and mentored over 40 young researchers interested in women's health and received the Chancellor's Award for the Advancement of Women and the UCSF Mentor of the Year award.

(25) Drugs that Don't Work, Natural Therapies that Do,
 is available from Dr David Brownstein.
https://www.drbrownstein.com/bookstore_NaturalT.php

Jeffrey Dach MD
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