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Lack of Trust in the Healthcare System: The Reason We Have Not Embraced Telemedicine and Technological Medical Advancements

Written by Courteney

Posted on July 6, 2016 at 6:40 pm

By: Steve Okhravi MD, FACP, MBA, CPE
Courteney Pritchett
July 6, 2016

 

As of 2010, The Institutes of Medicine estimated 750 billion dollars in wasted medical resources. The unnecessary procedure, test and surgery rate may be as high as 35% among American doctors. Why is this happening, and more importantly, what can be done to reverse this economic pitfall?

 

Plenty can be done if we begin collectively utilizing available medical technology such as telemedicine. Unfortunately, there is a steadfast communal resistance to change from the traditional methods of delivering medicine to more innovative solutions. Before we see a positive change in our broken medical system, everyone must accept that the future is now, and it is here to help. Not only are patients leery of today’s rapidly advancing technology, but doctors are apprehensive to embrace it as well. When we are making use of current medical technology such as robotic surgery, we are often misusing it which contributes to mistrust. This suspicion and misuse has an adverse influence on innovation.

 

Unnecessary Cardiology Procedures

The unnecessary surgery rate in certain medical fields such as cardiology may exceed 20%. Unnecessary procedures are causing undue expenses, needless patient suffering, recovery, complications and in too many cases even patient death. Acknowledgement of the issue dates back as early as 1974, when a congressional report approximated 2.4 million avoidable surgeries were performed annually, resulting in over 12,000 patient deaths. With the ease of surgery nowadays, that number is expected to be much higher. Hundreds of doctors are being sued over their inappropriate surgical responses to patients’ easily treatable ailments. It is no wonder why patients are losing faith in our system.  

 

There is special contention surrounding stent and angioplasty overuse as there are no hard and fast rules for stents. Some cases fit in gray areas where the attending cardiologist sees a stent or angioplasty procedure as necessary, while other doctors may disagree when looking at the circumstances of the case on paper. Weighing in on the debate was an article written in USA today which dubbed interventional cardiology as one of the chief areas of unnecessary surgeries and procedures, largely based on a 2011 study done by Dr. Paul Chan et al. The article claimed at least 12% of stents and angioplasties surveyed were done needlessly. However, that number is argued to be much higher when looking beyond one study.

 

Whatever the exact statistics may be, there is no debate that the majority of cardiac stents are life-saving and necessary in response to emergency cardiovascular distress. However, there are some indisputable statistical outliers, including one Louisiana doctor who each year triples the national average for cardiac procedures, catheterizing and probing the arteries of hundreds of patients annually in his small rural county. Dr. David Jones, Harvard doctor, writer and historian says of the many doctors peppered throughout rural United States performing outrageous numbers of heart procedures, “You have to wonder what’s going on. Are these doctors going to get bigger paychecks at the end of the month for doing more of these procedures? That may be an uncomfortable question to ask, but it’s something patients should wonder about.” Dr. Jones raises a valid question, one worth investigating more closely.

 

If more cardiology patients utilized home monitoring technology or telemedicine for continued chronic condition management, perhaps issues that have been hastily dealt with using surgery could have been detected earlier. This may have resulted in less invasive treatments such as medication changes to reroute some of the issues.

 

The Appendectomy Debate

 

As many as two thirds of appendix surgeries may be unnecessarily performed. Up to 80% of appendicitis cases consist of mild-to-moderate flare-ups in which the organ isn’t under critical duress and hasn’t been perforated, therefore the inflammation can easily be treated by antibiotics. This is a much less intrusive measure than the commonplace yet potentially unneeded appendectomy surgery. Of course, some practitioners disagree on the issue.

 

Medical researchers from Nottingham Digestive Diseases Centre followed a group of patients with appendicitis who were treated with antibiotics to see how well it eradicated the affliction: 80% of patients suffered no subsequent flare-ups within the year, whereas the other 20% did have another attack. Thus, the study yielded that approximately 64% of appendectomies performed may be unnecessary. However, many doctors argue that an appendectomy is the only course of action that will guarantee the patient no more unpleasant appendicitis attacks in future and is therefore the only foolproof method of treatment. But what about cases where the patient may never have had another attack after initial treatment, yet endures superfluous surgery which comes with financial and possibly health-related consequences? It can be a hard call to make and is certainly situation-dependant, but the fact of the matter is that a significant share of appendectomies are unessential.

 

A Surplus Of Diagnostic Tests

 

Nearly 80 million CT scans are ordered annually in the United States today, compared to 3 million ordered in 1980. While diagnostic tests are invaluable tools for detecting disease, unnecessary CT scans expose patients to excess radiology, as well as excess cost. In 2009, findings by the Mount Sinai Medical Center and Weill Cornell Medical College in New York purported that $32.7 million was spent on inappropriately ordered tests that year alone. While tests should certainly be conducted when any concern is present, they are many times performed unnecessarily. For example, it is estimated that during 56% of routine physicals, doctors order complete blood cell count workups without any concerning reason. Unnecessary tests can lead to false positives, which can lead to more unnecessary tests. This adversely affects the patient’s care by causing undue worry, procedures and financial strain.

 

Misdiagnosis – Telemedicine Versus Brick-And-Mortar Medicine

 

While many people still dismiss the notion of telemedicine, this mistrust is unfounded and largely rooted in ignorance, as only a couple small studies have illustrated diagnostic errors through telemedicine. One particular study utilizing faux patients sought care from 16 different telemedicine websites to see if telemedicine doctors would catch clandestine skin issues, and ultimately several companies misdiagnosed their condition. Of these companies, the participants of the study surveyed a few and found that some had doctors working from overseas who were not board certified or sanctioned to practice in their particular state, which perhaps skewed the results. This is another unfortunate factor when it comes to examining telemedicine effectiveness and misdiagnosis that often isn’t taken into account: uncertified companies tarnish the overall reputation of the field. The majority of telemedicine companies are reputable and have experienced, knowledgeable, board-certified physicians on staff.

 

There isn’t enough data available at this time to determine the exact rate of telemedicine misdiagnosis as many factors have to be considered, but shockingly, over 20% of brick-and-mortar medical cases are misdiagnosed, often leading to worsening of a condition or even death. When it comes to telemedicine, unfortunately, people view these outlier studies as support for their mistrust, contributing to the mass resistance against technology. The bigger picture suggests telemedicine contributes a vast amount of good, allowing medical access to remote, under-resourced areas, providing an effective method of triage to cut down on ER congestion, providing chronic condition management, among many other beneficial services. Therefore, select studies that aim to debunk a blossoming field should be viewed with skepticism.

 

Gallbladder Removal

 

Over 7% of Americans deal with gallstones of varying degrees of severity. There are numerous gallbladder procedures available for patients, the most common by far being the laparoscopy for its minimally invasive nature and quick healing time. Even though the laparoscopy has greatly improved upon the once popular and more invasive cholecystectomy, there has long been a concern that the ease of the laparoscopy would lead to more procedures than before. It appears those concerns were founded, as there are over 700,000 laparoscopies alone performed yearly in the United States. Moreover, a whopping 40-50% of patients surveyed reported symptoms such as gas, bloating and pain that continued after they received the surgery. There are alternative treatment options available to those with gallstones, such as a lithotripsy (a procedure that uses high frequency sound waves to shatter the stones into tiny pieces that can exit the body more easily), medications for flare-ups, as well as diet and lifestyle changes that some patients can follow to reduce frequency and severity of attacks without having to resort to organ removal.

 

Unnecessary gallbladder surgery can lead to staph infections, long-term complications such as chronic diarrhea, or in rare cases even certain types of bowel cancer. For these reasons, doctors should be exploring less invasive and costly treatment and management options.

 

Colonoscopies and the Elderly

 

Needless colonoscopy screenings can cause not only financial strain on the patient and system, but also potentially serious health complications, namely for the elderly. Unnecessary colonoscopies take place with patients of all ages, but there should be an extra spotlight cast on the number of elderly patients that undergo superfluous and quite dangerous colonoscopy screenings. According to an alarming Texas study, nearly 25% of elderly Americans may be having needless colonoscopies, some of these patients even undergoing more than one. Colonoscopies do not come without risks. Even the healthiest patient can experience internal bleeding, a perforated bowel or consequent incontinence from the procedure, let alone an immunocompromised 75-year-old.

 

One study by JAMA Internal Medicine found that of the 75,000 elderly colonoscopies surveyed, over 18,700 may have been unnecessary. Unfortunately, it is not only doctors who must be convinced to cut back on these risky procedures. Because of previous campaigns to “get screened” over the years, most elderly patients feel colonoscopies are a necessary procedure for the aged individual to undergo. It will take some time and effort to move away from this mindset and prevent the medical system from subjecting frail persons to risky procedures in cases where benefits do not outweigh the hazards.  

 

Avoidable Prostate Surgeries

 

Another over-performed procedure that has garnered much attention is the overscreening and overtreatment of prostate cancer. There are approximately 240,000 cases of prostate cancer diagnosed, and more than 160,000 radical prostatectomies performed annually in the United States. There are not only high costs associated with these procedures, but also potentially devastating complications such as impotence, incontinence or even death (in over 1000 cases yearly). Some of these surgeries are being performed via Da Vinci surgical robots. It is debatable whether the robotic surgeries really improve upon recovery time or complications, which again may further people’s trust in medical technology.

 

According to the National Cancer Institute, prostate cancer accounts for approximately 14% of all cancer cases diagnosed in the United States. The five-year survival rate for prostate cancer is 99%, making it the highest among any type of cancer. Despite these relatively low-alarm statistics, prostatectomies are on the rise. Most cases of prostate cancer do not spread beyond the initially affected area, so a man can have this type of cancer for most of his life. One study published in the New England Journal of Medicine deduced that there was hardly any statistical difference in mortality between a group of observed patients who had prostatectomies and a group who kept a watchful eye on the progress of their disease.

 

Screening has saved countless lives, as early detection is to thank for prostate cancer’s lower mortality risk. However, many cases may be better treated with cautious monitoring or cancer medications, postponing invasive procedures unless the disease worsens. In response to this, the American Urological Association has adjusted its screening recommendations to discourage low-to-normal risk men under the age of 55 from undergoing PSA screening.

 

Misused Technological Resources

 

Surgical robots are installed in nearly a quarter of American hospitals, performing up to 400,000 surgeries annually. These metal surgeons have been making headlines as of late for causing complications and even avoidable deaths in patients. One particular study spanning 14 years has uncovered over 10 annual deaths and over 1000 injuries at the arms of robotic surgeons. These complications have been caused by malfunctioning equipment, parts of the robot dropping into the wounds, system errors and internal burns.

 

This problem has been especially noted in the gynecological arena, specifically concerning hysterectomies. An extensive study conducted by Columbia University medical researchers examined 264,000 hysterectomy patients over the course of 4 years. Da Vinci surgical robots accounted for over 20% of surgeries in hospitals that had them, and the rate at which robotic surgeries were being used increased from 0.5% to 10% over the 4 year period in these hospitals. Robotic hysterectomies were pushed in hospitals that had the Da Vinci systems, promising shorter recovery times and less risks. However, the study showed nearly identical outcomes between manual and robotic surgeries, except patient costs were much higher for robotic procedures. The issue seems to be that doctors recommend Da Vinci procedures indiscriminately, often for financial reasons, when they should be more case dependent and based on how comfortable the patient is receiving this care.  

 

While we certainly should be utilizing advanced medical technology such as robotic surgeons, it is essential to ensure the robots are properly serviced, extensively tested, and only used under the appropriate circumstances. Unfortunately, some hospitals are financially motivated to push, and sometimes overuse the surgery bots in order to recoup the millions they’ve spent purchasing them. This should not be the motivation, and it is causing undue suffering and patient expense by pressuring non-eligible patients into drone surgeries.

 

When compared to manual surgery, the complication rate may be much lower for drones, but studies like these influence the public to believe drones shouldn’t be used at all for surgery. Such overuse and misuse of medical technology strongly contributes to public mistrust of innovation in the field, which is counterproductive.

 

Choosing Wisely  

 

In 2012, the American Board of Internal Medicine (ABIM) launched a revolutionary and much needed campaign to promote awareness about unnecessary medical tests, treatments and procedures. Choosing Wisely was devised to initiate change on doctors’ and patients’ parts alike to avoid medical redundancies. This campaign has opened up a crucial nationwide dialogue about the problem and what must be done to fix it. Since the campaign’s launch, over 60 medical societies have joined the mission, helping shed light on hundreds of tests and procedures that are being overused and abused. According to a subsequent study, 73% of physicians agree there is a big problem in the industry with wasted resources, and 72% admitted to using unnecessary medical tests at least once a week. Similarly, 53% of physicians said they often order tests for overly insistent patients even though they know the tests to be unnecessary. This last statistic brings up an equally concerning point: patients have a role to play in Choosing Wisely too. Patients who blindly demand inappropriate testing often influence the doctor to go against his or her best judgment and proceed with a knowingly uncalled for test or procedure. This causes financial strain on the patient and the system overall. It may even cause potential harm to the patient from procedure complications or unnecessary exposure to x-ray radiation. In each case, both doctor and patient must come together to choose wisely and strike a balance between performing preemptive tests and impulsively ordering additional procedures.

 

A Staunch Resistance to Change

 

One of the major contributing factors to our medical debacle is the collective resistance to move forward with the times. Even though we live in a rapidly advancing technological world, we can’t seem to harness the problem-solving technology that is sitting directly under our fingertips. American doctors and patients alike are virtually ignoring a potentially superhero level solution: telemedicine. Many patients are stuck on the idea that brick-and-mortar is the only way to receive healthcare. But as the rest of our world advances technologically, why shouldn’t our medical system?

 

According to the AMA, telemedicine can handle up to 78% of all patient concerns. People can be treated, receive prescriptions, follow up with their attending physician, and have chronic conditions closely monitored via telemedicine. Despite this, the majority of people continue to make use of the nearest ER instead, causing overcrowding and further contributing to the problems with the healthcare system. Over 136,300,000 people flock to the ER annually, many for complaints that would be better handled at a clinic or through telemedicine. That aside, telemedicine can also save costs across the board. Travel expenses, time off work, unnecessary hospital visits and admissions, and the list continues. Technology is calling, but we’re not picking up the smartphone to answer. It is time to change that.

 

Conclusion

In summary, while many of these tests and procedures are case-dependent, for the sake of the country’s collective pocket and for patient safety, there must be more standardization when it comes to testing and over-performance of invasive treatment. The reason most doctors choose to err on the side of caution with extra diagnostic testing is that they often deem it better to over-test, over-diagnose and over-treat than to risk a dangerous missed diagnosis or lawsuit. But there has to be a better solution than billions of wasted dollars and procedure complication risks. Luckily, medicine is making modest strides in the right direction with such movements as Choosing Wisely, but there is still ample room for improvement.

 

A recent John Hopkins study asserts that nearly a quarter of patients distrust their primary care doctor, which can heavily influence whether they take medications prescribed for their conditions. So this distrust is hurting patients in more ways than one. But with over $6.8 billion spent on 12 particular unnecessary diagnostic tests and treatments alone each year, a needless surgery rate of over 20% and thousands of patient deaths annually due to needless procedures, it’s no wonder American citizens are beginning to lose faith. Patients also report feeling rushed and unheard by their doctors – another reason to consider other options such as telemedicine.

 

Hearing the horror stories of unnecessary surgery complications and reading worrying statistics leaves patients reluctant to seek care or follow the advice of their doctors. Award winning New Jersey family physician and medical writer Dr. Linda Girgis says of America’s lack of faith in the medical system, “Even our own Commander-in-Chief, President Obama has alluded to the fact that doctors have financial incentive to do more surgeries.” Dr. Girgis also notes statistical outlier doctors are skewing the results, making well-meaning doctors look untoward to patients. “Most doctors truly put patients’ care first, before profit. But there are a few who inappropriately use their medical degrees for profit. These doctors make us all look bad.”

 

It is clear from these blatant diagnostic and procedural wastes why the American populace is losing faith in our flawed medical system, but it is also clear that people haven’t been willing to open their eyes to see the bigger digital picture. As with everything, if we want change to happen, we all must work to initiate deliberate action. Collectively embracing telemedicine is exactly that action we need to be taking. Telemedicine can help alleviate so many of the problems in the system by cutting costs for everyone, saving time for doctors and patients, providing care to those who are out of reach or immobile, monitoring chronic conditions, as well as serving as an effective triage to help reduce ER congestion countrywide. Change is hard, yes, but doctors and patients alike need to embrace advanced solutions to help patients, the overstrained system and the country at large.

 

SOURCES:

http://www.telegraph.co.uk/news/health/news/9188433/Two-thirds-of-appendix-removals-unnecessary.html

https://www.minnpost.com/second-opinion/2013/03/many-older-americans-get-unnecessary-colonoscopies-study-finds

http://khn.org/news/michelle-andrews-on-unneccesary-tests-and-treatments/

http://emerald.tufts.edu/med/apua/consumers/faqs_2_4154863510.pdf

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1065571/

http://www.newyorker.com/magazine/2015/05/11/overkill-atul-gawande

http://www.telegraph.co.uk/news/health/news/9188433/Two-thirds-of-appendix-removals-unnecessary.html

http://www.usnews.com/news/articles/2015/02/11/are-doctors-exposing-heart-patients-to-unnecessary-cardiac-procedures

http://www.usatoday.com/story/news/nation/2013/06/18/unnecessary-surgery-usa-today-investigation/2435009/

http://www.choosingwisely.org/survey-physicians-are-aware-that-many-medical-tests-and-procedures-are-unnecessary-see-themselves-as-solution/

http://www.savvypatients.com/gallbladder_disease.htm

http://www.diagnose-me.com/symptoms-of/consequences-of-gallbladder-surgery.php

http://www.everydayhealth.com/gallbladder/laparoscopic-gallbladder-surgery.aspx

http://healthland.time.com/2012/07/19/study-surgery-for-early-prostate-cancer-doesnt-save-lives/

http://tucson.com/news/local/ua-researcher-says-many-men-are-undergoing-prostate-surgery-unnecessarily/article_7b381c3b-d9c5-5b06-a020-6dac0a30de45.html

http://www.usnews.com/news/articles/2015/02/11/are-doctors-exposing-heart-patients-to-unnecessary-cardiac-procedures

http://www.bbc.com/news/technology-33609495

http://www.today.com/id/25890068/ns/today-today_health/t/dear-doctor-weve-lost-our-faith-medicine/#.V17bzfkrLIU

http://www.physiciansweekly.com/doctors-losing-publics-trust/

http://audetlaw.com/davinci-surgical-robot-misused-for-hysterectomies-and-other-procedures/

http://www.foxnews.com/health/2016/05/16/study-telemedicine-finds-misdiagnoses-skin-problems.html

 

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