Is Our Current Approach to Medicine Insane? Part I

Dr. Sarah LoBisco, ND
@DrLoBisco

A fact that many naturopathic, functional, and integrative practitioners have been well-aware of, and frankly alarmed by, is the ineffectiveness of our current healthcare model to effect meaningful and lasting positive changes in our society’s wellness outcomes. In fact, many doctors, regardless of specialty, are discouraged that even if their patients reach target values in lab test ranges or achieve stable imaging results,¹ they still seem to lack “physical and mental well-being,” the definition of health by the American Medical Association (AMA).²

In this blog, I’m going to review some sad statistics of our current medical care system and provide some explanations for why these dreary outcomes continue. Finally, I’ll discuss that unless we change our current approach, we won’t be able to achieve the healthy nation that we all desire.

An Unhealthy (U.S.) Nation

A recent analysis published by the Common Wealth Fund compared 13 high-income countries in regards to health care spending, supply, utilization, prices, and health outcomes. Using data compilations from the Organization for Economic Cooperation and Development and other cross-national analyses, Australia, Canada, Denmark, France, Germany, Japan, Netherlands, New Zealand, Norway, Sweden, Switzerland, the United Kingdom, and the United States were assessed. The data, which predated the major insurance provisions of the Affordable Care Act, concluded:

In 2013, the U.S. spent far more on health care than these other countries. Higher spending appeared to be largely driven by greater use of medical technology and higher health care prices, rather than more frequent doctor visits or hospital admissions. In contrast, U.S. spending on social services made up a relatively small share of the economy relative to other countries. Despite spending more on health care, Americans had poor health outcomes, including shorter life expectancy and greater prevalence of chronic conditions.”
The analysis reported health care spending at 17.1 percent of the U.S. GDP, making our country devote at least 50 percent more of its economy to health care than other countries.³

I think it’s important to note that although Obamacare may have afforded more people with access to modern healthcare, it may not have provided more admittance to the right solution. This may be why in 2007, 38% of Americans were seeking complementary or alternative health care, according to the National Center for Complementary and Integrative Health (NCCIH).⁴

“Doc, Is That Test Really Necessary?”

As noted by the Commonwealth Fund report, a large amount of spending is due to greater use of medical technology, yet these methods aren’t resulting in quality health care. This recognition of excess expenditure on testing has not gone unnoticed. The Choosing Wisely campaign was initiated with the goal of patients and clinicians to choose care that is, “supported by evidence, not duplicative of other tests or procedures already receive, free from harm, and truly necessary.” It currently consists of more than 70 lists of medical practices and procedures determined to be of little clinical benefit and specialty societies recommend their judicious use.
The campaign was formally launched in 2012 with the ABIM (American Board of Internal Medicine) and Consumer Reports. It was built on the 2010 work of Howard Brody, MD, who published “Medicine’s Ethical Responsibility for Health Care Reform-The Top Five List” in the New England Journal of Medicine. This was followed by the National Physicians Alliance’s (NPA) set of three lists for physicians in internal medicine, family medicine and pediatrics to use health care resources more effectively, initially published in Archives of Internal Medicine.^5,6

Recently, a retrospective analysis aimed to study the effectives of “Choosing Wisely.” The study consisted of “claims data for members of Anthem-affiliated commercial health plans. The low-value services selected were (1) imaging tests for uncomplicated headache; (2) cardiac imaging without history of cardiac conditions; (3) low back pain imaging without red-flag conditions; (4) preoperative chest x-rays with unremarkable history and physical examination results; (5) human papillomavirus testing for women younger than 30 years; (6) use of antibiotics for acute sinusitis; and (7) use of prescription nonsteroidal anti-inflammatory drugs (NSAIDs) for members with hypertension, heart failure, or chronic kidney disease.”⁷

The results weren’t too impressive and the authors concluded modest changes for two recommendations (headache and cardiovascular imaging in low-risk patients) and marginal effect sizes, “and although 4 of the 7 lists had statistically significant changes—unsurprising given the large sample size—the clinical significance is uncertain. These results suggest that additional interventions are necessary for wider implementation of Choosing Wisely recommendations.”^6,7

Therefore, it appears that doctors are still widely using expensive tests and technology that may not be clinically useful. Hence, our health care bills increase and our outcomes are not affected.

Another issue with medical technology is the disagreement of certain tests as truly medically necessary for clinical outcomes. For example, the mammography controversy, which I wrote about here, was recently sparked again by the American Cancer Society’s release of their recommendation to delay annual mammograms until 45 years old. This re-ignited heated debates among various specialty organizations for and against the guidelines.^8.9(Maybe the new hand-held optical scanner for noninvasive imaging will provide an option for consensus?)¹⁰

“What Do You Mean My Tests May Not Be Valid!?”

Perhaps, one of the biggest contributors to why our health outcomes aren’t making the grade is that our measurements are off. 1,^11-15 An estimated 60-70% of decisions for patient care are based on lab results,^1,11,12 yet these results are highly variable based on the lab, the instruments used, and a person’s age and gender. Furthermore, all labs use different reference ranges, complicating interpretations and consensus. Another issue is that these ranges are based on different populations of individuals who not displaying symptoms of a specific disease that the lab is set to determine.^11-15 This doesn’t necessarily making these ranges optimal measures of health. According to the Chicago Tribune:

Moreover, the phrase “normal results” isn’t commonly used because it can be misleading. Instead, for some tests, such as the blood glucose test, labs use what’s called a “normal reference interval” or “reference range.” These numbers — the set of values that 95 percent of the normal population falls within — help guide a doctor’s interpretation of the results.¹¹

Therefore, doctors may be basing a lot of their decisions on tests which don’t necessarily reflect what is optimal for the particular patient in front of them, but rather, what was considered a “normal reference interval” for a subpopulation. Many disgruntled patients have experienced this frustrating fact when they are told “everything is normal,” yet they still feel lousy.

There is also the issue of accuracy of the lab itself. According to an investigative report in the Journal of Sentinel:

But laboratories across the nation aren’t following basic policies and procedures designed to ensure the accuracy of test results. Patients have no way to know if their lab is taking shortcuts and private accrediting organizations that inspect labs fail to cite serious violations that put patients’ health and lives at risk, an investigation by the Milwaukee Journal Sentinel has found. One of those main accreditors missed enough violations to require review by federal regulators last year.¹²

Many doctors are aware of some of the validity and reliability issues. This is why several of many of us have done our own “validity testing” of labs by sending in the same samples with different names, to see if results are consistent. Thankfully, there are also newer, functional tests that are basing ranges on healthy and optimal functioning, versus merely the absence of symptoms.^16,17 Still, even valid tests require interpretation within a patient’s content. Therefore, it’s important to be or to have a clinician who is aware of the limitations of lab testing and uses it in conjunction with the whole patient history and presentation.

(In the next blog, I’m going to review the big elephant in the room, harm by treatment. I’ll specifically be discussing medication safety and adverse effects and present a new viewpoint and approach to healthcare.)

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Sarah Lobisco, ND, is a graduate of the University of Bridgeport’s College of Naturopathic Medicine (UBCNM). She is licensed in Vermont as a naturopathic doctor and holds a Bachelor of Psychology from State University of New York at Geneseo. Dr. LoBisco is a speaker on integrative health, has several publications, and is a certification candidate in functional medicine. Dr. LoBisco currently incorporates her training as a naturopathic doctor and functional medicine practitioner through writing, researching, private practice, and through her independent contracting work for companies regarding supplements, nutraceuticals, essential oils, and medical foods. She has a small, private wellness consultation practice through telephone and Skype. Dr. LoBisco also enjoys continuing to educate and empower her readers through her blogs and social media.

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References:

1. Mayo Clinic. Mayo School of Health. Medical Laboratory Sciences. May 8, 2015. Available at: http://www.mayo.edu/mshs/careers/laboratory-sciences
2. American Medical Association. H-440.880 Definition of Health. 1995-2015.Available at: https://www.ama-assn.org/ssl3/ecomm/PolicyFinderForm.pl?site=www.ama-assn.org&uri=/resources/html/PolicyFinder/policyfiles/HnE/H-440.880.HTM
3. The Common Wealth Fund. U.S. Health Care from a Global Perspective: Spending, Use of Services, Prices, and Health in 13 Countries. 2015. http://www.commonwealthfund.org/publications/issue-briefs/2015/oct/us-health-care-from-a-global-perspective/
4. National Institute of Health, National Center for Complementary and Integrative Health (NCCIH). The Use of Complementary and Alternative Medicine in the United States: Cost Data. US Department of Health and Human Services. July 2009. https://nccih.nih.gov/news/camstats/costs/costdatafs.htm
5. ABIM. About. Choosing Wisely. org. 2015. Available at: http://www.choosingwisely.org/about-us/
6. ABIM. History. Choosing Wisely. org. 2015. Available at: http://www.choosingwisely.org/about-us/history/
7. Rosenburg A, Agiro A, Gottlieb MP, Barron J, Brady P, Liu Y, Li C, DeVries A. Early trends among seven recommendations from the Choosing Wisely Campaign. JAMA Intern Med. Published online October 12, 2015. doi:10.1001/jamainternmed.2015.5441
8. Thompson D. Women Should Get Annual Mammograms Starting at Age 45: Cancer Society. Health Day News. October 20, 2015. http://consumer.healthday.com/cancer-information-5/mammography-news-460/women-should-get-annual-mammograms-starting-at-age-45-cancer-society-704388.html
9. Oeffinger KC, Fontham E, Etzioni R, Herzig A, Michaelson JS, Shih Y-C T, et al. Breast Cancer Screening for Women at Average Risk: 2015 Guideline Update From the American Cancer Society. JAMA. 2015;314(15):1599-1614. doi:10.1001/jama.2015.12783
10. Erickson-Bhatt SJ, Roman M, Gonzalez J, Nunez A, Kiszonas R, Lopez-Penalver C, Godavarty A. Noninvasive surface imaging of breast cancer in humans using a hand-held optical imager. Biomedical Physics & Engineering Express, 2015; 1 (4): 045001 DOI: 10.1088/2057-1976/1/4/045001
11. Deardoff J. What’s normal for bloodwork? How blood test ‘reference ranges’ are calibrated, why they may vary from lab to lab. Chicago Tribune. November 21, 2011. Available at: http://articles.chicagotribune.com/2011-11-21/a-z/sc-health-1123-bloodwork-20111121_1_labs-range-glucose
12. Gabler E. Hidden Errors: A Watchdog Report. Weak oversight allows lab failures to put patients at risk. Journal Sentinel. May 17, 2015. http://www.jsonline.com/watchdog/watchdogreports/weak-oversight-allows-lab-failures-to-put-patients-at-risk-303445851.html
13. Wians FH. Normal Laboratory Measures. Merck Manual for Professional Edition. Appendix. Available at: http://www.merckmanuals.com/professional/appendixes/normal-laboratory-values/normal-laboratory-values
14. American Association for Clinical Chemistry. Reference ranges and what they mean. Lab Tests Online. 2015. Available at: https://labtestsonline.org/understanding/features/ref-ranges/start/1/
15. Dufour R. Laboratory General Checklist: How to Validate a New Test [Presentation]. College of American Pathologists. Washington, DC. September 17, 2008. Available at: http://www.cap.org/apps/docs/education/lapaudio/pdf/091708_Presentation.pdf
16. Genova Diagnostics. Licensing. https://www.gdx.net/about/licensing
17. Diagnostic Solutions. Learning the GI MAP. http://diagnosticsolutionslab.com/learning-gi-map
18. Center for Disease Control. Therapeutic Drug Use. CDC/National Center for Health Statistics. May 14, 2015. http://www.cdc.gov/nchs/fastats/drug-use-therapeutic.htm