When to treat

Really, really loved this Wired article about a physician who insists on being relentlessly empirical and evidence-based in determining the best course of treatment for his patients.  So much of our medical treatment is entirely unnecessary (as nicely detailed in the terrific book, Overtreated).  David Newman bases much of his practice of medicine based on a concept called NNT:

Developed by a trio of epidemiologists back in the ’80s, the NNT describes how many people would need to take a drug for one person to benefit. (The NNT for antibiotics in a case of acute bronchitis is effectively infinity, because the medicine is no better at curing the illness than a placebo.)

Consider a couple other examples: If your kid is throwing up and you take her to the hospital, she might get a drug called Zofran. The NNT for that is 5, meaning that only five kids need to take Zofran for one of them to stop throwing up. And if you look at Zofran’s “number needed to harm” (the number of people who would need to take a drug for one to have a bad side effect) the answer is … well, there really isn’t one—no one has a significant side effect.

Now, say you’re pushing 50. You’re healthy, but your doctor suggests you start taking a baby aspirin. Just in case, you know? That NNT is 2,000. That’s how many people have to take a daily aspirin for one (nonfatal) heart attack to be prevented. Statistically speaking: Not especially helpful.

They don’t have the NNT here for the PSA, but I’m damn sure it’s not good.  I think I have a favorite new medical care statistic (replacing mortality amenable to health care).  Check that– the article doesn’t have the PSA NNT, but I went over to the awesome NNT website and started playing around.  The NNT for the PSA is infinite (no benefit) whereas the number needed to harm is 5.  Um, yeah, no PSA.  Meanwhile, one of my friends just started warfarin for atrial fibrillation, and that gets the green light.  (NNT of 25).

Anyway, back to Wired, because there was more of the article worth sharing:

Newman has just arrived at work in the emergency department where he’s an attending physician, and he’s giving his residents the “Three Networks” spiel.

“ABC, always be closing. You want to be moving patients back home or into the hospital for treatment. At the ER, the front door is always open, but if the back door is closed, and you have people mounting up, things get missed, heart attacks occur, sepsis gets worse, and people die. Always be closing.” Then comes NBC, never be consulting—don’t call specialists if you can avoid it. Then CBS, close before signoff. There’s good evidence that medical errors are more likely to occur with handoffs. Discharge your cases before the end of your shift to avoid these errors, he tells his charges…

Newman wants to use science to protect his patients from treatments that are not justified by research and evidence, and he wants to impart that science to young medical residents. So he’s constantly grilling them on the assumptions that underlie their recommendations and diagnoses…

Habits—whether based on old literature, biased studies, or just educated hunches that get ingrained in protocol—die hard.

Indeed, more than 90 percent of doctors believe that their colleagues practice this kind of “defensive medicine,” according to a survey published in the Archives of Internal Medicine. You do what’s done because it is considered to be the so-called standard of care. And not adhering to the standard of care can be considered negligence if something goes wrong and you get sued for malpractice. The unfortunate result of this contorted logic, according to the Institute of Medicine, a policy research organization, is that the US spent $210 billion on unnecessary services in 2011 (some 8.4 percent of the more than $2.5 trillion we spend annually on health care), and untold numbers of patients are subjected to pain, anxiety, and even death as a result. The NNT could help prevent a lot of that suffering—physical, mental, and financial…

If Newman’s site continues to expand beyond its current number of about 200 write-ups, and if the NNT were included with every published article about a treatment, the result would be happier, healthier patients and less waste in our health care system.

Great stuff.  This won’t be easy because we are talking about changing a culture, and that’s never easy.  But we all stand to benefit if we do.  And given how much of health care expenses are paid by the government, there’s potentially a big role for public policy in making this happen (we could start with no Medicare reimbursement for red-light treatments).