Less Is More in Medicine

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Commentary

In modern medicine, the zeitgeist today seems to be captured in one word: “more.” We need more MRI machines, more screenings, more surgical interventions, more drugs, more doctors. More. More. More. Like the internal logic of capitalism that is built on eternal growth, so too is our healthcare system.

Given this ever-expanding demand, we need to be asking some hard questions about whether sending even more of our collective wealth toward our healthcare system is producing good returns. We might expect that anything spent on healthcare provides good returns, but what if, frequently, those investments end in losses?

There have been some significant strides against diseases over the past 30 years, but for many of the common sicknesses we all face, we’re seeing very little progress—this despite the climbing price tag. Americans spent about $3.2 trillion in 2015 on healthcare, and that ballooned to about $4.8 trillion in 2023, representing a roughly 50 percent growth. By contrast, gross domestic product grew by only 25 percent over that period of time.

What’s all the additional money buying us?

In the things that matter, such as life expectancies, we are going backward. The average life expectancy of Americans has dropped by two to three years since the COVID-19 pandemic, and we currently have among the lowest life expectancies among the world’s developed countries. The mental health of children and many adults is cratering, despite the mountains of expensive drugs we throw at these problems. Any advances on reducing mortality due to cardiovascular disease or cancer—the two biggest killers of Americans—are mostly disappointing, small, and incremental. And above all, in some key areas of healthcare, the more money we spend, the worse outcomes we seem to get, a practice that culturally and financially threatens to bankrupt us.

Despite the juggernaut of more, more, more, there has been a small but growing voice of those who say it’s time to apply the brakes, and fast. Regardless of what area you look at: hospitals, medical screening, drug treatments, orthopedic surgeries, cancer treatments, you name it, a case can be made almost everywhere that we need to slow healthcare activity, especially in areas where it’s clear that it’s delivering us negative returns.

I would argue that we are increasingly allowing the normal ups and downs of aging to be medicalized, where typical signs of lives well-lived are redefined as sickness and in need of medical intervention. An aging population, therefore, becomes an increasingly lucrative market to go after.

Medicalizing Normal: The ‘Gray Hair’ of Joints

Let’s take one example, orthopedic surgery, to examine what I mean by the medicalization of normality. Orthopedic surgeons typically operate on hips, knees, elbows, shoulders, spines, and hands, often providing an important and essential service.

No one would argue against the value of hip replacement surgery in those suffering intolerable pain from worn-out hip joints. But not all surgery or medical imaging relating to our joints is necessary. And some of it is harmful. Looking closely at the evidence behind MRI or CT scans, X-rays, and knee, shoulder, or elbow surgeries, you will find that many of the scans or surgeries we submit to do almost nothing to improve the length and quality of our lives.

The use of MRI machines provides a stellar example. Everyone seems to believe that there are not enough MRI machines to go around even though the overall volume of MRI machines has grown immensely. Over the past decade, the number of MRI machines has grown by 35 percent in some states, and total MRI-related revenue has increased by up to 40 percent.

MRIs are clearly a big moneymaker for hospitals, but what do those machines really do? Spoiler alert: They often do little more than detect the natural physiological signs of aging.

Earlier this year, the Finnish Centre for Evidence-Based Orthopaedics did something so amazing it’s hard to believe that no one else had thought of this. They took about 600 healthy middle-aged Finns and conducted MRIs of their shoulders. These were people who had no pain or no symptoms. They were just like you and me, everyday people.

The result? Ninety-nine percent of these healthy adults aged 41 to 76 had at least one rotator cuff abnormality on an MRI. No symptoms. No pain. No disfigurement. But a high-tech machine telling them they were diseased. This eye-opening study was published in February in JAMA Internal Medicine. It should have shaken the medical world, but it barely made a ripple.

Let’s think through the implications of this. What should we make of the fact that “abnormalities” in our shoulders are found by MRIs in almost all of us who have no symptoms at all? There was no difference in the prevalence of full-thickness tears between symptomatic and asymptomatic patients. Despite the zillions of expensive MRI scans Americans have every year, this study’s findings suggest that in the case of rotator cuff changes after midlife, they are as normal as gray hair and wrinkles in older people. When we use these incidental findings to justify surgery, we aren’t curing a disease; we are performing expensive, invasive procedures on the natural process of growing older.

Now extrapolate that to knees. Same thing: Many people with “normal” knees will have a “meniscal tear” found on an MRI machine.

Making the Case for ‘De-implementation’: Why Some Surgeries Must Stop

In the world of prescribing, there is a lot of interest lately in “deprescribing,” which is about actively cutting, reducing, and sometimes eliminating prescriptions in order to improve the care of patients. In the world of medical procedures, there is a strong case to be made for “de-implementation,” which is about rethinking the value of the procedures and rewriting the rules on when those procedures should be done. This is not just about avoiding unnecessary scans; it is about avoiding common surgeries that high-quality science has proven to be ineffective. Two major trials, again produced by Finnish researchers, have shattered deeply held medical beliefs regarding shoulder and knee pain.

Arthroscopic subacromial decompression (ASD)—the act of removing a section of bone in one’s shoulder—is done to theoretically “increase space” for tendons for those who are suffering what is colloquially known as “shoulder impingement.”

It is one of the most commonly performed orthopedic procedures globally. However, high-quality research has found that the ASD procedure offered no relevant benefit compared with a placebo surgery (during which they go in to inspect the joint but remove no bone). Even after a 10-year follow-up, the results remained unchanged. The British Medical Journal made a “strong recommendation” against performing this surgery, seeing as it is no more effective than doing nothing. Despite this evidence, ASD surgeries are done worldwide, and frequently.

But that’s not the worst example.

The poster child for unnecessary surgeries is arthroscopic partial meniscectomy (APM) for degenerative knee tears. This long-used “meniscal resection” surgery for torn menisci in the knee has been studied for many years. The best and longest trial was likely the FIDELITY trial (published in April in the New England Journal of Medicine), which involved following patients for 10 years, a span of time almost unheard of in the world of orthopedic surgery. The results are definitive: APM provides minimal to no improvement in symptoms compared with placebo surgery. Beyond its clinical futility, economic evaluations conclude that APM for degenerative tears is not cost-effective. Why? Long-term, patients are generally worse off, because those surgeries are more likely to actually accelerate the development of knee osteoarthritis.

The Economic Toll: The North American ‘Cash Cow’

While countries such as Finland are world leaders in “de-implementing” low-value orthopedic procedures, North American hospitals are heavily invested in these “cash cow” procedures. In the United States, approximately 750,000 knee meniscectomy or repair surgeries are performed annually. The financial burden is immense, amounting to several billions of dollars per year in the United States alone. The average cost of an APM ranges from $3,800 to $4,300, but without insurance, costs can reach $10,000 to $15,000.

In the United States alone, unneeded pre-surgical testing and imaging for these knees accounted for an estimated $9.5 billion in avoidable spending in a single year.

A key marker of low-value care is the variation between jurisdictions. Compare two similar places and ask: Why is there such a massive difference in the frequency with which some procedures are performed? For example, what should we make of the fact that surgeons in Florida or Texas perform twice as many meniscectomy procedures, per capita, as those in Washington or Oregon? Are Texans and Floridians receiving better care? Big no. Now compare Finland, which does virtually no meniscectomies, with the United States, which does half a million per year. Can we say the American knees are better off? Not at all. The key here is when you’ve got a procedure that is low value, you see wide ranges of variation, and this unwarranted variation—differences in treatment rates based on geography rather than clinical need—is a hallmark of a system that rewards volume over value.

A Systemic and Ethical Imperative: We Need to Wage War on Healthcare Waste

There are a number of noteworthy groups in the United States trying to buck the incessant demand for more and more medicine, groups such as Choosing Wisely, the Institute for Healthcare Improvement, and the Lown Institute. They are good at studying the futility and waste that characterizes a lot of modern American medicine. They are, however, like heroic Davids fighting against the Goliaths of the medical-industrial complex.

However, what they are fighting for is a noble public-spirited exercise, such that medical practices or interventions that have been found to be ineffective or harmful are abandoned. Reports from the Institute of Medicine suggest that as much as 30 percent of all healthcare is considered low-value, providing no patient benefit or, worse, causing evidence-based harm. Unless health systems are reined in against the tide of “more,” we will be denying needed resources to provide high-value care to those who truly need it.

De-implementation is not merely a cost-saving exercise; it is central to health equity and sustainability. Low-value care has physical, psychological, and financial consequences that affect the healthcare workforce and the environment. When the public payers decide that certain procedures aren’t worthy of public funding, it often drives people to the private market, where they pay for the low-value care out of their own pockets. It’s crazy. Especially when you consider that we’ve also got the problem of underserved populations at the highest risk of receiving low-value care, further widening disparities in health outcomes.

The United States has to catch up to the rest of the world and systematically identify areas of overuse, barriers to change, and then produce and disseminate effective reduction and “de-implementation” programs.

The path to a sustainable healthcare system requires us to stop treating the “gray hair” of our joints as a surgical emergency. As long as we continue to pour billions of dollars into surgeries for sore shoulders or knees that have been proven no better than a placebo, we drain the resources necessary for life-saving care.

From the Brownstone Institute