Monday, July 7, 2014

Preventitive Healthcare in the Era of Healthcare Austerity

I spend a lot of time reading and thinking about the healthcare system, about health policy, about what the system does, and about what it does not do. I spend a lot of time thinking about what is measured, and what goes unmeasured. I spend a lot of time thinking about not just the costs of healthcare, but the value of healthcare.

Lately, there are a lot of calls for “less is more”: the campaign to assign low-risk women to midwife led care and to encourage more women to birth at home; calls to discontinue the annual check-up; calls to discontinue screening pelvic exams and mammograms for those between 40 and 49; and calls to not order tests. Many of these calls to reduce the supply of health services have been based on what the evidence has to say about the outcomes that are observed. There is a widespread perception out there that the population is being over-treated and over-diagnosed and that the system could save a bundle of money if the unnecessary things just were not done.

Never mind that the determination of “unnecessary” is almost always retrospective, and not prospective in nature. Never mind that there is a dearth of “patient perspective” research on health care.

We have entered an era of healthcare austerity and there is a surprising lack of skepticism about what “less is more” will result in. A lack of critical analysis about the data we have and what information can be gleaned from that data – and even less critical analysis about the data we do not have and critically need to make meaningful conclusions (and policy decisions). The enthusiasm to do less in healthcare is perhaps a symptom of a system that is simply over-whelmed with the demands that are being made of it and a knee-jerk reaction to do something to manage what seems to be a wholly un-manageable problem.

Doing less seems like an easy and logical answer to the problem at hand.

Unfortunately, there is an incredible risk that broad calls to do less will result in unintended consequences and will ultimately save nickels at an unacceptable cost down the road (most likely at a time when such a cost will be least affordable).

As an example, the call to do away with the annual physical exam, and specifically, the annual pelvic exam ( – it seems like an easy target for savings. After all there is a lack of evidence of benefit and some presence of demonstrated harm, based on the following study: The results were reported widely – and most women applauded the call to do away with the annual pelvic exam – after all, undergoing an annual pelvic exam is for most women, about as fun as filing an annual tax return.

However, it should be noted the study that called to do away with the annual pelvic exam also indicated that that no studies evaluated the potential indirect benefit of annual pelvic examination being an incentive for women to access health care and eventually receive recommended gynecologic services such as contraception, screening for STI’s or other non-gynecologic care. The study also indicated that there were no studies that assessed the benefits of pelvic exams for pelvic inflammatory disease, bacterial vaginosis and other benign conditions.

The study then went on to expound upon the harms that are caused by pelvic examinations – mostly fear, embarrassment, pain and discomfort.

It then concludes that the routine annual pelvic exam should be done away with, as a medical ritual with little evidence of benefit.

And that is where the drive for “evidence based medicine” is perhaps going off the rails. “No evidence of benefit” is being confused for “no benefit”, and rather than undertaking the necessary qualitative and quantitative research to come to the conclusion that there is “no benefit” there is a headlong rush into broad policy changes.

There is a need for a lot more skepticism when it comes to healthcare austerity – and a whole lot more research needs to be undertaken so that we can be certain that we are not foregoing benefits that are important but unmeasured.


  1. My practice is such that I work out of different clinics in different neighborhoods on different days. One clinic is in a wealthy suburb, another is in a very poor area that has one of the highest rates of chlamydia in the nation. I would be fine with doing away with annual physicals in the wealthy area. I would feel comfortable giving women at that clinic a prescription for birth control pills and renewing it for 3 years until their next pap was due. But in the clinic in the poor neighborhood, I wish I got to see them every 6 months. At that clinic, nearly every annual exam ends in some sort of diagnosis whether it be chlamydia, gonorrhea, BV, PID or an unintended pregnancy. I need the extra visits to do even basic education about how reproduction works, STI prevention, birth control options etc.


  2. FiftyfiftyOne - and that is an important distinction. I fear there are some that might fall through the cracks of the system with blanket approaches....particularly the young (18-30) and economically disadvantaged.