Is it just me or has there been a deafening silence from the wellness proponents of forced HRA/biometric screening since Dr. Atul Gawande’s article Overkill appeared?
Two salient quotes from the article capture the issue. The first about over screening and testing in general, not specific to wellness but applicable:
“Often, these are fishing expeditions, and since no one is perfectly normal you tend to find a lot of fish. If you look closely and often enough, almost everyone will have a little nodule that can’t be completely explained, a lab result that is a bit off, a heart tracing that doesn’t look quite right.”
Now, read the article and Dr. Gawande’s story of how he treated a patient who’d been diagnosed with thyroid cancer. Please-read it, this is what overscreening leads to and can do to your employees. It is not an academic issue, real people are impacted. His quote here is especially impactful
“All the same, she thanked me profusely for relieving her anxiety. I couldn’t help reflect on how that anxiety had been created. The medical system had done what it so often does: perform tests, unnecessarily, to reveal problems that aren’t quite problems to then be fixed, unnecessarily, at great expense and no little risk…An entire health care system has been devoted to this game.”
Now an example from the wellness industry. I recently corresponded with a staunch defender of the Koop award-winning Nebraska state wellness program, the one the consultant Al Lewis outed as having falsely diagnosed 500 cases of cancer that-oops-weren’t really cancer. This person said the report should have read “pre-cancerous lesions.” He insisted the program was sound, and well-deserving of the award notwithstanding conflicts of interest that have been covered elsewhere and the cancer misdiagnosis. Really.
Now re-read Gawande’s quote. How many of the 500 people were treated, suffered, or at best experienced anxiety at the thought of having “cancer?” Would ANY of them have been worse off without the program? Has the cost of misdiagnosis, lost productivity and over treatment been factored into the program?
This should be a concern for those purchasing, monitoring or approving wellness programs that utlize forced HRA’s and biometric screening. Does your program follow the preventive screening task force’s recommendations?
Mitch Collins is an executive who advises corporate clients on health, wellness and fitness issues facing their businesses.
I don’t think a doc can have too much information. But he can jump and react inappropriately to that information. After all, if tests and images and ultrasounds, etc., were all intrinsically safe and costless, how can you have too many? …if you have the wisdom and experience not to chase all of them down? Everyone says you cannot have too exhaustive a history. Well, tests are simply biochemical histories . Good docs know what info to ignore. Now that we have totally screwed medicine by allowing tests to become artificially expensive, we cannot be so sanguine about testing. It costs essentially nothing in reagent costs to do a chem or hematology panel. And, of course, some tests, eg biopsies, can be intrinsically dangerous; so take my above speech with salt.
The way to handle thyroid nodules is to have experience and good training. If they are multiple and the person is a woman, you can watch them as it is probably Hashimoto’s thyroiditis. Check some autoantibodies. Very common. If it is single, and small, watch it for awhile and then, if it grows, stick a needle into it, aspirate, and send it to a good pathologist. You can also get a good idea about nodules from ultrasound. Papillary carcinomas look dense. Follicular carcinomas less dense and irregular. Cystic follicular adenomas are pretty empty looking and are the most common and harmless of all thyroid lesions.
A good general rule is that the only thing you really have to worry about is follicular carcinomas. Hardly anyone dies from papillary cancers. These can even be metastatic and that is true. Weird. There are a few exceptions, like medullary CAs.
You don’t have to spend a lot of dough workimg up thyroid lesions. You just need experience.
Reading your post highlights the larger issue: testing done on the advice of and in conjunction with a physician is usually fine. Some people have risk factors, chronic conditions or perhaps it is just time. Biometric screens and intrusive HRA’s should not be forced-usually because HR doesn’t know any better and the more tests, the more the vendor makes.
I emailed the Gawande article with highlights to the Koop defender I mention (not Dr. Goetzel)….I am still awaiting his response.
And John, no I don’t expect them to recant or resign…but if enough of us are informed, we can help pressure our companies to stop these practices. Or use vendors and consultants who tell the truth and will help design programs that do things for employees, not to them. They exist and there are more of them than just Lewis, Khanna, Robison and Emerick.
Let me be very clear about the fact that the cancer thing was a deliberate lie by Health Fitness Corporation. It wasn’t just that they “accidentally” called these “lesions” (mostly harmless polyps that doctors get paid extra to remove) cancer. Nor is it just that they have never changed the report, apologized, or offered to give their award back. (The Koop Committee is perfectly fine with them keeping the award–lying is part of the Koop Award DNA, far as I can tell.) It’s that the report said they made “life-saving catches” of these “early stage cancers.”
I challenge Gawande to comment on screening for breast cancer or, for that matter, HHS to obey the recommendations of USPSTF.
Go on. I dare you.
Two observations. First, the Nebraska proponents have not only failed to correct the lie (and they should have given back their award, if they had any integrity, once they admitted wrongdoing). Quite the contrary, Ron Goetzel rallied to their side and called them a “best practice” several times in print since then. Earlier this month Mr. Goetzel called the Nebraska program an “exemplar,” in a webinar, despite the vendor’s many lies, of which the cancer lie was only the most blatant. They are all at http://www.theysaidwhat.net . Just search on Nebraska.
Second, the thyroid example hit very close to home. My former sister-in-law was encouraged by her company, at the behest of the wellness vendor, to get an annual checkup. The doctor decided there was a lump in her thyroid. Several “inconclusive” tests and biopsies later, she decided to have it removed, just in case. Guess what? No cancer. So now she is on Synthroid the rest of her life…all because a wellness vendor wanted to overscreen people. The worst part? She is very grateful to the doctors and the hospital for the wonderful care she received.
What are we expecting them to do? Recant? Resign? Write letters of apology?
It’s going to take a lot more than a well-written magazine article for people to abandon their beloved business models.