NEJM Blasts “Crusade,” Omits that Its Former Editor Launched It

A blistering attack by the national editor of the New England Journal of Medicine against the “less is more” movement in medicine omitted that the publication’s former editor-in-chief played a foundational role in popularizing the idea of widespread medical waste.

The commentary in late December by Dr. Lisa Rosenbaum, “The Less-Is-More Crusade – Are We Overmedicalizing or Oversimplifying?” has attracted intense attention.  Rosenbaum berates a “missionary zeal” to reduce putative overtreatment that she says is putting dangerous pressure on physicians to abstain from recommending some helpful treatments. She also asserts that the research by Dartmouth investigators and others who claim 30 percent waste in U.S. health care, in which she once fervently believed, is actually based on suspect methodology.

What Rosenbaum fails to mention is that the policy consensus she seeks to puncture – that the sheer magnitude of wasted dollars in U.S. health care offers “the promise of a solution without trade-offs” – originated in the speeches, articles and editorials of the late Dr. Arnold Relman, the New England Journal’s editor from 1977 to 1991.

Waste’s “fundamental cause is doctors”? Although Relman consistently blasted a variety of culprits who “commercialized” medicine, he was clear in a 1985 article for the National Academy of Sciences that “more prudent choices by physicians” would substantially reduce costs.

A “crusade”? Relman by 1986 was being called “the leading exponent” of the view that by eliminating waste quality could be maintained or improved “while costs could be stabilized or reduced.”

A “solution without trade-offs”? Relman could have been the poster child for that position. In a 1991 article for Health Management Quarterly, he wrote: “At least a third of all the money we now spend on medical care in this country could be eliminated…[and] we could afford to do everything medically appropriate for all our people,” including coverage of the uninsured.

Flawed research? Relman’s waste estimates, though widely quoted, were essentially opinions reified by his rank. As such, his figures fluctuated. Waste was “at least 15 to 20 percent” in that 1985 article. It was “20 percent” in a 1988 interview with me. “As much as 20 to 30 percent” in a 1990 New England Journal editorial. And in 1991, as noted above, “at least a third.”

I know the history of this effort because I covered it as a journalist, researched the quality movement for a peer-reviewed book and have continued to be active in this field as adjunct faculty at Northwestern University. For this article, I went back to the literature and my notes to confirm my memories. The “30 percent” waste figure came from Relman, and others (including the Institute for Healthcare Improvement, employer groups, policymakers and Dartmouth) took it from there.

On a personal note, while Relman’s guesstimate was a great soundbite, I deliberately omitted it from my book, Demanding Medical Excellence, since one of the book’s tenets was the flaws of eminence-based, rather than evidence-based, medicine.

Why does it matter that the New England Journal omitted its role in every aspect of a movement its national editor denounces? While the omission may not affect the debate over Rosenbaum’s core assertions, it does raise questions about the editorial standards of one of most trusted medical journals in America. Put bluntly: are there professional standards for criticism, or does it depend upon who is being criticized?

I suggest the Journal’s editors follow the mantra, WWJD. Not “What would Jesus do?” but “What would journalists do?”

Your national editor launched a sustained attack against activities your former editor-in-chief inspired, engaged in and, although not in every detail, supported in your publication. Since Rosenbaum’s commentary claims to be research-based, this seems an important piece of data not shared with readers. How was it missed?

There’s another, less likely but more disturbing possibility. Rosenbaum, referring to the less-is-more movement, writes that the more coherent a story seems, the more believable it becomes whatever the evidence might say. That inevitably opens the question of whether the omission of Relman’s role was an attempt by the writer or editors to make Rosenbaum’s attack piece more coherent.

And that leads to the matter of language. A top-tier medical journal allowed its national editor to suggest that those with whom she disagrees are not only misinformed on the facts, but zealots who persecute their fellow doctors, pervert policy and injure patients. Do the editors believe that’s an appropriate manner to characterize their own former editor? If so, by all means run a correction saying that Relman, and the Journal itself, should have been included among Rosenbaum’s culprits.

Or, forced to look in the mirror, might the editors rethink whether, indeed, “less is more;” i.e., there’s a need for less invective and incitement masquerading as iconoclasm and more reasoned argument.

My layman’s diagnosis is that Rosenbaum, a smart and talented writer, was suffering from Sage Syndrome, a condition afflicting those whose pay, prestige and pride are linked to the perceived profundity and cleverness of their opinions. I suspect Rosenbaum relied on her memory, which was flawed, and her editors were no better. Because her put-downs were proffered in defense of deference to status-quo physician behavior and the general goodness of doctors, her editors gave her pejoratives a pass, possibly rationalizing that being “provocative” would “drive web traffic.”

Those of us who believe in continuous quality improvement would call this an opportunity for a respected individual and institution ­– and Rosenbaum and the Journal are deservedly that — to undertake some honest self-examination.

When I worked at the Chicago Tribune, I was active in the national Society of Professional Journalists. I know that the newspapers that are of the caliber in their field of the New England Journal in its field would unhesitatingly choose to be tough on themselves and transparent with their readers. That’s what journalists would do. What path will Rosenbaum and the New England Journal take?

Michael Millenson is President, Health Quality Advisors and a contributing editor to THCB.

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11 replies »

  1. Thanks Michael. Sharp piece. I agree that Relman was pioneer and zealot in this area and she should have mentioned him. I also agree that research on what we term “overuse,” wasteful or unnecessary spending and “less is more” is a bit all over the place and not as conclusive as one might want. The most cited source for the excess/wasteful/unnecessary dollars spent is a Feb 2011 IOM report– The Healthcare Imperative — from an IOM workshop. The assembled experts (and support staff) came up with a 30% estimate based on spending in the year 2009. What got that report a lot of attention is that they broke the wasteful spending down into 6 categories….excess administrative, prices, unnecessary services, fraud etc. No one had done that before that I’m aware of. But the reports admits the number is speculative, though it was based on a lit review. That lit review in no way rose to the level of a rigorous systematic review/research analysis, the kind AHRQ has specialized in in its treatment effectiveness reviews.

    I thought Rosenbaum’s piece was otherwise very well stated and warranted the attention it got. It’s a critical issue. Now if we can just get some better research!.

  2. Some people might argue that the NEJM’s decision to run an piece that is critical of a movement founded by a beloved former editor could be called open-minded ..

    Or do we not to allow discussion of matters that are “settled” by science?

    I understand this whole thing hits close to home for you Michael, you’ve done important work in this area. But is it possible there is a productive conversation to be had here? I think there is.

    I think we’ve all learned something this year about the harm that can come when we refuse to acknowledge critics, respond to criticism, answer legitimate questions and label the arguments we don’t like “fake news ..”

    I hope you can lead the way here …

  3. Hadler calls for a doctor-patient relationship where “the Patient is the captain of the ship and the doctor is the navigator”. And I believe an essential part of heath care reform is for the Patient to control the $ and have direct financial benefit from prudent use of services….guided by the doctor. Vouchers are one way to do that.

  4. Good review of the issues in NEJM’s editorial. Thank you.

    Whatever these philosophies, we only want 3 outcomes: prices to approach marginal costs as much as possible. And we want our diagnoses to approach reality as much as possible and our interventions to approach maximum efficiency as much as possible.

    We have a few things we can do to improve: Be sure anti-trust is working against monopolies and monopsonies (single large purchaser of health care–is good to have many buyers and many sellers so that prices are “taken”.)

    [Now I see groups of hospitals are going into the manufacture of certain generic drugs WSJ 1/19/18. This is going to allow a horizontal monopoly.]

    We should try to cause the patient to feel as if he is spending his own money as much as possible. Refundable vouchers. Cost sharing works a little but is tricky and can reduce needed care. The patient has to feel shopping as much as possible, but be protected against total lassez faire. This naturally can happen with only some patients, some of the time.

    We should try to cause the provider to feel as if the patient is spending his own money as much as possible. Refundable vouchers again. The provider has to feel competition as much as possible.

    We need the vouchers so that we can still help the poor and needy and be altruistic.

  5. The concept of healthcare utilization is not as simple and straightforward as it sounds. For example, the U.S. ranks very well on inpatient length of stay in hospitals. However, a lot more happens to patients during the time they’re there than in Canadian or Western European hospitals.

    It’s also well known that America is a more litigious society than those in most other developed countries. As a result, the medical practice patterns that define the standard of care are more testing intensive than elsewhere. Patients, for their part, don’t mind tests that are non-invasive and not painful. Think imaging and blood draws. Indeed, they see them as high quality / thorough care, at least as long as someone else is paying. They probably feel differently about invasive tests like a spinal tap, prostate biopsy or colonoscopy. Anyway, doctors want to ensure that they provide patients with the standard of care and the fact that providers get paid more for doing more also contributes to more treatment rather than less.

    So, I would like to see a definition of the standard of care for different treatments and management of chronic diseases and conditions in the U.S. vs. other developed countries. I would also like to see a comparison of the number of hospital licensed or occupied inpatient beds per thousand of population here vs. elsewhere. I’ve never seen either.

    Doctors want to take care of patients. They want to provide the standard of care at a minimum, earn a respectable living and minimize the risk of being sued. Cost to the system is not their primary concern. If the individual patient brings up cost as an issue for him or her, doctors can address costs to the patient on a case by case basis as needed.

  6. Parkinson’s Law continues to “operate,” as in work expands to use the resources available. The Design Principles for Managing a Common Pool Resource are the only known “antidote.” The applicable Common Pool Resource is the portion of our national economy allocated to health spending. Between 1960 and 2016, this increased from 5.0% to 18.2%, representing growth of 2.33% compounded annually (not corrected for economic growth or inflation).

  7. The NEJM piece is good and I think more balanced than blistering.
    Here is a relevant Hadler quote (who i see as a less is more believer): “America has made a tremendous investment in I.C.U.s. We have ….25 per 100,000 as compared to 5 per 100,000 in the U.K. Not surprisingly, when we build them, we also build the demand.” Page 9 2 By The Bedside of the Patient 2016

  8. An international comparison of nurses’ salaries shows that nurses in the UK, France, Germany, Canada and other first world countries make 25%-35% less than U.S. nurses on a purchasing power parity basis. Doctors also make more than their foreign counterparts. So, probably, do administrators, IT experts, etc. You get the picture. For an international comparison of nurses’ salaries, see http://www.worldsalaries.org/professionalnurse.shtml. Overall, over 15 million people work in healthcare in the U.S. including over 5 million who work in hospitals. So yes, prices per service, test and procedure are higher here but so too are employee salaries. Drug and device prices are a separate issue.

  9. NEJM editorial commitments have long been connected to the scientific dogma of research as the basis for meaningful change, principally if the research is performed by physician experts. For instance, the possibility that social factors could be the root-cause of our nation’s increasing incidence of unstable health and it attendant costs would not be an issue since the social factors are not within the realm of health’s scientific paradigm. I take it as a badge of courage to have been locked out of four healthcare blogs because they didn’t share my concern about our nation’s maternal mortality ratio…worsening for 25 years. Two of those are no longer operational.

    Baron C.P. Snow described it best, now 60 years ago, of his concern about the growing decrease in the level of connection between the scientific and humanitarian realms of knowledge. It is sometime lost amid this discussion that he was a physician.

  10. Its like the death of professionalism, the death of investigative journalism, and the death of scientific integrity all got together to sustain themselves perpetually.

  11. I’ve lost the reference and I’m neither an academic nor a journalist, but I recently read a convincing piece that claimed the US spending double to achieve worse outcome than other rich countries was due to pricing rather than utilization. I’m surprised that neither the NEJM article nor this post considered this other definition of “waste”.