The Over-Medicalization of America Continues – Executive “Health” Programs for Profit, but Not Health

The premise of using Executive Health Programs with their associated cardiovascular diagnostic tests is that the results may help reduce mortality from cardiovascular disease through earlier disease detection, more precise risk assessment, and therefore better treatment. As is often the case in medicine, physicians have beliefs about what works despite the evidence against their cherished, money-making beliefs. Screening tests in general have not been found to reduce mortality in asymptomatic individuals (Sussman and Beyth, 2015; Smetana et al, 2016). Nevertheless, many physicians have an enduring belief in the benefit of using diagnostic tests to discover cardiovascular disease in its earliest stages. In a highly deregulated, capitalistic medical system here in the US where physicians and hospitals are incented to perform procedures in order to make more money, leveraging their beliefs in cardiovascular diagnostic testing is a platform for increased income. The money-making mentality among physicians and hospitals is particularly acute in some specialities and in some areas where their are too many competing physicians and hospitals per capita, and therefore physicians perform unnecessary procedures to protect their income. As an example, the U.S. has more than double the number of congenital heart surgery centers that it needs, and about 40 of those centers in the USA aren’t cooperating with authorities to report their medical statistics. Further, those non-cooperating centers have “unexpectedly high mortality rates,” according to Dr. Carl Backer, MD presenting at the 2019 Annual Meeting of the American Heart Association in Philadelphia, PA. In 2014, the Institute of Medicine released their analysis on graduate medical education, arguing there was no shortage of physicians, and that we have no need to invest more in increasing the number of new physicians who are trained annually (IOM, July 29, 2014). With an oversupply of physicians comes more procedures – unnecessary procedures; but money is made (Schroeder, 1992).

As Prof. Ralph Crawshaw, M.D. has said, “Clearly, a serious problem with an exaggerated and misanthropic human trait, greed, challenges the medical profession to move to higher moral ground in the care of the sick.” When asked why he robbed banks, Willie Sutton supposedly said “because that’s where the money is.” For the sake of  increased incomes, physicians and hospitals have created the demand for early diagnosis by leading people to believe that early diagnosis leads to better health. Establishing executive screening programs targeted to wealthy individuals who are able to pay directly for cardiovascular screening tests that are generally not covered by insurance is in vogue. Why? Because that’s where the money is.

In a new study published in the Journal of the American Medical Association Network, executive screening programs have been found to “run afoul of healthcare’s goal of evidence-based cost-effective equitable care” (Alan and Brown, 2020). Indiscriminate screening programs in healthy people can create a cascade effect and thus violate the principle of primum non nocere (first do no harm) wherein unnecessary medical tests may create a chain of adverse medical events resulting in additional ill-advised tests or treatments that may cause avoidable physical and psychological harm.

In a previous study, Prof. Ganguli, M.D. has found in a survey of practicing physicians that almost all (398 out of 400) respondents had experienced medical cascades after incidental findings that did not lead to clinically meaningful outcomes yet caused harm to patients and themselves (Ganguli et al, 2019). The problem is widespread and contributes greatly to the medicalization of America, leading to increased rates of sickness and, as described by Prof. Arnold S. Relman, M.D., former editor of the New England Journal of Medicine, the out of control industrial-medical complex (Relman, 1980; 1983; 2007). Learn how to take care of your own health because the medical-industrial complex won’t; read “Thinking And Eating For Two: The Science of Using Systems 1 and 2 Thinking to Nourish Self and Symbionts.”

References

1. Alan AG and Brown DL (2020) Assessment of Cardiovascular Diagnostic Tests and Procedures Offered in Executive Screening Programs at Top-Ranked Cardiology Hospitals. JAMA Intern Med. Published online January 13, 2020. doi:10.1001/jamainternmed.2019.6607
2. Crawshaw R (1993) Greed and the medical profession. BMJ, 3016: 151.
3. Ganguli I et al (2019) Cascades of Care After Incidental Findings in a US National Survey of Physicians. JAMA Netw Open. 2019;2(10):e1913325.
4. Relman AS (1980) The new medical-industrial complex. N Engl J Med. 303:963-970.
5. Relman AS (1983) Lessons from the Darsee Affair. N Engl J Med 1983; 308:1415-1417.
6. Relman AS (2007) Medical professionalism in a commercialized healthcare market. JAMA. 298(22):2668-2670. doi:10.1001/jama.298.22.2668.
7. Schroeder SA (1992) Physician Supply And The U.S. Medical Marketplace. Health Affairs, https://doi.org/10.1377/hlthaff.11.1.235.
8. Smetana GA et al (2016) Should We Screen for Coronary Heart Disease in Asymptomatic Persons?: Grand Rounds Discussion From Beth Israel Deaconess Medical Center.  Ann Intern Med. 164(7):479-487.
9. Sussman J and Beyth RJ (2015) Don’t perform routine general health checks for asymptomatic adults. Society of General Internal Medicine, https://www.sgim.org/File%20Library/JGIM/Web%20Only/Choosing%20Wisely/General-Health-Checks.pdf.