“I feel like I’m gonna die, doc,” he said to me.
He looked like he might be right. He was bleeding — hemorrhaging — from his stomach. His blood pressure was low and dropping, his heart rate climbing, and his color was fading. We needed blood and quickly. The blood arrived and we rushed it into his veins, which kept up with his brisk losses. This man ultimately survived.
To those that have donated blood: Thank you. You may have saved someone’s life.
But, there is also a dirty secret: It is more likely that you did not.
The vast majority of blood transfusions we order for patients are not likely to save a life. In fact, most of the time, the patient can’t tell a difference.
And, it gets worse. Not only do a lot of these transfusions not help, we know they can do harm. Transfusions, although safe overall, can sometimes result in serious allergic reactions, lung injury or infections. When you need a blood transfusion, these uncommon risks are well worth it. However, when there is no benefit from the blood, all you are left with are the downsides.
The medical community can do better. And we need to. But it will take support at all levels to do it.
Recently, many medical centers have introduced programs to reduce unnecessary transfusions. It may seem counterintuitive, but as transfusion rates fell at some of these hospitals, fewer patients overall died.
This is just one example in medicine where less may be more, where the right medical care can be miraculous, and too much of it can be harmful.
In 2009, McAllen became one of the most talked about places in the country among health researchers. The reason was that a widely read article in The New Yorker identified McAllen as a place with some of the highest per-capita health care costs in the country.
As the author tried to understand why, he found evidence that the higher spending was not due to unusually sick patients. The difference was that McAllen’s doctors were ordering more of almost everything — diagnostic testing, hospital admissions and procedures, the article said.
The problem is that patients were not any healthier as a result.
According to one survey, nearly half of primary care physicians in the U.S. believe patients cared for in their own practice receive too much medical care. Ninety-seven percent of surveyed emergency room physicians said that at least some of the CT and MRI scans they order are medically unnecessary. CT scans expose patients to levels of radiation associated with increased rates of cancer, yet the use of CT scans has soared in the U.S. and around the world.
The sobering reality is that more than one-third of health care delivered today may not make patients any healthier, and a substantial portion of that unnecessary care may itself cause harm.
So what should we do?
The first step in starting to address medical overuse is shining a spotlight on the problem. Recently, the national “Choosing Wisely” campaign has brought attention to the harms of health care overuse, and Consumer Reports has created resources directly for patients, such as their handout about when patients may or may not need blood transfusions in the hospital.
The spotlight shined on McAllen in 2009 probably helped foment some of the tremendous reductions in unnecessary care that have been seen in that community since then.
However, a spotlight is not enough. Patients can help avoid unnecessary testing and treatments by asking their doctors simple questions about their care, such as, “What are the risks of these tests or treatments?” “How will this test or treatment help me?” and “What would happen if I do not do anything?”
Health care professionals can encourage these questions and can coach their patients through this sort of conversation. And policymakers can create payment mechanisms that support spending the time to have these conversations rather than merely reimbursing for completed procedures.
We can all do better. Curbing medical overuse in areas that lead to clear damages for patients and communities, such as unnecessary blood transfusions, is an area that we all should work together to “first, do no harm.”
Dr. Christopher Moriates is the assistant dean for health care value and associate professor of internal medicine in the Dell Medical School at The University of Texas at Austin.
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