By Christopher Moriates, MD
A few years ago I was eating dinner with a friend when, somehow, the conversation veered into the topic of mammograms and pap smears. I began explaining how the overuse of screening tests concerned me. My friend stiffened. What was I talking about? Screening tests save lives, don’t they, and who am I to say they are “overused”? I suddenly remembered my friend had lost her mother to cancer at a young age. The conversation sputtered forward as I tried to gently explain my position, yet my friend just dug in her heels. I took a big sip of my beer. I needed H. Gilbert Welch, and I needed him in a hurry.
Welch, an internist at the White River Junction VA and a researcher at the Dartmouth Institute, has made a career leading these difficult conversations. He has published articles with titles such as “The likelihood that a woman with screen-detected breast cancer has had her ‘life saved’ by that screening.”
Welch asks the tough questions, collects the evidence, and provides thoughtful, persuasive answers.
In his newest book, “Less Medicine, More Health”, he distills this all down into a casually written guide that is accessible to both patients and their doctors. He delivers his message through systematically debunking seven widely held assumptions about healthcare commonly held by patients and their families. He ends each chapter with a “prescription” that lays out actionable, simple strategies to avoid too much medical care.
He gallantly takes on medications, imaging, devices, surgeries, and screening. He even, as a lifelong primary care physician, questions the value of the “annual physical.” There are no sacred cows to Welch. And that is good for the rest of us, who are happy to pull up a chair and sit beside him as he smoothly walks us through the sometimes seemingly paradoxical truth that has emerged over decades of research. His conversational style is disarmingly effective, so that while he displays an authoritative grasp on the evidence, he slowly pulls you over to his side, wrapping his arm around you like he is letting you in on some of the secrets of the world that only come with hard-earned wisdom. Sometimes he charms you with corny jokes that you may imagine coming from your dad, while other times he employs some good ol’ country doc straight-shooting. He tells us his BMI (body mass index), then reassures us to not worry because by his “estimation well over half of the Supreme Court is overweight” and “they seem to be doing fine.” He shares personal stories about himself, his wife, his mother and father, to starkly illustrate his points.
The realization less healthcare may result in better health is one that JAMA Internal Medicine has highlighted throughout the “Less is More” series, and more recently with the addition of trainee first-authored “Teachable Moments” articles that tell the stories of harms from overuse. In this book, Dr. Welch uses well-trodden examples likely familiar to most physicians. We hear about the history of cigarette smoking, hormone replacement therapy, thalidomide, the COURAGE trial, and studies showing intensive glucose control may kill people. The stories are well known, at least to academic physicians, but it is clear that we are not necessarily the target audience.
Welch even addresses the academic community in the “notes” section: “This book is purposely meant to be more informal – read: less ‘scientific’.” He says, it is calculatingly “more narrative, with fewer numbers, and, perhaps most importantly, no scary tabular and graphical data and no superscript references.”
Nonetheless there were lessons aplenty for me. He turned the confusing conversation about screening into a parable about turtles, rabbits, and birds, which I will surely borrow for explaining the topic to anyone. He breaks down incredibly nuanced statistics into narratives that somehow finally all make sense.
My only worry was whether this book will really reach the people it needs to reach. Who picks up a book called “Less Medicine, More Health” anyways? Will this just be preaching to the choir? Furthermore, will explaining these topics to the lay public even really make a difference? After all, a recent JAMA Oncology study helped debunk another myth – one held by clinicians and policymakers: the myth of the demanding patient as a driver of medical overuse. Regardless, this book masterfully illuminates the issue in an accessible style that seems like it can only help the cause. To that end, this book is a valiant service for patients and physicians.
Next time I see my friend, I think I will hand her a copy.
Christopher Moriates, MD is Director of Implementation Initiatives at Costs of Care and is an Assistant Professor at the University of California, San Francisco (UCSF), where he directs the center-wide Caring Wisely program and serves as co-chair of the UCSF Division of Hospital Medicine High-Value Care Committee.