APeticola has an interesting post at the always-challenging Health Care Renewal, on the tendency for diagnostic “thresholds” to decline over time - that is, the fact that certain conditions will tend to be seen, and treated, in more and more patients as those conditions acquire greater salience in the medical community.

In the news recently was someone or other’s recommendation that less severe degrees of obesity than morbid obesity be also treated by gastric bypass. This should surprise no one. There are constantly “discoveries” that it is better to be more and more aggressive with blood pressure, cholesterol, blood sugar targets; etc.; and thresholds for treatment are generally lowered with each new series of recommendations.

Diagnostic and treatment thresholds ratchet ever downward. It’s definitely good business. But is it good medicine?

Good question, certainly. And Peticola does a good job laying out some of the problems that this phenomenon may generate:

As treatment thresholds move downward, medical expenses move upward. And something else occurs: as thresholds are lowered for treating various risk factors, the benefit/risk ratio changes markedly.

But I wonder if there’s a point being missed here.

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A group of occupational-medicine physicians has released a white paper on the issue of disability certifications for impaired workers, holding that doctors often keep workers off the job too long after an injury or illness and that the specialty should adopt a “Stay at Work/Return to Work Process” as its fundamental organizing model for treating disability. That process seeks to minimize the time workers spend off the job, which, the authors assert, would be beneficial in many ways:

We know that much work disability is not required from a strictly medical point of view. We see devastating psychological, medical, social, and economic effects caused by unnecessarily prolonged work disability and loss of employability. We also see wasted human and financial resources and lost productivity.

Finding better ways of handling key non-medical aspects of the process that determines if an injured or ill person will stay at work or return to work will improve outcomes. Until now, the distinct nature and importance of the stay at work and return to work process (SAW/RTW) has been overlooked. Improvements to that process will support optimal health and function for more individuals, encourage their continuing contribution to society, help control the growth of disability program costs, and protect the competitive vitality of the North American economy.

This may all be true, but it causes concern nonetheless. Without comment, these authors introduce multiple factors into their outcome evaluation which are not related to, and in fact may conflict with, patient welfare. They say explicitly here, and throughout the paper, that the benefits of encouraging workers to take less time off the job for disability-related reasons include, among other things, harm to the “economy” (GDP, presumably), “contribution to society”, reduced costs of disability treatments, and worker productivity. In other words, among the major drivers for doctors to determine the course of individual patients’ care are the contributions those patients can make to overall economic goals valued by their employers, third-party healthcare payers, or “society”, not the patients themselves.

To put that another way, these authors are openly encouraging doctors to admit external economic values (in addition to the many that already impact treatment decisionmaking) to directly influence their decisions regarding their patients’ recovery from illness or injury - values that run directly counter to the patients’ own. There may be a problem there.

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