by Marty Makary
“At what age do you recommend doing this test?” I asked.
She looked puzzled, as if no one had ever asked this question before. But medical guidelines often stipulate that screening tests should not be done until a certain age. Younger people aren’t at risk for many diseases, so screening can do more harm than good.
It’s important for patients to understand the screening-industrial complex. Some medical providers see it as a way to bring in business, just like in the D.C. churches.
We don’t have to guess which screening is useful and which may be bad for us. For common tests, we can rely on the work of the U.S. Preventive Services Task Force. The task force is a national group of volunteer physicians and academics from top universities who study the best available evidence on screening and see what’s supported by sound research. They consult experts in each specialty but remain independent, so their guidelines are trustworthy. When we wonder whether wellness companies are leading us down the right road, we can use the task force’s recommendations as a map. Wellness companies often make recommendations that go against task force guidelines.
Genetic screening sounds enticing. Same with biometric screening. But beware of tests that go fishing for diseases. At times in my medical training, I’d hear a doctor justify ordering a broad set of tests with the remark that one time, one of the tests revealed a rare medical condition. The real question is: Are these conditions treatable? Because if not, it can create tremendous angst. One patient of mine taught me just how dangerous it can be to go fishing for disease.
Tim didn’t have symptoms, but he had a CT scan for the sake of screening—a fishing expedition. The scan showed a cyst on his pancreas. Three percent of all people have these cysts, and they are rarely problematic. Based on his cyst’s size and features, it wasn’t clear what to do about it. Tim was given options. He could just watch it and wait to see if it became a problem. Or he could undergo an operation to have it removed.
Every night, Tim tossed and turned, agonizing over stories of people who didn’t do anything in the early stages of their pancreatic cancer. He felt tormented by the idea that he might be harboring a “precancerous” time bomb. The dilemma of whether to risk surgery or leave it alone consumed him. It strained his marriage and distracted him from his work.
Eventually, against my advice, he decided to put an end to the misery of not knowing. He underwent an operation to remove the cyst. The operation cost $25,000 and resulted in his missing eight weeks of work. Turns out Tim’s cyst was harmless. As a surgeon, I’m trained to crush cancer. For many years, every tumor I laid my eyes on fired me up, like looking an enemy straight in the eye. My experiences made me want to hunt and destroy the disease with every tool modern medicine has to offer. But these hunts to destroy cancer can have collateral damage.
Tim’s case is an excellent example of why a healthy person shouldn’t have a full-body CT scan just for the sake of fishing. Screening made Tim sick.
Wishful Thinking
Like many fields that go awry, the wellness industry began with good intentions. In 1990, the Centers for Disease Control and Prevention released a famous report entitled Healthy People 2000. It specifically recommended “worksite health promotion programs” to combat diabetes, obesity, smoking and more—a noble goal. A decade later, the number of workplace wellness programs had more than doubled, according to the agency’s subsequent Healthy People 2010 report. The report added growth goals for workplace wellness programs, and they continued to proliferate.
The wellness industry got a boost from a questionable number cited in a puff piece written by Harvard experts in Health Affairs.6 The article claimed that wellness programs have a 3.27-fold return on investment. The number had little scientific basis, but its timing was impeccable. The study came out just as the Affordable Care Act was being crafted, and the article quickly became a highly cited source as the legislation was being debated. As it turns out, the study’s coauthor was a political adviser to those drafting the ACA.
Many times in my medical career, I have witnessed one person’s opinion or estimate become “evidence” simply because their estimate gets published as a pretty PDF in a medical journal. That was the case for the Health Affairs piece. As soon as the Harvard researchers published their 3.27-fold return on investment, it got cited as “published science.” I call it the pseudoscience bandwagon effect. The same journals that advanced the low-fat diet and told us opioids were safe had now, in the case of the Health Affairs piece, increased health care costs by publishing a misleading ROI statistic.
Then, during the debate that led to the ACA law, the grocery store Safeway was held up as the model of wellness success amid a sea of confusion about health care. Safeway’s CEO had declared in a 2009 Wall Street Journal editorial, “How Safeway Is Cutting Health-Care Costs,” that wellness saved his company big money. Soon after, the wellness story had worked its way into the president’s speech before Congress, where he said, “It’s a program that has helped Safeway cut health care spending by 13% and workers save over 20% on their premiums.” It was a great story. There was just one problem: it wasn’t true.
The Washington Post7 exposed the truth months after the CEO’s editorial and before the passing of the law. The supposed savings cited by the Safeway CEO was caused by an overhaul of their benefits that passed more of the costs on to employees. In truth, the Post reported, the company’s health care costs had risen.
But truth couldn’t overcome legend. Americans trying to understand health care were so hungry for a simple solution that everyone could agree on that they latched on to the Safeway story. The medical establishment and health care industry’s powerful stakeholders conveniently piled on their support. I attended so many health care conferences where “experts” from the medical establishment proclaimed how the Safeway story was a big part of how to fix health care. It was a bandwagon that distracted from the real issues of price gouging, middlemen, and overtreatment. In fact, the Safeway story made victory laps around Capitol Hill. The new ACA health care law had inserted in it the “Safeway Amendment,” which allowed employers to use up to 30% of the cost of an employee’s health coverage as a “reward” to induce the employee to take part in the program. If you don’t participate, you pay a lot more for your health insurance. That’s how wellness programs proliferated in America.
I’ve seen this blind faith in good stories before. At Hopkins, when we described a program to lower large IV (central line) infections in hospitals, we saw policy leaders latch on as if the program were the salvation of health care. This program was important, but not a silver bullet. Similarly, when my colleagues and I published the first surgery checklist in the medical literature,8,9,10 and a few years later, when Dr. Atul Gawande and I worked with the World Health Organization to expand it,11 people were quick to sing its praises. I heard numerous speakers start their speeches on how to fix health care with a description of the surgery checklist as if it were the silver bullet of health care. It was a great story. But here was the problem in all the bombast: checklists address less than 1% of the preventable harm in medicine today. I wholeheartedly believe in checklists, but I know they’re just one small step in fixing health care.
So why do people want to focus on things like lowering central line infections by using the surgery checklist and Safeway model? I think it’s because the real drivers of health care costs are legacy stakeholders, like hospitals, insurance companies, or drug companies, or all the middlemen I’m exposing in this book. There are so many hands taking money out of the system that there’s no silver bullet solution to save money. To lower costs, we must take on the powerful stakeholders. It’s easy to blame bacteria for our health care woes, but infections are not the reason your premiums went up 15% last year.
Workplace wellness advocates hailed the support provided by the Affordable Care Act as a public health victory. Soon there were promises of lower rates of chronic disease and lower health care costs. Wellness companies bega
n to pop up all over. Wellness programs began to require people to answer extensive questionnaires that delved into their privacy. Wellness programs provide only a modest profit, so companies began to sell their employees’ collected personal health data to third parties. That was a good business model. On the open market, health data is coveted.
Where is the science to show that the enormous societal investment in wellness programs makes people healthier? It’s nowhere to be found. The evidence we do have does not show that these programs are effective.
A Tufts Medical Center research team assessed the economic impact of the programs. They analyzed more than 2,000 peer-reviewed studies that used experimental or quasiexperimental study methods to look at medical, pharmacy and work productivity costs and indirect costs. The team’s conclusion was hardly encouraging. They concluded that any evidence of a positive economic impact of workplace wellness programs was limited and inconsistent.12
In 2017, four members of the team behind the Incidental Economist blog published an extensive assessment of wellness programs and the evidence of their effectiveness. The title of the paper speaks for itself: “The Dubious Empirical and Legal Foundations of Workplace Wellness Programs.”13 They declared that most studies on the efficacy of the programs suffered “serious methodological shortcomings. Some are little more than thinly veiled promotional materials pulled together at the wellness industry’s behest.”
The evidence doesn’t support the “unbridled enthusiasm” for wellness programs found by the team. They also revealed that certain programs appear to violate the Americans with Disabilities Act, which prohibits employers from conducting medical exams and collecting histories of their employees unless they are voluntary. Some financial incentives don’t give employees a real choice about “volunteering” to share their medical information, the study said. “The evidence on wellness programs is discomfiting,” the authors wrote. “Most programs do not work; some raise serious legal concerns. It is time for employers and policymakers to rethink their enthusiasm for the wellness movement.”
In 2018, researchers from the Illinois Workplace Wellness Study published a large randomized controlled trial of a wellness program conducted at the University of Illinois at Urbana-Champaign. The study included nearly 5,000 employees who agreed to participate; some employees were invited to receive a biometric health screening and an online health risk assessment and offered a number of wellness activities. Employees were paid for completing screenings and participating in activities. The researchers followed the employees to see how the program affected their activities, their health, their productivity, and their medical spending. In the final analysis, there was no difference between those who did the wellness program and those who didn’t. In the words of the New York Times, “The results were disappointing. There seemed to be no causal effects.”14 Most recently a JAMA study of 32,974 employees randomized to participate in a wellness program found “no significant differences in clinical markers of health; health care utilization, absenteeism, or job performance.”15
When I first heard of them, I liked the idea of wellness programs. The idea seemed to make good sense. But after I attended the wellness class with my friend, I realized the industry had again sold America a bill of goods. It’s yet another example of money earmarked for American workers getting diverted into the hands of corporations.
A Wellness Disrupter
Al Lewis went from a wellness industry advocate to its foremost critic. He spent years in the industry but came to see its futility. He left and started his own company, Quizzify. The Boston-based company educates employees about overtreatment and dispels myths about healthy living. I traveled to meet with Lewis, and he didn’t hold back.
“Most of it is fluff. And I might add expensive fluff,” Lewis, a tall man beaming with a smile, explained to me over a snack after he had just finished speaking to a large audience. Quizzify uses an interactive game show approach to teach people about common medical pitfalls, including the risks of overscreening. It also alerts employees to the most common unnecessary tests and procedures in medicine today, according to the Choosing Wisely campaign.16
I was able to attend one of his workshops and take the quiz. With his comedic, engaging style, Lewis informed participants about how long a knee replacement lasts, the latest research on heart stents, the radiation risks posed by a CT, and the role of sugar in disease. He even covered the risks of Nexium, my old heartburn medication. In that room, I witnessed Lewis educate a large group of people with highly relevant techniques they can use to make everyday decisions—from how to read a nutrition label to how to ask questions about common medical procedures.
Quizzify offers a health risk assessment. But it doesn’t ask for personal information about drug, alcohol, and tobacco use. The Quizzify survey asks about diet and exercise, as well as educates people about the potential hazards of common medical tests and treatments. The idea is to help employees become wise stewards of their health and their health care spending.
Quizzify produces entertaining, interactive online quizzes to educate anyone wanting to learn more about health. The quizzes feature Lewis’s offbeat humor while offering information patients can use. Lewis calls their tone “Jeopardy! meets Comedy Central.”
Other wellness programs have value. Some employers provide fitness club memberships, regular yoga classes, medical second opinion services (I advise one called Veza Health17), or on-call clinicians to answer health questions. Warren Buffett’s nonprofit wellness company Welcoa teaches accurate nutrition science and promote lifestyle treatments for illness. When I asked Welcoa’s CEO, Ryan Picarella, why his company is so different, he said it was because they were focused on what actually makes people healthier instead of soft stuff that doesn’t work.
The solution isn’t to throw out all workplace wellness programs, but to choose a wellness program that is based on science and results in wiser health care choices. I like Quizzify’s approach because it educates people using a fun style. For example, one quiz question asks how the radiation from a CT scan compares to the radiation from an X-ray. The answer: Most CT scans emit between 100 and 1,000 times as much radiation as X-rays. The point is not to avoid CT scans; it’s to help people understand they should only be performed when necessary. CT scans are not for fishing for problems.
Lewis is part of a broader effort working to certify individuals and organizations in the wellness industry. The Validation Institute—a joint venture between Intel Corporation and GE Healthcare—certifies organizations in the wellness arena by evaluating results. The effort educates brokers and benefits consultants on how to evaluate vendors, since they are intermediaries for many in the employer marketplace.
Florida-based U.S. Preventive Medicine (USPM) is one such company that has been validated by the Validation Institute for sustained reduction in health care costs.18 The Validation Institute says USPM reduced asthma, cardiac events, COPD, diabetes, and more across its entire book of business. USPM is a shining example of what’s possible when companies do wellness right.
CHAPTER 17
The Words We Use
In junior high school, I was told I needed to take a foreign language. I had three options: French, Spanish, and Latin. I asked my guidance counselor, “Which one do I pick?”
“Well, son, what do you want to do when you grow up?”
“I think I want to be a doctor, but I’m not sure.”
“Then Latin.” He ruled like a judge quickly resolving a dispute.
I had never even heard of Latin. Furthermore, I didn’t know what population group in the world spoke it. I quizzed my mentors around the school for their opinions, and they had the same response: “If you want to be a doctor, Latin will help you in medical school.”
Even after I found out that Latin is spoken nowhere in the world, I obeyed the unanimous recommendation that it would someday help me in medical school. To be honest, I got excited at the idea of having a head start in med school. I took
Latin for four years in high school, memorizing 20 new words for every Friday exam.
Four years after high school I sat in the lecture hall in medical school, ready for my first anatomy class to be taught in Latin. But med school was not taught in Latin. It was taught in English. Within months, I realized my Latin was not helping at all. Then one day in my second year of medical school, the professor said that a necrotic lymph node is a lymph node with dead tissue in it. Yes! I perked up. I recognized that “necro” meant “dead” in Latin. Even though I recalled that derivation quicker than anyone else, I felt depressed when I realized I spent four years studying Latin for the benefit of recognizing one word in medical school. I could just have memorized that one word! To this day, that one word comes a bit quicker to my mind. Say it with me: “necrosis.” Meanwhile, I cannot communicate well with the 10% of my patients who are Spanish-speaking. Latin was a bad deal.
Whenever a colleague mentions that a patient has a necrosis, I flash back to those four years of Latin. That’s followed by a sense of anger that I spent so much time learning stuff that doesn’t matter at the expense of not learning more important stuff that does.
Today’s medical education is dominated by a similar disconnect. About a dozen times in my extensive medical education I had to memorize things that I can simply look up—like the genetic conditions multiple endocrine neoplasia (MEN) type 1 and 2, conditions the majority of doctors will never see. I’ve seen the condition twice, and each time I quickly looked it up to refresh my memory. Yet all doctors must memorize these rare, non-urgent conditions and their specific gene mutations over and again on the road to becoming a board-certified physician.
Our medical education system is skewed toward things that don’t matter. It’s focused on rote memorization instead of treating the whole person. For example, it indoctrinates medical students that every adult woman needs a screening pap smear at regular intervals. But it fails to tell them that doing a screening pap smear in a 90-year-old woman is just wrong. The medical system teaches operative technique but does not prioritize care coordination. It gives students a passion to stamp out disease but fails to teach the importance of humility.