NEJM Blasts “Crusade,” Omits that Its Former Editor Launched It

A blistering attack by the national editor of the New England Journal of Medicine against the “less is more” movement in medicine omitted that the publication’s former editor-in-chief played a foundational role in popularizing the idea of widespread medical waste.

The commentary in late December by Dr. Lisa Rosenbaum, “The Less-Is-More Crusade – Are We Overmedicalizing or Oversimplifying?” has attracted intense attention.  Rosenbaum berates a “missionary zeal” to reduce putative overtreatment that she says is putting dangerous pressure on physicians to abstain from recommending some helpful treatments. She also asserts that the research by Dartmouth investigators and others who claim 30 percent waste in U.S. health care, in which she once fervently believed, is actually based on suspect methodology.

What Rosenbaum fails to mention is that the policy consensus she seeks to puncture – that the sheer magnitude of wasted dollars in U.S. health care offers “the promise of a solution without trade-offs” – originated in the speeches, articles and editorials of the late Dr. Arnold Relman, the New England Journal’s editor from 1977 to 1991.

Waste’s “fundamental cause is doctors”? Although Relman consistently blasted a variety of culprits who “commercialized” medicine, he was clear in a 1985 article for the National Academy of Sciences that “more prudent choices by physicians” would substantially reduce costs.

A “crusade”? Relman by 1986 was being called “the leading exponent” of the view that by eliminating waste quality could be maintained or improved “while costs could be stabilized or reduced.”

A “solution without trade-offs”? Relman could have been the poster child for that position. In a 1991 article for Health Management Quarterly, he wrote: “At least a third of all the money we now spend on medical care in this country could be eliminated…[and] we could afford to do everything medically appropriate for all our people,” including coverage of the uninsured.

Flawed research? Relman’s waste estimates, though widely quoted, were essentially opinions reified by his rank. As such, his figures fluctuated. Waste was “at least 15 to 20 percent” in that 1985 article. It was “20 percent” in a 1988 interview with me. “As much as 20 to 30 percent” in a 1990 New England Journal editorial. And in 1991, as noted above, “at least a third.”

I know the history of this effort because I covered it as a journalist, researched the quality movement for a peer-reviewed book and have continued to be active in this field as adjunct faculty at Northwestern University. For this article, I went back to the literature and my notes to confirm my memories. The “30 percent” waste figure came from Relman, and others (including the Institute for Healthcare Improvement, employer groups, policymakers and Dartmouth) took it from there.

On a personal note, while Relman’s guesstimate was a great soundbite, I deliberately omitted it from my book, Demanding Medical Excellence, since one of the book’s tenets was the flaws of eminence-based, rather than evidence-based, medicine.

Why does it matter that the New England Journal omitted its role in every aspect of a movement its national editor denounces? While the omission may not affect the debate over Rosenbaum’s core assertions, it does raise questions about the editorial standards of one of most trusted medical journals in America. Put bluntly: are there professional standards for criticism, or does it depend upon who is being criticized?

I suggest the Journal’s editors follow the mantra, WWJD. Not “What would Jesus do?” but “What would journalists do?”

Your national editor launched a sustained attack against activities your former editor-in-chief inspired, engaged in and, although not in every detail, supported in your publication. Since Rosenbaum’s commentary claims to be research-based, this seems an important piece of data not shared with readers. How was it missed?

There’s another, less likely but more disturbing possibility. Rosenbaum, referring to the less-is-more movement, writes that the more coherent a story seems, the more believable it becomes whatever the evidence might say. That inevitably opens the question of whether the omission of Relman’s role was an attempt by the writer or editors to make Rosenbaum’s attack piece more coherent.

And that leads to the matter of language. A top-tier medical journal allowed its national editor to suggest that those with whom she disagrees are not only misinformed on the facts, but zealots who persecute their fellow doctors, pervert policy and injure patients. Do the editors believe that’s an appropriate manner to characterize their own former editor? If so, by all means run a correction saying that Relman, and the Journal itself, should have been included among Rosenbaum’s culprits.

Or, forced to look in the mirror, might the editors rethink whether, indeed, “less is more;” i.e., there’s a need for less invective and incitement masquerading as iconoclasm and more reasoned argument.

My layman’s diagnosis is that Rosenbaum, a smart and talented writer, was suffering from Sage Syndrome, a condition afflicting those whose pay, prestige and pride are linked to the perceived profundity and cleverness of their opinions. I suspect Rosenbaum relied on her memory, which was flawed, and her editors were no better. Because her put-downs were proffered in defense of deference to status-quo physician behavior and the general goodness of doctors, her editors gave her pejoratives a pass, possibly rationalizing that being “provocative” would “drive web traffic.”

Those of us who believe in continuous quality improvement would call this an opportunity for a respected individual and institution ­– and Rosenbaum and the Journal are deservedly that — to undertake some honest self-examination.

When I worked at the Chicago Tribune, I was active in the national Society of Professional Journalists. I know that the newspapers that are of the caliber in their field of the New England Journal in its field would unhesitatingly choose to be tough on themselves and transparent with their readers. That’s what journalists would do. What path will Rosenbaum and the New England Journal take?

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