Nearly everyone is for health-care reform until it affects them, and now that details about the reform proposals in Congress finally are emerging, hackles are raised. Despite all this vitriol, I hope the country can have a meaningful dialogue to help solve the upcoming crisis of unsustainable levels of health-care expenditure.

The current debate seems to be consumed with the question of public versus private funding of health care. It's taking on the appearance of the pro-life-versus-choice debate . . . not reconcilable. But either way we must develop cost-accountable systems instead of the fragmented quantity-driven systems that now predominate.

More health care is not necessarily better health care.

So, with that in mind, it's helpful to take a look at what treatments and procedures have a low benefit-to-cost ratio. I have conducted a totally blind, out-of-control survey of some members of the Spokane County Medical Society. They sent me the following responses:

•"Antibiotics for sinusitis is a very common one. I'm sure hundreds of pounds (sic) are prescribed every day for this diagnosis to no effect."

•"Two things come to mind since they are common in my practice: PSA tests—evidence is lacking for the benefit of doing them beyond the anecdotal. And there is little if any evidence for doing a yearly physical on healthy adults. There is evidence for doing certain screening tests such as pap smears, mammography, colonoscopies, immunizations, and blood pressures. But we spend an enormous amount on 'well exams' when most likely we could do as well with doing the screening tests at appropriate intervals for which we have good evidence."

•"This country could save millions of dollars, maybe hundreds of millions of dollars, by changing the way we screen for colon cancer.There is no evidence to show that populations of people screened first with colonoscopylive longer or have lower mortality than populations screened firstwith hemoccult (fecal occult blood test) then colonoscopy of any positive hemoccult. We do know that some people are seriouslyharmed by the colonoscopy that did not find any abnormality. No one ever isharmed by doing a hemoccult that doesn't find any abnormality, so why is it such a common practice to go directly to colonoscopy for CRC (colorectal-carcinoma) screening?"

•"CT scanning of the head is out of control. If you present at any emergency room with the isolated complaint of 'headache,' then there is an extremely high chance you will have a CT scan of the head. The CT scan often isn't preceded by any symptom-directed history of the patient's complaints, or by any physical examination. There are many textbooks and clinical manuals that demonstrate the workup for headaches, and most of the algorithms advocate imaging studies further out in the decision tree. CT scans of the head help to eliminate the 0.01 percent chance of missing a brain tumor (or less, depending on the source). This one imaging modality is emblematic of our overuse of diagnostic testing, and deference to clinical examination.

"In our era of entitlement and perfection, society expects doctors to be perfect, every time.The government advocates evidence-based medical practice, but the malpractice arena dismisses anything other than an ideal outcome.The practice of CYA medicine is completely understandable in today's tort environment. CYA medicine is a significant contributor to our health-care expenditures, but unfortunately has been less than a pixel on the screen of health-care debate.

"According to a University of California-San Francisco 10-year study, CT scans have doubled between 1997 and 2006.In an article in the journal "Headache" in 2000, the authors concluded that 'neuroimaging is not warranted in children and adolescents with defined clinical headache syndrome diagnoses whose neurological examinations are normal.'However, in practice, a CT scan is often ordered despite what the literature suggests. If we were to take the amount of money involved with CT scans of the head for just one day in our country, the dollar amount would be staggering. But then again, anything less than a trillion dollars is pocket change in today's medico-political landscape."

•"Statins for the elderly. Long-term prevention of heart disease with people who have only a 5- to-10-year life expectancy. The statins constitute the largest cost category for pharmaceuticals."

Ceramic hip prosthetics and advanced imaging are other examples. "Every time we get a new technology that provides insights into structures we didn't encounter before, we end up saying, 'Oh, my God, look at all those abnormalities.' They might be dangerous," says Dr. David Felson, a professor of medicine and epidemiology at Boston University Medical School. "Some are, some aren't, but it ends up leading to a lot of care that's unnecessary."

Avastin is a monoclonal antibody that blocks the effects of VEGF (a chemical signal that induces the development of new blood vessels) and prevents cancer cells from establishing new blood supplies. Avastin has become one of the most popular cancer drugs in the world, with sales last year of about $3.5 billion, $2.3 billion of that in the U.S. But there is another side to Avastin. Studies show the drug prolongs life by only a few months, if that.

Roy Vagelos, a former chief executive of Merck who is considered an elder statesman of the industry, said in a recent speech that he was troubled by a drug—he didn't name it, but clearly was referring to Avastin—that costs $50,000 a year and adds four months of life. "There is a shocking disparity between value and price," he said, "and it's not sustainable."

End-of-life care has become the focus of the most emotional responses in the health-care reform debate. There is a lot of unnecessary suffering for the patient, family, and friends as life is prolonged with little hope of meaningful recovery. Reimbursing primary physicians to counsel patients to avoid these decisions being made in the midst of a crisis seems practical, but this effort has been misunderstood.

These are ideas that surely will engender debate. The task ahead of us seems insurmountable. We might disagree with President Obama on many issues, but I think you have to concede his insistence that the status quo is unsustainable. The speed and haphazard appearance of the current proposals are disconcerting. We need well-thought-out and tested programs to bring about sustainable change. Physicians have a lot of credibility with the public. We need to recognize our prejudices and preconceived notions so we can critically evaluate the new options and be part of the discussion.