Today I opened my AGA and AMA E-mail to see the headline:
Survey: Patients may be getting too much medical care
This was a blurb about a study in the Archives of Internal Medicine published online on September 26 which surveyed US doctors regarding the amount and aggressiveness of the care they provide to patients (http://www.nationaljournal.com/healthcare/survey-shows-doctors-admit-to-overtreating-patients-20110926).
The results of the study are no surprise to anyone who practices medicine the US currently. We all order more tests than we think are necessary, but most of us feel compelled to do so either by our litigious environment, our abject fear of “missing something”, or our overly concerned patients.
That last part is what I’d like to focus on for a bit, simply because I think no one mentions it when this topic is raised.
I just graduated to “attending” level, and finally I provide care directly instead of running everything by a superior. Even though I have been a practicing physician for 7 years, this new title confers me within an increased responsibility for my patients as well as an increased responsibility for the “health” of our medical center. I want my patients to know they are cared for and listened to. Providing good customer service is also good business practice. It’s the right thing to do, and it improves our standing in the community.
However, as one who has studied quality of care in a formal setting, I know that patient perceptions of quality of care do not necessarily echo physician perceptions of quality of care. During my graduate studies in the Gilling’s School of Public Health at UNC Chapel Hill, I took several classes quality of care. In one class focusing on the research and theoretical basis of the quality of care movement, I was asked to write a short brief about whether patient satisfaction equaled quality of care. My conclusion was that while patient satisfaction is an important component of high quality medical care, it was not a substitute for other markers of quality of care. One simple reason is this: often the highest quality care is no “care” (i.e. more tests), and this leaves many patients feeling neglected or ignored.
This directly relates back to headlines I saw last week regarding one physician’s cry for the need to teach financial responsibility to medical residents (http://www.latimes.com/health/boostershots/la-heb-health-care-costs-residents-20110919,0,5453286.story). I did not read the article, and I probably won’t. Don’t get to me wrong, I think it’s tragic how little physicians in training are taught about the economics of healthcare in this country. However, I go to clinic every week, I think about every test I order, and I feel strongly that one of the main barriers impeding my ability to provide cost effective, high-quality care is the patient themselves.
Patients come to me with their concerns and fears. They are just as heavily entrenched in the structure of our US healthcare model that incentivizes “doing stuff” as we are. Patients expect this “stuff” to happen in the normal course of seeking care. Every physician knows that patients believe that if doctors aren’t “doing something”, they are not good doctors. We subspecialists are particularly used to hearing patients report they felt their previous doctors didn’t listen to them and didn’t do anything about their complaints.
So what am I to do? Even if I gently counsel patients that I don’t think the tests are necessary, I can see the skepticism plainly on their faces. They feel bad, and are convinced something dire is wrong.
After their reactions, I generally give in and order the tests if there is any justification for doing so (I put my foot down on testing that carries more than minimal risks and has absolutely no indication). How can I explain pre-test probability, utility of tests, false positive/negative, medication complications yada yada yada adequately to a normal non-medical individual (particularly in my 40 minute new patient time slot?) Even I have to look up those concepts sometimes, and I have an advanced degree in it!
Hopefully with time I will learn to be a better counselor, and my patients will take my words as reassurance that they will be okay without a blood draw or endoscopy test telling them so.
Until we as a community address our patients’ desire for more aggressive care, as well as our desire to avoid lawsuits against us when we fail to meet their desires, no physician can be the ultimate arbitrar of reducing healthcare costs in this country. Indeed, I’m not sure how anyone expects to reduce healthcare costs until the American public is willing to accept that “less is more” when it comes to their health.test Filed under Genteel Health | Comments (3)