Do Physicians Provide Too Much Medical Care?
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.
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Counterpoint. I once fired my primary care physician for providing too much care. After asking me about my sexual habits (non existent at the time!), we decided I didn’t need any pregnancy or std tests. Imagine my surprise when I went back to discuss my other bloodwork results and he started by congratulating me for not being pregnant or having any std’s. Um, duh, I’d already told him I was a virgin! After questioning why he ordered such unnecessary tests, he shrugged, and said I shouldn’t worry about it because my insurance covered it. I told him that was insurance fraud and never went back.
This is the real problem with healthcare in the US — consumers are completely divorced from the pricing of healthcare. They pay their little co-pay and tiny share of their health insurance premiums but have NO clue of the costs behind it (or how much more $$ their employers pay towards the premiums). That’s why us economists are such big fans of HSA’s, at least for the young and healthy, and why my doc was wrong when he said my insurance company picked up the tab — it came straight out of my HSA dollars!
Sorry for the long comment but this topic strikes a nerve with me.
Super post. Some great points you highlight in there.
Thanks for posting! I’m so excited a real person and not a spammer read my post! (case in point, the next one for me to review is from “casino en ligne bonus”, ~awesome~)
I totally agree with you that people are divorced (up front) from the cost of health care. Neither the MD nor the patients know what they are getting into when they order the tests they order. I had an excisional lymph node biopsy in med school (a 20 minute surgical procedure I pushed for because I was a cancer phobic med student) that wound up costing $10K, of which I paid 20%. This came out of student loans, of course, because I had no income. I had NO CLUE how expensive it was going to be. I was so scared of cancer, though, I think I would have done it anyway even if I knew the costs up front.
I think we should incorporate pricing at the point of ordering so that both docs and patients know the cost.
HSA can be good choices with the right type of person, but not every person is going to have the information, the time, the ability or the motivation to make wise decisions with their care (i.e. people may choose to address a self-limited health problem that causes them immediate discomfort but will defer paying for preventive care). You could argue that it is their decision to risk future health problems by avoiding preventive care (in this example), but it’s not really fair to punish a patient for bad choices he or she made in the absence of an intelligent discussion with someone who can place those choices into perspective.
Medical jargon and testing characteristics are overwhelming for the most educated, but the degree of poor health literacy in this country is staggering. Studies have indicated that 66% of adults over the age of 60 have inadequate or marginal literacy. Another study showed that 75% of surveyed people with a chronic disease have inadequate literacy, and yet another study estimated that poor functional literacy adds $32 to $58 billion in additional health care costs (born mostly by Medicare and Medicaid). http://www.chcs.org/usr_doc/Health_Literacy_Fact_Sheets.pdf
People falling into these categories are unlikely to be good candidates for health savings accounts.
My concern in writing was that the healthcare industry and those of us who work in it are often blamed for the ballooning costs of care, and we certainly play our part, but responsibility should be taken on both sides of the desk. Patient and family priorities influence what I order, and I rarely refuse to honor requests from patients that have some justification.
I love it when people tell me they don’t want to have extra or minimally helpful tests done–come see me next time you need a gastroenterologist!!