Medical Testing: Rethinking the "More Is Better Philosophy"
I saw a patient recently who was having a recurrence of her period a couple years after entering menopause. This is a difficult problem for doctors who treat women's health issues. By this, I mean that we almost always find that the uterus is just having "one last hoorah." But that specter of uterine cancer always looms as a possibility. With this patient, I carefully outlined findings and options, and she carefully considered her options. At this point in a visit, I am accustomed to hearing patients deliver a "whatever it takes to figure this out" type of response. This patient, however, chose to minimize any aggressive work-up, opting for a "watch and see" approach. While this stance requires patience, it is commendable in my book. In fact, the medical field is rethinking our mindset, trading in the "more is better" philosophy for a more structured, analytic approach to some medical issues.
How Did We Get Here?
In the old days, a doctor usually had a stethoscope and a few tools in his trademark black doctor bag. But let's not forget his most important tools - his brain and his hands. The focus was on listening to that heart murmur, for instance, carefully navigating the auditory cues as to what was wrong (or not wrong) with the heart.
Today, we are quick to throw on the echocardiogram to figure things out. Or, worse, ordering the echocardiogram just to make sure or just in case the diagnosis is incorrect. Society has participated in this mindset - the high-tech, full measure is seen as better. In reality, when all is said and done, many problems come to the same end diagnosis other than on the one end where the doctor's backside is covered and the bill is horrendous.
Winds of Change
In most business arrangements, market forces drive trends. For instance, if a restaurant produces food that is tasty but costs way too much, nobody will fill the seats, and the restaurant will go under. Basically, consumers shape supply and demand.
In medicine, however, there have traditionally been no consumers. Insurance companies paid the bills and kept their mouths shut. But over recent years, insurers are more vocal about costs and coverage. In addition, patients are in the mix, lending their voice. Health savings accounts are becoming more popular, leaving patients with the bill.
Consider this scenario: your doctor tells you that you have a heart murmur and he is quite sure it's harmless, but that a $500 echocardiogram can confirm the diagnosis. The cost of the study is on you. What would you opt for?
Large-Scale Changes in Attitude
So much is ambiguous when it comes to making diagnoses that I've learned to appreciate certainty when I get it. Opinions are given, odds are discussed. When I get that "slam dunk," I have come to savor it. And atop this, I, like virtually all doctors, practice defensive medicine to some degree. Tests are ordered to satisfy patients and their implied litigenous and judgmental attitudes toward services provided. (In other words, so we won't get sued.)
Thankfully, things are changing with tort reform measures and, more importantly, our attitudes. Think about what has happened on public beaches. The most severe safety measures that you will find on a beach these days is a sign that states, "No lifeguard on duty- swim at own risk." Medicine can never nor will it ever get that way. The pendulum is swinging the other way and market forces are helping make this more natural. Uncertainties are accepted.
From within medicine, an interesting initiative is taking place in the Choosing Wisely program promoted by the American Board of Internal Medicine. This program considers low-yield tests and procedures often ordered by doctors and moves to educate both patients and practitioners on being more conservative. Doctors are encouraged to spend more time explaining all the options and discuss the benefits (or lack thereof) with testing, making a joint decision with patients. Cost, once never discussed, is also a consideration in this newer, patient-consumer model.
Medicine is changing on the front of the wastage garnered by too many tests that are not necessarily needed. This will require a large-scale change to the mindset that more is not definitively better. With the help of fiscally responsible patients, doctors can hopefully reclaim their brains as the most important tool they have in diagnosing and treating disease.
P.S. this mindset is not being fueled by Obamacare... just common sense.