Saturday, March 15, 2008

Too Many Tests, Too Many Doctors

I've written often about the primary care doctor shortage and the crazy system of health care financing that we have in the United States. To get a clear example of this, check out the great op ed article in the New York Times, titled "Many Doctors, Many Tests, No Rhyme or Reason."

The writer, a medical intern, had his eyes opened when he witnessed a 50 year old man who was admitted for shortness of breath, ended up staying a month in a hospital with consults by a hematologist (blood specialist), endocrinologist (gland specialist), podiatrist (foot specialist), two cardiologist, nephrologist (kidney specialist), ID (Infectious disease), pulmonary (lung), urologist (male urinary), Gastroenterologist, nutritionist, pain specialist, two surgeons and a thoracic surgeon.

The patient underwent 12 procedures, including a pacemaker and cardiac cath. His main diagnosis (which does cause shortness of breath) was anemia.

The question to be asked is, did that extensive and mind boggling expensive work up benefit that patient? It wasn't mentioned in the article but I am pretty certain he was not paying the fee. Either an insurer (read the working guy) or Medicaid (read your taxes) coughed up the dough for the hospital, the tests and the 17 doctors.

In the "old days", when patients had a family doctor or Internist, there was someone to coordinate and manage the patient. Now, if a patient sees an Orthopedic physician for a bad knee and surgery is planned, the Ortho doc will ask for surgery clearance which can start the cascade of one specialist after another. Some of this is defensive medicine, some are thoughtless referrals, some are feeding patients to your buddies.

For example a cardiologist may find an abnormal EKG. Without an old one to compare, he may think those extra beats are worrisome and that leads to more tests and more referrals. The physician thinks they are doing the best by being "complete and comprehensive" but you end up with the scenario of multiple consults and tests that have nothing to do with the knee replacement.

Less than 20% of medical school trainees choose primary care medicine and studies show that even fewer stay in the field to practice. That means we are cranking out more and more ultra specialists. Studies show more specialists do not translate to better care and in fact, there is an inverse relationship with quality outcomes and more specialists.

Read the Op Ed. It's an eye opener and sadly very true.


Healthnut said...

Too much greed. They don't make moral human beings like they used to. Everyone wants a "piece of the pie". Comments #22 and #50 made sense. Comment #68 was "touchy". Thanks for sharing.

Toni Brayer MD said...

Healthnut: I think the overuse of testing and consulting is a complex subject and greed is but one small aspect, not the whole cause. I don't know what comments you are referencing. Thanks for reading and sharing.

Toni Brayer MD said...

Addendum...the comments Healthnut referenced are on the NYT article. They are very informative also!

Anonymous said...

On #22 I don't think for someone to say a doctor dosen't care about them is a justification to refuse to take responsibility of their own health when told by that doctor to reduce your chol., stop smoking, and follow up with your primary care doctor. No matter how excellent or how much a physician cares he/she can't control or make you do the work to take charge and change unhealthy lifestyle choices and habbits.

By the way I'm not a physician but from an objective prespective, think it should be a patient working together respectfully with a doctor like a team or partnership towards that patients individual goals for their best health interests with following your doctor's expertise as ordering treatment, educating, advocating,encouraging and guidiance. In this case it does seem unfair that the physician lost the malpractice case.


Jonathan said...

Excessive testing yet again reveals the importance of the internist as the quarterback of ones healthcare. And an internist of long standing, one who has a familiarity with their patient’s medical history, and where the patient/physician relationship allows for good communications, can go a long way towards guiding the patient as to which tests are medically worthy of pursuit and for which tests a delay or even a pass is the preferred course of action.

The institutional demands on physicians for diagnostic testing are many. In addition to the medico-legal considerations that dog our physicians and the procedure based fees that together provide incentives for tests, is the more subtle and difficult to quantify intellectual demand for diagnostics in the environment of the academic teaching hospital. Perhaps the excessive tests described in the NY Times article were in part driven by the teaching hospital’s intellectual culture? Such a culture rewards the physician-scientists who can solve the mystery of the underlying disease process of the often tough cases that end up in up in a big city teaching hospital, and diagnostic tests are the foundation of the disease discovery process.

Yet, the demand for tests, a complex issue indeed, originates not just from physicians, but from patients and their families as well, as we are enculturated to demand that our medical system render us its full potential. I have been guilty, for instance, of asking a hospital ombudsman for an additional test for my aging father.

I suspect that both enculturated patient and intellectually driven physician demand for medical answers are likely subconscious, but with the guidance from the internist hopefully this demand can be slacked. Institutional demand, especially medico-legal driven testing, need be reduced as well, but relief here will need to come though legislation (or internist legislators).

No matter what the origins of the demands for excessive testing, such tests need be reduced. Not only are the opportunity costs of these excessive tests measurable in patient and insurer dollars, but the misallocation of physician and hospital resources that would otherwise be better spent in addressing other patients’ needs or simply allowing physicians, labs and hospitals to encompass more patients. As we include more patients in our medical system, hopefully the result of universal healthcare, physician hands-on and thinking time, along with constraints in hospital resources, will make the allocation of physician, lab, and hospital resources even more critical in providing optimal care for us all. The internist quarterback’s importance can only grow, for they are part and parcel of the allocation process.