Commercial Appeal (Memphis, TN)
July 25, 2012
As an infectious-disease specialist, I often see patients who complain of a headache, nasal congestion and short-term fatigue. There is no fever or cough, and it appears the problem is sinusitis, which requires no further testing or treatment.
But when I say, “Let’s wait and watch,” many of my patients seem disappointed. In some cases, it seems they are satisfied only if I prescribe an antibiotic or order a blood test or X-ray. I understand where they are coming from: I often feel similarly let down when I take my daughter to the pediatrician for an earache and leave without a prescription for an antibiotic.
When we go to the doctor, most of us want something done, even if the benefits are questionable or marginal. Both parties are at fault: Many patients demand tests, and doctors often encourage them. How much excess care is being carried out is debatable, but some studies indicate that nearly 30% of U.S. healthcare expenditures are unnecessary. That’s $700 billion of waste each year.
Choosing Wisely, a new campaign supported by several professional medical societies and consumer groups, is encouraging doctors and patients to kick this habit to curb the overuse of tests and procedures, including the prescription of antibiotics and imaging studies for sinusitis within the first seven days of symptoms.
In April, the ABIM Foundation, which is affiliated with the American Board of Internal Medicine, published a list of 45 overused tests and procedures, including routine electrocardiograms during a physical and imaging studies for back pain.
Seeing both sides
As a doctor and, at times, a patient, I can appreciate the need for Choosing Wisely. I often come upon situations in which the doctor-patient encounter feels like a push-and-pull dance, with both partners leaning toward overtreatment.
As patients, we push for more tests, genuinely fearing a debilitating or fatal illness such as pneumonia, cancer or heart disease. Some of us do not understand that more testing can be harmful due to radiation, medication side effects or a spurious lab finding that begins a cascade of unnecessary and invasive diagnostic tests.
As a doctor, I pull for more tests because I’m genuinely concerned about missing a diagnosis or apprehensive about malpractice suits, or because I lack time to carefully talk to or examine patients but want to satisfy their demands. All of this is exacerbated when there isn’t a strong doctor-patient relationship.
One time, when working in the emergency room, I had 15 minutes to make a judgment about whether a patient’s headache was due to a migraine, sinus infection, life-threatening bleed in the brain or just a bid to get pain medication. With no previous relationship with the patient and no certainty he would return to the emergency room if his symptoms worsened, the best option was to order a CT scan of the head just in case. As one doctor told me, “No one will ever sue you for ordering an extra CT scan.”
Sadly, some doctors who overtest are motivated by financial self-interest, especially if they own the lab doing the test, which is fairly common. I know an internist who orders a chest X-ray and blood count for anyone with a cough and a cardiologist who routinely has patients with chest pain give consent for a cardiac catheterization before talking with or examining them. These extra tests tend to lead to more procedures, which mean more money for the doctor.
Choosing Wisely is a first bold attempt by doctors to self-regulate this sort of behavior. Yet I don’t think a “just say no” approach to overtesting and overtreatment will work. A better system would approach the problem in three ways: defined measurement, peer-to-peer reporting and payment alignment.
Let me explain. I believe I am guilty of overtesting my patients and overprescribing antibiotics, yet I do not know my own data—how many particular tests or expensive antibiotics I have prescribed compared with my peers. We need individualized physician data on who is doing the testing and how much of it.
Second, we need to compare our rates of testing and procedures among peers at a local level. This will stimulate conversation on best practices and the use of guidelines. As a doctor in private practice, I never sit with peers and compare my cost and quality data.
Last, we need to establish payment incentives for less testing, moving toward bundled or global payments in which a fixed amount is paid for a particular diagnosis or a given patient, rather than payment for individual tests can add real teeth.
To make the campaign successful, patients also need to change their behavior. Patients should be encouraged to ask questions about the risks and benefits of a given test and how the results will affect their health. Moreover, a punitive measure such as higher co-pays and higher deductibles might discourage some patients from demanding excessive testing and procedures.
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