OP-ED

The ‘CSI Effect’ Hits Medicine

I’m in Israel, home to some of the most innovative care in the world.  Doctors here wanted to know if the high-tech tests that are an increasing part of their work help.  A couple of weeks ago, they published their results.

It turns out that in about 90% of cases, it didn’t matter.

A physical exam, the patient’s history, and the basic set of tests that doctors have done for decades was almost always all that was needed to get a diagnosis.  As one of the doctors in the study put it, “basic clinical skills remain a powerful tool, sufficient for achieving an accurate diagnosis in most cases.”

The conventional wisdom is that doctors – at least in the U.S. – order extra tests to protect themselves from getting sued.  But this study was done in Israel, where the problem of medical malpractice is nothing like it is in the U.S.  American-style defensive medicine can’t be the reason doctors in Israel use so many diagnostic tests.

Instead, the answer is revealed in a comment from a Canadian doctor who wasn’t involved in the study.  According to him, the use of high-tech studies has become so “routine” that doctors need to be reminded that they aren’t a replacement for actually diagnosing the patient.

There is something more fundamental happening – and it’s happening around the world.

To understand it, look to something that is happening in courtrooms across the U.S.  Some call it the “CSI Effect,” after the TV show, CSI.  In that show, a police team uses sophisticated technology to identify criminals with almost complete certainty.  Researchers have found that shows like CSI have changed jurors’ expectations of what kind of evidence the prosecution should be able to present.

Something like this is happening in medicine.

Patients show up with the expectation that the doctor will use sophisticated technology to get a quick diagnosis.  They’re often surprised to see how it really works.  Their doctor is rushed, uses paper files, and it can often take a long time before you get a clear diagnosis.  Doctors often order high-tech tests because patients expect it.

But doctors also do it because they are so pressed for time – because a test is a convenient short-cut that might reveal the answer without having to go through the trouble of asking questions, spending time with the patient, studying their medical history, and thinking about the meaning of more routine test results.

So are doctors lazy?  Do patients have overblown expectations of what doctors can really do?  Maybe.  But there is a more important truth which studies like this help reveal.

The most valuable piece of equipment your doctor has is his or her brain.  High-tech tests may give more information, but they are no replacement for your doctor’s training, judgment, and insight.

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21 replies »

  1. Do you want a health care styesm that runs just like the socialized eduation styesm you have now?I am a Canadian expatriate. Let me tell you how the Canadian styesm works:One friend I have, developed an anemic condition due to a series of heavy periods. However, her GP had retired, and she couldn’t find a new one; GP’s are in short supply outside the major cities, and none in her town were taking new patients. As GP’s are the gatekeepers of the styesm — you must get referrals from one to see a specialist — it took her about seven months to find a way in. By that time, however, she was already recovered; she’s a retired RN, and was able to medicate herself. Were she not an RN, the few months of lethargy she endured because of the styesm would have gone on for more than twice as long.Next story: A 70-year old man ends up in the hospital after a heart attack, his third. Amidst 1950’s era equipment, interspersed with a few modern bits here and there — invariably inscribed with a plaque thanking some private donor — his doctors are horrified to discover that he’s been on Inderal for years, despite it’s having been obsoleted by better drugs for some time. But since his GP had retired, nobody had bothered to follow up. How many years off his life, lost down that crack in the styesm? Your guess is a good as mine. Seeing as this man was my father, I don’t want to know… we buried him five years ago. He was lucky to have a whole year between his third and final heart attack, all four seasons one more time… I like to call that his “victory lap”.Next story: another friend of mine had a young daughter with a suspected condition that required a test to verify it. The condition was such that delay in the diagnosis was potentially dangerous. The waiting list fot the TEST (not the treatment) was several months long. She is an RN, so she pulled levers within the styesm “jump the queue” and get the test earlier.God knows where she and her daughter would be, if she were just one of us instead of an insider.Would you call her choice immoral? I would call the styesm that put her in that position immoral. The styesm, and its advocates.The styesm does this *because it is socialized*. You can’t make it or any half-breed of it (like the current styesm here in the US) “work”. If Tenncare wasn’t enough to show you where that road leads, perhaps the Canadian experience will.. if you look past the guff from socialized health care’s advocates and try reading Canadian news directly. Let your northern neighbor’s experience be your guide.You can thank us later.

  2. CSI is an American crime drama television series, which premiered on CBS on October 6, 2000. This is one of the best show which going really well and strong from last 11 years. My favorite show and I Watch CSI Episode online.

  3. “I don’t think ACO’s will be able to control the local press because they are unlikely to be significant advertisers”

    I think, in regard to other providers, they already do. Our local academic medical center has advertisements masquerading as news stories planted in all media outlets, including public TV and radio, on an almost daily basis.

  4. “But what power will the employers have if there’s one dominant ACO in the market, an ACO that controls the local advertising and the press?”

    Market concentration is a risk and anti-trust regulators need to be mindful of it. Personally, I think the risk is greater in less populated areas where there is likely to be only one hospital for many miles around. In large cities and the surrounding metropolitan areas, competition should be adequate.

    I don’t think ACO’s will be able to control the local press because they are unlikely to be significant advertisers. In the print media, the big advertisers are mainly retailers like car dealers, supermarkets, discount stores and department stores as well as classified ads. There are also many more television stations than in years past. Moreover, I think price transparency would also be helpful. It would be a lot easier to shame price gouging by market dominant hospitals and ACO’s if actual contract reimbursement rates were in the public domain than if they remain confidential as they are today.

    I don’t think it’s correct to say that insurers don’t care about costs per se. They see their job as to please customers. Remember there was a time when a lot of employers paid for health insurance with both a broad network and first dollar coverage with employees contributing nothing directly toward the premium though it was implicitly paid for by employees in the form of lower wages than would otherwise be paid. Some employers, mainly in the public sector, still do this. Employer priorities started to change as healthcare costs rise to levels they consider untenable and unsustainable. There is more willingness to trade less choice that comes with narrow networks and more cost exposure for employees and their families if they want to access the most expensive providers in exchange for lower premiums. Employees who still want the broad network products can pay the entire premium difference themselves if employers choose to continue to offer such products.

  5. Agree, but that’s the original point I was making. The control on spending has to come from those who are doing the spending (i.e., the employers). The insurers have no interest in real cost control (they just pass the expenses along and take their cut off the top), and doctors no longer have the ability to do so.

    But what power will the employers have if there’s one dominant ACO in the market, an ACO that controls the local advertising and the press?

  6. pcp —

    Outside of the individual insurance market, commercial insurers traditionally viewed the employer as the customer, not the individual member(s). Employers generally favored broad network insurance products because that’s what they perceived their employees wanted. Within the last year or so as costs continue to approach unaffordable levels, employers have finally started to embrace value based insurance design (VBID). These are both narrow network products and tiered network plans that require members to pay higher co-insurance if they want to access hospitals and doctors that are in a non-preferred tier because they are more expensive for comparable quality care. Even requiring members to pay an extra $500 to go to a high cost AMC or an extra $250 to go to a hospital owned imaging facility can be enough to get their attention. As these plans gain critical mass and enough people start to avoid the higher cost providers, they will ultimately have to become more efficient and significantly reduce the price differential with more cost-effective providers in order to compete effectively. There is actually a three day conference devoted solely to this subject coming up in DC next month. I think VBID has the potential to make a positive difference with respect to healthcare costs over the intermediate to longer term, at least for the under 65 commercially insured population. If Medicare Advantage insurers embrace the approach as well, that would be even better. For Medicaid enrollees, I look for more of them to be moved into managed care over time with more aggressive use of case managers for the most expensive patients.

  7. “…. we’re kidding ourselves if we think docs can do anything about it.”

    Maybe at one time they could, but as more and more docs are being pushed into becoming employees of said expensive systems, the freedom to refer outside the system is not there any longer.
    The shortsightedness of those pushing to eliminate independent practices is pretty amazing. Corporate medicine will be either high quality and expensive or low quality and cheap, just like all other corporate offerings designed by definition to maximize profits.

  8. “The investor-dominated health industry in this country is on an uncontrolled rampage for increasing profits, and we’re kidding ourselves if we think docs can do anything about it.”
    ___

    Indeed.

  9. Don’t disagree with anything you say, but when I hear Insurer X advertising on the radio that their enrollees use Medical Center Y, and I know that Y charges 10 times what Z charges for all imaging studies, I decide I have better things to do than save X from their own cupidity.

    The investor-dominated health industry in this country is on an uncontrolled rampage for increasing profits, and we’re kidding ourselves if we think docs can do anything about it.

  10. pcp –

    About 70% of all prescriptions are generics these days but the 30% that are brands account for 80%-85% of the dollars spent on drugs including the rapidly growing specialty drug category. If there is no generic substitute for an effective brand name drug, nobody from PBM’s to large drug retail chains to Wal-Mart and Costco have any leverage with the big drug companies. If the doctors are prescribing them and patients expect to be able to get them, insurers generally believe they have to pay for them. Patients are not enthusiastic about highly restrictive formularies like the VA’s.

    As for imaging, consolidation in the hospital sector has shifted the balance of power toward the hospitals in recent years. While the insurers negotiate as best they can, in the end, the famous medical centers and the large hospital systems that dominate a region command high prices for every service they provide. Non-hospital owned imaging centers often charge as little as 15% of what an AMC gets for the same MRI.

    I’m not putting all the responsibility for cost control on primary care doctors. I’m putting it on specialists too. You’re the guys who, through your decisions, drive almost all healthcare spending. That said I don’t expect you to go out of your way to save money for the system, especially if it might reduce your own income. That’s why I believe in financial incentives like bonuses financed by shared savings for practicing cost-effective, evidence based care including referring patients to the most cost-effective high quality specialists and hospitals. For patients whose expectations are unreasonable, they should incur a financial penalty and they should also pay more to go to expensive well known teaching hospitals for routine care that could be provided perfectly well by a nearby community hospital.

  11. The interesting thing about this study being done in Israel is that their system is quite different from the American one – and yet we see things happening in the delivery of care that sound very similar.

    The truth is that there is something fundamental and troubling happening in medicine all over the developed world.

    Evan

  12. You always try to put the responsibility on the PCP.

    Why not go directly to the root of the problem, the grossly inflated prices insurers (including CMS) are voluntarily paying for imaging and drugs?

  13. Peter –

    As much as some doctors may think or wish otherwise, an implicit part of their job is to please enough customers (patients) enough of the time so that they get positive word of mouth advertising and stay in business. The two categories of care that lend themselves best to what I suggested are imaging and prescription drugs, which account for over $300 billion of annual spending combined. Insurers could analyze ER visits on their own for patients who come their frequently for non-emergencies. If the cost of all the medical decisions a PCP makes were tracked by insurers, including Medicare, the docs would at least have some incentive to rein in unnecessary testing and drug prescribing. Defensive medicine is a separate issue that I’ve addressed many times – health courts instead of juries to resolve disputes and safe harbor protection from lawsuits for following evidence based guidelines where they exist.

  14. Barry, my understanding is “defensive” testing is the doc’s decision where the patient does not know the tests are unnecessary. If the patient is trying to play doctor by telling the doc how to practice then the doc only needs to say no.

    In a hospital environment or where doc groups do their own testing where billings count, I doubt they’d want anyone looking over their shoulder affecting the bottom line. And who is going to pay for the monitoring.

    I guess “the system” could bill the patient for unnecessary tests they order, but doubt docs would want to piss their customers off by actually reporting.

    Why can’t doctors take responsibility for this – they are the gatekeepers?

  15. I wonder if a simple mechanism could be incorporated into billing codes that would identify tests which the doctor thought were unnecessary, even for defensive medicine, but the patient insisted on anyway. Maybe the same could be done in the case of ER visits for clear non-emergencies. Insurers, including Medicare, could then identify patients that are utilizing too many healthcare resources unnecessarily. After a warning or two, an insurance surcharge could be imposed. If we want to change behavior like this, there needs to be adverse consequences, preferably financial.

  16. Guess y’all got it all figured out. Your so smart. In fact I’m pretty sure your the types who do lots of research before you go to your doc, and know which tests you do and don’t want. But when the doc says “I don’t think you need that test” I’m afraid some rather choice words come to your mind that don’t sound much like “I’m so glad my doctor is using his brain….”

  17. A paper in NEJM in mid 90s looked at the successful resucitation rate post cardiac arrest on 3 TV shows, ER was one, cant remember the other two, but reported a rate of circe 90% vs. <10% in real life. Bottom line was essentially same point as above, TV distorts patient perception of what is possible.

  18. Without a question things are much different in Israel, Things should be different in the USA but American Doctor do make big mistakes and this is where the problems come to light. The fee’s are tram induce and it seems hard for me to understand why produces are left behind in surgery. Doctor visit is $150.00 for 5 minutes; oh the nurse took my blood pressure. Most people cannot afford these prices so just do not see the doctor and this in its self causes another problem. Doug

  19. “I’m in Israel, home to some of the most innovative care in the world.”

    Really, and with a government run system with mandatory participation doing it for about 1/2 the U.S. cost. Who could have guessed.

  20. I agree. I think we rely on technology way to much in almost all aspects of our daily lives, not just in the world of medicine. We have brains for certain reasons, to use them. I see kids these days using calculators for the simplest addition. It’s sad.

  21. “The most valuable piece of equipment your doctor has is his or her brain. High-tech tests may give more information, but they are no replacement for your doctor’s training, judgment, and insight.”
    ___

    Agreed.

    I spoke of this in my first health policy blog post a couple of years ago.

    “…pose some questions I ask myself all the time. To what extent is our potentially bankrupting dependence on crushingly expensive and ever more “sophisticated” medical technology at least in part a function of our enslaving cognitive enfeeblement wrought by reliance on such technologies? Would we have ICD-9 or CPT “dx” (“diagnosis”) 3rd-party payor billing codes through which to encapsulate (and reimburse for) the (accurate, as they were) evaluative encounters of a Yeshi Dhonden or a Yi Pan?

    The answer to the latter question is an unequivocal “no”.
    ___

    http://bgladd.blogspot.com/2009/05/us-health-care-policy-morass.html

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