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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Categories: OP-ED, THCB

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Coffeejason breesMargalit Gur-ArieEvan Falchukpcp Recent comment authors
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jason brees
Guest

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.

Barry Carol
Guest
Barry Carol

“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… Read more »

pcp
Guest

“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.

Barry Carol
Guest
Barry Carol

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.… Read more »

pcp
Guest

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?

Coffee
Guest

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… Read more »

Margalit Gur-Arie
Guest

“…. 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.

pcp
Guest

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.

BobbyG
Guest

“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.

Barry Carol
Guest
Barry Carol

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.… Read more »

Evan Falchuk
Guest

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

Barry Carol
Guest
Barry Carol

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,… Read more »

pcp
Guest

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?

Peter
Guest
Peter

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… Read more »

Barry Carol
Guest
Barry Carol

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.

Dr. Mike
Guest
Dr. Mike

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….”

David
Guest
David

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.

DOUG
Guest

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

Peter
Guest
Peter

“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.

Mike Dovan
Guest

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.