Testing Wisely

I remember going to see the movie “Oliver” in the theater when I was a kid.  Since this was my first movie in a theater, my mom made me a treat: a bag full of raisins and chocolate chips (Raisinets for Dutch people) and sent me there with my sister.  It was a fine film, with Oliver getting kicked out of the orphanage when he wanted more gruel, the dastardly Bill Sykes threatening Oliver and sweet Nancy, the funny and clever artful dodger and Fagan teaching Oliver about life on the street, and with (spoiler alert!) good overcoming evil in the end Oliver getting adopted by a rich dude so he can get all the gruel (or real Raisinets) that he wanted.  And though my memories of the movie are still vivid, my strongest memory was the look on my sister’s face when I walked out of the theater covered with melted chocolate chip goo.  It went into family lore (and wouldn’t have happened if they had sprung for Rasinets, I might add).  I think they still don’t trust me with chocolate chips.

The key line in the film comes when Oliver loses a bet and goes up to the gruel-master and says: “Please Sir, I want some more.”  Which, as I am sure Oliver expected, causes the gruel-master to break into the song, “Oliver! Oliver! Never before has a boy wanted more!” and the whole dining hall to pull out musical instruments and singing harmony to the gruel-master’s admonition.

I can see why Oliver was scared.  A whipping is welcome compared to his whole world breaking into song and dance.

Asking for “more” has caused trouble over the ages.  Adam and Eve wanted more food choices, the people of Pompeii wanted more mountain-side housing, Napoleon and Adolph Hitler wanted to spend more time in Russia, and America wanted more of the Kardashians. We can all see what destruction those desires reaped.

Americans have been viewing health care the same way, always wanting more: more antibiotics, more technology, more robots doing more surgery, more expensive treatments for more diseases.  The result: health care costs more in America than anywhere else.  Some folks think that our “more” approach makes our health care “the best in the world,” after all, where else can you get so many tests just by asking.  MRI’s for back pain, x-rays for coughs, blood tests for anyone who dons the door of the ER.  ”Tests for everyone!” shouts the bartender. “Tests are on the house! ”

They aren’t, of course, and we are paying the price for “more.”  This hunger for “more” is fueled by the media’s fascination for the “latest thing,” the long disproved idea that technology will solve everything, and docs who aren’t willing to take time to explain why it’s actually better to do less.  It’s hard to do, when we are paid more to spend less time with patients, and when the system is willing to pay for more and more.

There is a voice against this: the “Choosing Wisely” campaign, which argues against unnecessary treatments and tests.  This is a welcome voice of reason in the cacophony of cries for “more.”  Yet the battle goes against the irresistible tide of our payment system.  The root problem is this: there are a whole lot of people whose jobs depend on America’s addiction to “more.” The payment system has created an ecosystem that thrives off of waste (of which I once wrote an allegorical fantasy).  True health care reform will be catastrophic to many who work in health care, with many very nice and hard-working Americans losing their jobs at the ACO factory, at Meaningful Use Inc., and even at Stents-R-Us hospital here in my home town.

This is what you get when you make disease more profitable than health, when we treat problems instead of people.  The simple fact that our system would be destroyed if everyone got healthy should tell us something is terribly wrong.  Doctors want their offices full, not empty.  The goal of every patient – to be healthy and to stay away from the doctor – goes directly against the economics of “more.”

I have always tried to be a non-test orderer.  I was trained well by docs who believed it weak-minded and bad care to blithely order tests and prescribe medications without a well-defined reason.  This has always made it harder for me, as it’s far more time-consuming to explain why a drug or test is not needed than to simply order it.  But in my new world, one in which an empty office is a good thing, I’ve found my patients much more open to my aversion to “more.”  The main reason for this is that I am giving them more of me.  More of me means they can call if they don’t get better, or if their symptoms develop.  They know I won’t force them to take more of their time and spend more of their money to get my attention.

Ultimately, I want my patients to see as few doctors, be sick as infrequently, and be on as few drugs as possible.  I hope to wage an all-out assault on “more.”

Here are my rules to battle “more”

  1. Never order a test that doesn’t help you decide something important. Ordering tests “just to know” does much more harm than good.
  2. Use consultants only to do things you can’t. Orthopedists will aways give an NSAID and physical therapy for problems, so I don’t send patients to them unless they’ve failed those treatments (where appropriate).  I am just as good at ordering PT, and am more careful with NSAID prescriptions than they are.
  3. Don’t give a patient a drug without explaining to them why they need it. If I can’t make a good case for a drug, I shouldn’t be giving it.  This is not simply “to lower your cholesterol,” or “to treat your blood pressure,” but because doing so will raise your life-expectency.
  4. Remember the number that really matters: how many birthdays a person gets to celebrate in health. I don’t care about blood pressure, LDL, or even A1c if treating it doesn’t raise the birthday total.
  5. Don’t forget about another number: how much money patients have in their wallets. There’s no point in ordering a drug they can’t afford, or making them pay for a test they don’t need (even when they ask for either).

I hope my new world of less overhead, less regulation, and less antacids for me continues on this trend toward less sick patients, less drugs, and less tests.  Perhaps I need to break into a song and dance number whenever my patients ask for “more.”

That would teach them.

Rob Lamberts, MD, is a primary care physician practicing somewhere in the southeastern United States. He blogs regularly at More Musings (of a Distractible Kind),where this post first appeared. For some strange reason, he is often stopped by strangers on the street who mistake him for former Atlanta Braves star John Smoltz and ask “Hey, are you John Smoltz?” He is not John Smoltz. He is not a former major league baseball player. He is a primary care physician.


20 replies »

  1. An excellent thoughtful post by the kind of physician we have too few of in our culture, but whose clarity about how to care for people well is admirable.

  2. Excellent! The rules you’ve mentioned is so true, every doctor should always explain the prescription they’re giving to the patients.

  3. You speak a lot of sense. Here in the U.K. we take for granted our doctors and expect antibiotics to be prescribed for coughs and colds, which of course is nonsense and dangerous for future generations. I applaud you.

  4. Dear Dr. Lamberts, Your Dutch is showing:-) You know; that things that sets the Dutch apart as frugal and able to conserve . Those folks with the ‘do not waste’ mentality. Unfortunately this is a treatable disease by all the other doctors but rest assured, ALL the folks who read this article will sigh and wish their doctor was like your, or… just you! You make me happy. There IS hope for health care:-)

  5. Interesting post doctor. My wife is also a medical doctor and she tells me that explaining the drugs you are giving to patients is vital. She practices medicine in the UK but has also done in other countries. In other countries, they did not explain what medicine the patient was being given!

  6. Thanks, Neel. I got your other email – am awash in new patients after being on the evening news….I agree that this is the right use for specialists, but as a PCP I was always tempted to not take the extra time and instead pass the problem on to the specialist. When taking extra time hurts the bottom line (or time with the family) it is always a battle to go the extra mile (and our system does not pay more for doing that mile). This is why I think the estimates of waste in our system are huge underestimates (even though they are in the 40% range) – unnecessary consults wouldn’t count, but cost a whole lot.

  7. Fantastic rules to battle the wasteful and potentially harmful consequences of over-testing. Rule #2 is particularly salient in academic medical centers where an abundance of consultants are readily available.

    Rule #2 states “use consultants only to do what you can’t”. What other reasons to use a consultant could there be? Often residents see consultants used for academic, political or perceived medico-legal reasons rather than clinical ones. Because the job of a consultant is typically to help investigate a broader differential diagnosis, we spend significant time mired in fruitless hunts for zebras rather than true patient care.

  8. Do you have many patients from your old practice that used to ask for and expect you to order lots of tests and prescribe drugs but are now willing to accept less of both? If so, is the key reason simply that you have more time to explain why the testing and drugs aren’t necessary or is it a more subtle psychological perception that you are more available on a timely basis in person, by phone, or through e-mail?

    I think you make an important point about the birthday metric. Even relatively uneducated people should be able to understand and appreciate that. At the same time, as long as the treatment is unlikely to cause any harm, the “just to be sure” mentality is also powerful, especially when the patient pays little or nothing incrementally out-of-pocket.

  9. I have a dear friend undergoing his 10th round of treatment for Mantle Cell Lymphoma. Two days of chemo infusion this round. $87,000 per daily infusion bag.

    Of course, NO ONE believes that chargemaster accounting fiction. There is simply no way to determine actual cost + reasonable margin.

  10. I normally have to ask 3 times: “how much does this cost?”…the first 2 times the reply is “the copay is…” or “it costs you….”

    On the third time they finally understand what I am asking, but they still usually avoid answering. I assume this is because the amount of the “actual cost” sounds obscene! like just one example:

    procedure: cauterize the edge of the retina to prevent detachment

    Invoice: $1800
    amount paid: $1100
    out-of-pocket: $35

  11. It’s interesting to me how many people forgo common sense. I remember asking a doctor how much a procedure cost when I was 12 because my mom wasn’t there with me and I wanted to report back to her like a responsible kid. The doc freaked out so totally, I was quite impressed. Insurance took on the guise of the unexplainable but necessary evil system in which we were all enrolled. I still wonder at the lack of common sense. Doesn’t good management call for the sorts of measures you are talking about here? The whole health care predicament still blows me away.

  12. Bravo Dr. Lamberts–as an RN, and now as an insurance agent, ugh. Doing emergency nursing, things were always over ordered because there was no room for an honest mistake. And that was with the good physicians. The bad ones, they wouldn’t listen to the nursing staff, so they ordered everything in creation for the obvious reason.

    As an insurance agent, I try to get people to buy judiciously, not spend a fortune on coverage they probably won’t need. But I encounter a different, yet similar mentality–one client will ONLY take brand drugs. That eliminates a lot of plans. More than once people have said to me I might as well go to a doctor for my cold, what is insurance for. And the best one, when a clinician says oh, we might as well run a few tests, your insurance will cover it……my personal favorite.

    People are finally starting to ask questions about cost, but not enough. It does not cost $10 to see a doctor, no matter what the copay on your ID card says.

  13. I’m still hoping for cloning tech to develop, so we can have more of you, including here in Rivah City (Richmond VA). Not the “Multiplicity” version of cloning, though.

    Seriously, this approach would prevent needless wallet biopsies from sea to shining sea. I’m a member of the school of thought that says “unless you’re bleeding heavily, have a sucking chest wound, or a fever over 102F, go lie down and let it run its course” – but I realize I’m in the minority in this very-medicalized society.

  14. I hope my new world of less overhead, less regulation, and less antacids for me continues on this trend toward less sick patients, less drugs, and less tests. Perhaps I need to break into a song and dance number whenever my patients ask for “more.”

  15. EXCELLENT! Dr. Lamberts

    Of course the $ incentives have to change more dramatically if we are to successfully wage war on “more”

    Here’s another example- When after an exasperating and long Congressional hearing with former AFL-CIO President George Meany was asked “what do you really want?” – He had a one word answer- “MORE”

    In Medicine, however, more can actually harm a you state.

    Dr. Rick Lippin

  16. “Going to the doctor is the quickest way to get diagnosed with something.”

    Q: What’s the definition of a healthy person?

    A: A patent who hasn’t been adequately worked up.

  17. I always say, “stay away from doctors unless you really need one”. Going to the doctor is the quickest way to get diagnosed with something. Until doctors aren’t afraid of being sued, things won’t change. It sounds like you have structured your practice in such a way that your patients get as much of your attention as they need, which is one of the best ways to prevent lawsuits. Good on you!

  18. Thank you for doing your part.amazing for having people like you.
    I wonder they let you on any hospital as staff because they like people who create complications for which the docs and hospitals get paid more money.