Preventive Medicine Column
Dr. David L. Katz
The big medical news of the past week was about common sense restraint, rather than scientific advance. It was, mostly, about when not to use the medical technology at our disposal.
I refer, of course, to the ‘Choosing Wisely’ program, set in motion last year by the American Board of Internal Medicine (my home turf), and emulated now by 9 medical specialty organizations representing such disciplines as Internal Medicine, Radiology, Family Practice, Cardiology, and Oncology.
The extensive media coverage that has ensued has, in my opinion, spent too little time on the root problem: why over-testing, which reports suggest may account for an incredible 1/3 of all health care expenditure in the US, developed in the first place. There is passing reference in most articles I’ve seen to profit, implying that’s what this is all about- greedy physicians who need more policing by their professional colleges- and then the subject is dropped. Let’s pick it back up, because there is more to it. Why do excessive tests get done?
Sometimes, it is, indeed, about profit. One of the problems here is that procedures and the use of technology are far better compensated than the application of hard-earned knowledge to a robust decision NOT to do a procedure. Attempts to fix this systemically in Medicine have thus far failed- and need to succeed. Good medicine should be rewarded. At present, ‘more’ medicine is.
Another issue is momentum- often referred to as the ‘standard’ of care. The more a test gets ordered under given circumstances, the more it gets ordered under those circumstances! What everyone is doing becomes the ‘standard’ of care whether it’s a good standard or a bad standard, and the standard pulls everyone along with it.
Another issue is that doctors and patients are both people- and motivated by the same basic impulses. One of which is: it’s fun to play with cool toys.
As kids, we all share this penchant. But we’re wrong to think we outgrow it. If you have a shiny new car, you want to drive it. If you have beautiful new shoes, you want to wear them. If you have new crampons, you want to climb a rock wall. And if you have technology that provides you a privileged view and interesting information about the inner workings of the human body- you want to use it! From a 20-year vantage point, I truly believe that every medical specialist, however erudite, is also a grown- up kid with some very cool toys- and he or she wants to play. It’s human nature.
Choosing Wisely provides guidance about specific tests and treatments. But the issue is generalizable- so I think the approach should be as well.
The best way to deal with all of this, in my opinion, is for you to be the boss- provided you are a good boss. You may need your own reality check: more testing isn’t necessarily better. Less testing isn’t necessarily better, either. Better testing, better treatment, is better. Set your sights on the right target.
Then take control. It is your body, your health, and your life. You are the boss — so act like it! Do not just go with the flow. Be courteous, but always assertive. I recommend the following questions as a matter of routine in response to any recommended test or treatment:
(1) Is this the lowest risk option? (2) If not, does this approach add benefit that more than offsets the risk? (3) Is this the test or treatment you would have if you were in my shoes? (4) Is this the test or treatment you would prescribe for a loved one in my shoes? (5) Is there another option with less risk, more potential benefit, or both — that we should consider? (6) Are you sure I need another test, and will the results change my treatment options? Can you tell me how? (7) Are you sure I need a treatment, and will it reliably change my results for the better? Can you tell me how? (8) How confident are you in this recommendation you are making?
A lot of truly good information can be gleaned from such an exchange, but actually — it serves another purpose too. It slows down a doctor who may be harried and hurried, and forces her/him to deal with you as … a person, rather than a patient. It may be that an emphatic introduction of the human element into the medical equation is the best defense against human fallibility. Not a perfect defense, but good nonetheless.
The standard of care is just … standard. Make your standard better than standard. Be a good boss- ask good questions- get good answers. By doing so, you can help ensure that you and your doctor are always diligent, and choosing wisely- together.
Dr. David L. Katz; www.davidkatzmd.com