Sunday, September 30, 2012

More is Not Always Better


Dr. Robert Dickman is the founding Jaharis Chair of Family Medicine at Tufts University School of Medicine

More than 40 years ago as a third year medical student, I recall the Chief of Medicine praising a fellow student for his rare diagnosis of paroxysmal nocturnal hemoglobinuria in a patient who had presented with the common symptom of “painless hematuria”. The lesson was not lost on any of us: good medicine means an expansive differential diagnosis and an even longer list of tests (including expensive ones) to “rule them out”. “More is better” and “being complete” while rarely explicitly stated were nevertheless at the foundation of the practice of medicine.

I have, over these many years, constantly pushed back against this approach. While it may earn academic praise, it rarely leads to answers and often adds unncessary costs. In my own practice whether on an Indian Reservation (where few tests were available) or in an Academic Health Center (where everything was) I have tried to practice efficient and cost-effective care. Whether ordering a throat culture only when indicated (rarely) or not getting yearly MRI’s on my Alzheimer patients, I was always mindful of not wasting resources. Along the way, I never felt I was compromising care.

Over the years, I have been honored to teach countless numbers of students and residents.  I have asked them questions like “how will your care change with information from this test?” or "is that the first thing you think of in a patient with these symptoms?” I have told them over and over again “time is our ally not our enemy” and “medicine is all about probabilities not possibilities. I have hoped to demonstrate on patients in the clinic or on the wards that good care is providing the highest quality at the lowest cost.

I know I’m not alone but sometimes it really does feel like it. The misuse of resources continues unabated. Many years ago I wrote an article decrying the routine use of skull films for head trauma in ED’s. I argued that there were guidelines in place that could reduce the use of this “expensive” resource by over 50%!  Today the situation is even worse. An 80 year old woman with a scalp laceration will almost definitely be “imaged” in most of our ED’s. Inpatients on a medical ward get daily labs regardless of their problems

We are, I think, on a collision course. Our medical arsenal continues to expand and our population continues to age. CT scans replace skull films, MRI’s replace CT’s  and PET scans replace MRI’s, each considerably more expensive than it’s predecessor. Patents and providers BOTH continue to believe that more is better.   Unless we are prepared to spend 50% of our GNP on health care, our present system is simply not sustainable.

While it is not hard to define the “problem” solutions are much more challenging. We can (and  have) utilize financial disincentives to alter provider and patient behavior. This has been tried off an on since the early 70’s when the HMO bill was passed (in my view one of the most progressive pieces of health care legislation in the last century). There was and continues to be a belief that such an approach is all about money. The “gatekeeper” metaphor has at its core the notion of keeping patients “away” from something. For some patients (and their lawyers) it was about cost saving trumping quality. For some (mostly on the political right) it’s about the government practicing medicine.

It will, I believe, be necessary to dramatically change the nature of this conversation. The kind of medicine about which we are speaking has much more to do with value than cost. No one would buy a  TV set that cost $10K more than its competitor yet performed in exactly the same way. In medicine, however, many think that the more it costs the better it is regardless of performance. Until we have a new generation of physicians and their teachers who believe in value-driven medicine (and patients who seek it out) we will never get the health care system we deserve and need. Until doctors and medical students are rewarded for logical evidence based problem solving and not test ordering we can expect health care costs to rise with no change in quality. As a result value will diminish.

2 comments:

  1. First a thank you, Dr. Dickman, for being such an early adopter of value-based medicine. It's too bad it's taken so long for your message to begin to resonate - though the prospects for near-term success remain bleak.

    As you probably know, the Accountable Care Organizations (ACOs) in Massachusetts are among the state's most expensive providers, so banking on them to contain costs isn't exactly evidence-based.

    Studies have shown we can expect only about a 1% savings from ACOs even when they do perform well. And by the time they have any kind of significant impact, our healthcare costs will have doubled from where they are now.

    I continue to believe we need to enlist patients to take greater responsibility for their healthcare decisions rather than deferring to their doctors' often self-interested recommendations. Fewer parents, for example, would consent so easily to that CT scan for their child if they knew of the increased cancer risk it poses for him or her.

    Nothing else has worked, including the wise counsel of people like yourself. The neglected player in all this remains the patient - and they may be our last, best hope for resolving this crisis in a way that doesn't devolve into second class care for all.

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