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.

Costs of Care Essay Contest 2012: Stories from Patients and their Caregivers Uncover Opportunities to Improve Healthcare Value

Neel Shah, MD is the Executive Director of Costs of Care and a chief resident in obstetrics and gynecology based at Harvard Medical School.

As a presidential election looms and the American economy struggles to recover, the spiraling costs of healthcare have become a contentious political focal point without an obvious solution. Yet for patients and their caregivers, opportunities to get more bang for our buck present themselves every day. Over the last two years, as part of the Costs of Care Essay Contest, we have collected hundreds of anecdotes from all over the country that are filled with lessons learned.

Some stories describe all too common medical oversights. Renee Lux, a patient from Connecticut wrote to us about an unnecessary CT scan her doctor should have never ordered that labeled her with a preexisting condition and caused her insurance premiums to skyrocket. Other stories describe easily replicated ingenuity. Molly Kantor, a third year medical student, told us how she figured out how to treat her patient’s heart failure on a $100 budget.

Increasingly, these stories and the insights they provide are striking a chord, helping drive an important professional discourse that in recent months has reached the New England Journal of Medicine and even the Institute of Medicine. This effort has been buoyed by the success of the ABIM Foundation’s Choosing Wisely Campaign, and several other notable initiatives aimed at getting caregivers to examine their own role in healthcare spending.

That is why this year we’re running the contest again.

With the help of Jeffrey Drazen (editor-in-chief, New England Journal of Medicine), Donna Shalala (former United States Secretary of Health and Human Services), Zeke Emanuel (ethicist and former White House healthcare advisor) and Pauline Chen (surgeon and New York Times columnist), Costs of Care will be awarding $4000 in prizes to stories that best illustrate the importance of cost-awareness in medicine.

All stories are fair game and everyone is welcome to participate - examples may include a time a patient tried to find out what a test or treatment would cost but was unable to do so, a time that caring for a patient generated an unexpectedly a high medical bill, or a time a patient and care provider figured out a way to save money while still delivering high-value care. Submissions are due to contest@costsofcare.org no later than November 15, 2012.

Ultimately, no amount of regulating, reorganizing, or otherwise reforming the healthcare system will successfully contain costs unless we—both patients and providers--are invested in fixing the problem.