Medicine and healthcare are complex. Often, patients hear from friends or family members regarding their medical condition, or they search the Internet regarding their symptoms, and somehow always come up with the worst-case scenario as they present to our offices worried and seeking medical care that is often not medically justified, of low quality, or potentially dangerous and with benefits that are questionable at best.
One very specific example I always remember is an asymptomatic patient who was in her 70s and had a routine screening EKG performed for no specific reason other than she asked her doctor because she was worried about her heart. The EKG showed some non-specific changes, she was sent to a cardiologist who recommended a cardiac catheterization, which was complicated by an embolic stroke and resulting hemiplegia. This is obviously an extreme example, but would she have had a stoke anyway? Was an EKG indicated?
Part of the problem is that we are trained to “just be careful” or “keep the patient happy.” Thus, we often order tests that are of low value, with very little potential impact on patient QOL or patient-oriented outcomes, but with potentially high risks and unintended consequences, additional tests, patient anxiety, etc.
Very Low Health Literacy & Healthcare Spending That’s Breaking the Bank
Also, the health literacy of our nation is very low. Even highly educated individuals come to my office at times with a very poor understanding of their own health. They do not always understand the ramifications of each test or that just because we can do a test doesn’t mean we should. When you think about an individual patient, one additional test or study does not seem like a big deal; however, when you develop a culture, like we have in this nation, of excessive testing and repetitive testing for millions and millions of individuals, we end up in a negative, downward spiral of increasing costs without really improving health or health outcomes.
Without medical knowledge or experience, it can be exceptionally challenging to put health information into context or take information and apply it to an individual patient. This is where the role, experience, and communication skills of physicians becomes exceedingly important. I fully support my patients empowering themselves with knowledge and information regarding their health and medical conditions. However, without context or a deeper understanding of the health information, this can be detrimental and lead to low-value care, excessive or wasteful utilization of healthcare resources, and worse yet, put the patient at risk.
Often, patients and the lay person equate “more” with “better” when it comes to medical treatment and testing; however, there is increasing evidence demonstrating just the opposite. While antibiotics are usually not indicated for a viral illness or a head CT for a headache without any concerning features, patients often think these are part of good care. And ordering something is often easier and faster than taking the time to educate the patients that what they’re requesting is likely of low value and low-quality, with potential risks that outweigh the benefits.
Layered on top of this is the fact that current healthcare spending in this nation is literally breaking the bank of many individuals and our nation has a whole. We spend more than $4 trillion per year (~20% of our nation’s GDP) on health and healthcare; however, we have little to show for it, with some of the worst—if not THE worst—health outcomes in the world.
All Physicians Play a Part
We all have a part in this challenging and complex healthcare landscape, but what role do physicians play, and what can we do to help break this trend? Part of this situation is driven by physicians practicing defensive medicine and offering to order unnecessary tests or procedures just to avoid malpractice claims, keep patients happy, and/or because of a lack of time and energy. The downstream and deleterious effects of testing “just to be safe” is immeasurable, often resulting in additional tests or additional work up, to say nothing of patient anxieties and return visits, messages, etc.
So, how do physicians help engage patients in their care, inform them, be medical interpreters, if you will, and also be good stewards of our resources? Physicians have the power to help mitigate the exorbitant costs and epidemic of low-value care. The Choosing Wisely campaign demonstrated that when physicians are able to talk with a patient about the risks and benefits of a potentially low-value procedure or test, the patient will often want to avoid it as well. Evidence-based and appropriate medical care that engages patients in their care and helps them understand what is or is not indicated can likely avoid potential risks.
General guidelines and agreed-upon care has been very important. Yet, ensuring patient and physicians generally agree and follow these guidelines can be challenging at times. Just one physician ignoring the recommendations can undermine all our efforts, but collectively, physicians all need to step up, educate patients, and help hold each other accountable. We also need to advocate to be compensated appropriately for this work. Unfortunately, in our current system, taking 5 minutes to perform a cursory physical exam and order some meds and tests will result in greater compensation than taking 10 or 15 minutes to educate a patient on why these tests may be inappropriate. And we all know time is a physician’s most precious commodity.
There is no easy solution here; however, it is going to take every physician doing their part to educate patients, educate themselves, and educate each other regarding what is medically appropriate. I will leave you with my favorite quote from Kevin Grumbaugh at UCSF that perhaps sums up best how we have improved health and reduced low-value medical care: “Get healthcare, not too much, mostly primary care.”