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5 Things Physicians and Patients Should Question

In January, 2010, Dr. Howard Brody wrote an article for the New England Journal of Medicine attacking physicians for not taking more responsibility in the current health care problem. He suggested that physicians have sworn an oath to put the interests of the patients ahead of their own. But when it comes to financial interests, physicians can sometimes ignore that oath. Dr. Brody proposed that each specialty use evidence-based medicine to develop a “Top Five” list of diagnostic tests and procedures that are the most expensive without providing any meaningful benefit. Each “Top Five” list would then be distributed to several other specialty societies to assure that they had each come up with their best “Top Five”, and not left anything off the list.

It took over 2 years, but the lists were just recently released by the Consumer Reports Health Ratings Center, in a campaign called Choosing Wisely. I read this article in the NY Times last weekend which addressed the “Top Five” lists just issued by 9 professional societies. There will be 8 more professional societies releasing their lists in the Fall.

Intrigued by the article, I watched an interview from C-Span with Dr. John Santa, the Director of the Consumer Reports Health Ratings Center. It’s a little long at 41 minutes, so I’ve provided you a synopsis.

There is an estimated $550B in health care cost waste every year.
Failures of care delivery – $110B to $154B
Failures of care coordination – $25B to $45B
Overtreatment – $158B to $226B
Administrative complexity – $107B to $389B
Pricing failures – $84B to $170B
Source: Donald Berwick, Journal of American Medical Association

Dr Santa postulates that up to 30% of healthcare services may not be necessary. He argues that an EKG is a great test if you have symptoms or risk factors, but is more likely to confuse a physician and patient if it’s only on a routine basis. The scope of imaging tests have recently been increased to include instances if a patient has a complicated headache, has fainted, or has low back pain. Generally, the results of these tests are more likely to confuse the patient and the doctor than to help.

Dr Santa was then questioned about the ‘silent killer’ of heart disease. His reply was:
“Angioplasty and stents, even bypass surgery for heart disease, primarily helps with symptoms. Its affect on longevity is limited to a very small group of folks. Our challenge is to identify which of those folks are likely to have problems.” Dr. Santa commented that many of us have abnomalities in our coronary arteries, but we will go on to lead long and fruitful lives and die of something other than heart disease. The ‘silent killer’ is certainly an issue, but we have to realize that it only affects a small percentage of the population. With the large number of imaging, diagnostic, and screening tests currently performed, we may be doing more harm than good to the large majority.

The subsidies from both the Government and the Health Insurance companies has lead to an expensive system. As well, advertising and promotion confuses consumers and doctors. It’s hard for doctors to say ‘no’. It’s time for doctors and patients to talk to each other and make good decisions.

Dr Santa says that, “We need do is get out of the mindset that in all cases, more healthcare is better, more testing is better, more treatment is better. That’s not the case. Sometimes, more testing can be worse, more treatment can be worse.”

Some physicians and patients will certainly push back against this report. But, remember that these recommendations are provided by a panel of physicians chosen from their specialty, who used their own experience and evidence-based medicine to compile the list, then the lists were distributed to other specialties for their review. It’s difficult to think, once you consider the process, that there can be much improvement to the lists. And, while we live in an ‘entitlement society’, we have to realize that, as Dr. Santa said, ‘more testing can be worse, more treatment can be worse.’ Become an educated consumer of your healthcare. Understand these lists, and don’t be afraid to challenge your provider when they recommend unneccesary and costly imaging, diagnostic, or screening tests.

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