Sunday, June 21, 2009

Drs. Elton and Sanchez Get it Right

I've taken the liberty of copying two letters from today's New York Times. The AMA's ongoing resistance to progressive reforms has given physicians a bad name, so it's a pleasure to see the wisdom of these letters coming from the heartland:
To the Editor:

As a physician, I see every day the type of overuse of medical care described in “Something’s Got to Give in Medicare Spending” (Economic View, June 14).

But the column took too narrow a view in asserting that “the financial incentives for doctors and medical institutions to recommend more procedures” are the chief driving force behind the high cost of care; non financial incentives are at least as strong.

Much has been written about defensive medicine, wherein physicians order additional, and often unnecessary, tests to avoid being sued. Even without the threat of lawsuits, I suspect that this practice would continue. Physicians don’t want to miss things, lawsuits or not. There are also times, perhaps due to the harried nature of medical decision-making, when ordering tests takes the place of careful consideration of a test’s usefulness or the likelihood of an important finding.

Patients are also often insistent on having tests, just as they are insistent on getting prescriptions for the latest, greatest drugs they saw advertised on TV.

Reining in this overuse of care thus goes against the perceived interests of both physicians and patients. Necessary as it may be, changing these attitudes will be difficult.

Eric Elton, M.D.

Evanston, Ill., June 15

To the Editor:

Universal coverage, cost control and quality medical care are essential but insufficient to achieve good health in our nation. As the column stated, factors including where and how we live, as well as social standing, are the significant determinants of health.

Until we begin to seriously address those factors, worsening health status and a growing burden of preventable chronic disease will exceed the health system’s ability to adequately deliver necessary care — health care reform notwithstanding.

Eduardo J. Sanchez, M.D., M.P.H.

Dallas, June 17

The writer is vice president and chief medical officer of Blue Cross and Blue Shield of Texas.
Dr. Elton correctly identifies how poorly we physicians deal with uncertainty as a major driver of runaway costs. And he's right linking our penchant for throwing the kitchen sink at patients to "rule out XYZ" to the "harried nature" of medical practice.

In the 1990s I spent a full day with each of three outstanding GPs in London. Since the average consultation time in the NHS was less than 10 minutes I wondered how they handled their practices. The answer was - they leveraged time and the relationship better than we Yanks do.

With symptoms that could, conceivably, represent what doctors-in-training call a "zebra" (an obscure and frightening but exceedingly rare cause of the symptom), they said - "Here's what I think is going on and here's what I think will happen if we do ABC...Let's try it for two weeks. If things don't work as I expect, please come back to see me..."

Dr. Elton is also right that patients often "insist" on having tests and drugs that aren't necessary. That's where time comes in. A key part of good medical practice is education. Doing a scan or prescribing a branded drug that isn't necessary is harmful, not neutral. Apart from the radiation exposure scans can show "incidentalomas" - findings that look funny but don't mean anything and lead to further unnecessary tests. And unless the patient is paying full freight for the unnecessary branded drug, we're using money that could be put to better use in other ways.

Dr. Sanchez correctly points out that focusing on medical care is a relatively small part of what our nation needs to do to improve health and contain health care costs. Happily, we're beginning to see ideas like keeping high sugar drinks and foods out of school cafeterias and even imposing taxes on foods that are driving the epidemic of obesity and diabetes.

A lot of the success in the effort to improve quality and reduce costs will be driven by what our federal and state governments do. But if we physicians comported ourselves in accord with the common sense wisdom that Drs. Elton and Sanchez propose that would accomplish even more!

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