Wednesday, January 27, 2010

Trendspotter: When doctors and patients think more is better

By Ken Terry

A post on MedPage Today by my former colleague, Marianne Mattera, made me think about how much medicine has changed in the past few decades and why it costs so much more than it used to.

Back when I was in high school (long, long ago), I sprained my ankle playing basketball, and I was taken to the emergency room. After an X-ray showed that there were no broken bones, the ED doctor put a plaster cast on my ankle and recommended that I use crutches until it healed. It did heal completely in about six weeks, and I’ve never had any trouble with it since.

Mattera took her college-student son, who had also sprained his ankle, to an orthopedic surgeon on the recommendation of an ED physician. Because none of the orthopedists suggested by that doctor had an immediate opening, she went to another physician who was on the health-plan list. His office was so ragged, his receptionists so unfriendly, and his examination so cursory that when Mattera left with her son, she decided never to return. She then made an appointment with one of the doctors the ED physician had recommended. The second orthopedist had a much more patient-friendly office and seemed more competent. But, like the first one, he wanted to order an MRI.
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Why? It wasn’t because Mattera had asked for it; she said she questioned the first doctor when he suggested an MRI. Perhaps the expensive test was justified because of her son’s symptoms. Maybe the orthopedists wanted to protect themselves against liability in case surgery was indicated. Or maybe, because they’re specialists, they were hunting zebras. But whatever the reason, most sprained ankles got better on their own before MRIs were invented.

There is even some question about whether X-rays are normally required. A test known as the Ottawa Ankle Rule reliably determines whether an ankle is broken without the use of X-rays. But most doctors still order X-rays of sprained ankles to reassure patients and guard themselves against even the remote chance of a lawsuit.

When asked about the Ottawa Ankle Rule, an old country doctor whom I know was fond of telling medical students: “My radiographic dictum is, ‘It’s the patient’s ankle, but it’s my ass.’ I would rather X-ray 100 sprained ankles than go through the hassle of defending a single missed fracture in a malpractice suit.”

At least this primary-care physician, who hailed from North Carolina, treated sprained ankles. In some areas, including parts of the Northeast, primary-care physicians are not expected to handle anything that complex. If a patient has a serious condition, the assumption is that he or she will be referred to a specialist. In California and Minnesota, on the other hand, primary-care doctors tend to do much more for their patients before referring them out. The reason for those regional differences is not entirely clear, but it probably has to do with local physician cultures and business environments.

Over the past 40 years, U.S. medicine has increasingly emphasized the intervention of specialists and the use of expensive technology. In some cases, this has been a change for the better; but in other cases, doctors may be calling in the heavy artillery when a little judicious medical-decision making is called for. Unfortunately, when physicians try to do the right thing, they may find themselves being lambasted by patients who would rather leave no stone unturned and by a medical establishment that has convinced itself — and patients — that more is better.

There’s a lot of talk these days about shifting to a new reimbursement approach variously called “pay for value” or “pay for outcomes.” But until attitudes among doctors and patients change, that will be a very difficult transition to make.

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