• The epidemic of low-value care

    The ophthalmologist was underwhelmed by my findings. But “just in case,” he wanted a brain MRI scan, eye ultrasonography, and a visual field test to rule out multiple sclerosis (MS), subclinical neurovascular disease, masses compressing my fourth cranial nerve, and thyroid disease causing ocular muscle hypertrophy. We agreed that these diagnoses were extremely unlikely because I had no symptoms and no changes in examination findings over 2 years. But he “wanted to make sure.”

    I tried to understand and put myself in his place. But it was difficult, because he seemed so unimpressed. Even if I had MS or vascular disease, I wouldn’t do anything differently. I was already getting blood pressure checks and was taking a statin for a family history of early heart disease. An intracranial mass also seemed unlikely given the duration and asymptomatic nature of my findings. But despite my own medical and epidemiologic training, it was difficult to resist his advice. As my physician, his decision making was important to me. I trusted his instincts and experience.

    – Craig A. Umscheid, MD, MSCE. Being a physician does not confer immunity from clinical capture disease.

    @afrakt

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    • I agree with your sentiment but at what point would out of pocket cost change this dynamic? Would it at any cost on the physician side? Just curious.

    • Agree it is a epidemic.

      The standard explanations here are not very compelling though:

      1) Liability-induced caution: Many studies have shown underwhelming evidence of defensive medicine’s impact but potentially they have underestimated it (?)

      2) Misaligned incentives: Provable in cardiovascular care (see Neil Jensen’s latest paper) and a few other well-publicized cases but in many fields in medicine (especially where physicians are primarily employed or don’t see test revenue like in hospital EDs), this theory doesn’t seem to have as much impact as one would expect (especially in light of the Stark laws)

      3) Culture of American medicine: Is there any convincing proof that this is the causative factor? Would like to believe this is the answer

      4) Patient expectations: Favorite culprit for many physicians but again, I have not seen systematic evidence of this. Have others on the board (Aaron? Austin?) seen it?

    • I have no concrete evidence to back this up, just my own 8 years of medical practice and resident education. But in my experience, physicians absolutely detest ambiguity. Fundamentally, they hate not knowing something. At root I believe this tendency drives utilization patterns much more than does the fear of malpractice suits.

      I see this trait in physicians in all levels of experience. Perhaps I see it more strongly in subspecialists and academic types, but no one is immune. I am a palliative care physician, and still I catch myself wanting to order labs or studies I know will have no bearing on a patient’s quantity or quality of life. I try to teach our residents to think before ordering the next day’s bleedings, that we shouldn’t order tests that won’t change our management. But it’s swimming upstream.

      Again, with no evidence base to back this up, my best guess is that medical schools artificially select for ambiguity intolerance by demanding that most incoming students have straight A science grades and high 30s on the MCATs. It will be interesting to see this widespread tendency run smack into the capitation/ACO phenomenon, or a more cost-conscious patient population. The immovable force meets the irresistible object and all that… Anyone have real evidence to back up my WAG?

      • Study idea: give 1st year medical students and, as a comparison, 1st year law students a series of questions meant to illicit whether they are more or less ambiguity intolerant. Maybe the battery could include a question where one has to balance knowledge with safety in some fashion.

    • Patients aren’t trained to question medical advice. When I challenged a specialist’s recommended invasive medical test (with its attendant small % risk of complications), he took personal affront. When I pressed him, he reluctantly admitted that the course of treatment would not be affected by the test results.

      From a human perspective, I can understand the desire (I first typed “need”) to have all the facts but how often is this driving up costs (and patient risk) without resulting in an improved outcome?

    • A patient perspective. Do doctors prescribe medications which are always clinically proven effective as opposed to correlation-based? Seems like they do. Ordering more tests to gather information to aid decision-making is a laudable idea if the course of treatment might be altered. However, if not, the same sloppy mind-set is in play.

    • a lawyer who works for himself has a fool for a client

      heaven forbid, anyone should be crass enough to inquire about the compensation rules, formal or informal (1) for the eye doc

      1) at the country club, round of golf, you refer some eyepatients to me for MRI, I’ll refer some MRI patients to you for vision work…

      anyway, why does an MS and thyroid test cost more then, say, 5$ ?
      we all know these are high volume immunoassays, or similar tests, done on highly automated machines from roche abbott siemens agilent etc (maybe you do thyroid now by mass spec, or hplc/mass spec)

      this blog post is also more then a little misleading, cause the first sentance doesn’t really allow the reader to understand the full interaction
      revision is suggested

    • @ Romaine Johnson

      If Austin and all other patients were paying for care from, say, their Heath Savings Accounts, doctors could not compete if they ignored the extra costs they impose on patients from low-valued care. Just like lawyers, accountants, engineers and other professionals do routinely, doctors would have to care about their patients pocket books in addition to their health.

    • “If Austin and all other patients were paying for care from, say, their Heath Savings Accounts, doctors could not compete if they ignored the extra costs they impose on patients from low-valued care. Just like lawyers, accountants, engineers and other professionals do routinely, doctors would have to care about their patients pocket books in addition to their health”

      This won’t be news to John, but this already happens – even in the E.D (not every patient in the ED is there for a life threatening emergency). When the patient has to pay this *forces* both the doctor and the patient to engage in a dialogue about the costs and benefits of each diagnostic test or treatment. Without this incentive this kind of dialogue, the kind that’s necessary for SDM, rarely if ever takes place.

      When patients have skin the game result isn’t just lower spending (RAND I and II), it’s better medicine (IMO) because the incentives catalyze this kind of dialogue in ways that the third-party-payor system just doesn’t. What’s baffling to me is that the people I encounter who are the most concerned about excess spending, unnecessary testing, physician induced-demand, etc, etc, etc, are often the most staunch advocates of zero-deductible, third-party payer plans.

      This is particularly confusing when you could easily use VBD in conjunction with HDP’s to address concerns that people in high-deductible plans will underspend on preventive care.