Other People’s Money
Medical care is expensive and to a large extent this is unavoidable. Medical knowledge has advanced considerably in even my lifetime and there are hundreds of new medical therapies and technologies of unquestionable value to both individuals and society as a whole. It is therefore impossible to bring back the Good Old Days when doctors were paid in chickens or bushels of produce from their grateful patients, all of whose medical care the kindly country doctor could provide out of his well-used black bag. On the other hand, it cannot escape anyone’s attention who works in the medical industry that we waste prodigious sums of money with very little to show for it. I happen to be at the cutting edge of this profligacy but only because we have easy access in the Emergency Department to most of the expensive toys, not to mention that the nature of our specialty predisposes us to use them even when maybe we could substitute a little clinical judgment for technology.
We don’t, of course, for various reasons most of which are out of our control. It cannot be denied, for example, that the threat of litigation drives a lot of our medical decision making. As our good blog friend the Happy Hospitalist points out, a large percentage of the money we spend in medicine is to rule out conditions that are either rare in and of themselves or, if common, not very likely given the clinical picture of the patient. We spend the money anyway because there is very little incentive for most physicians to control costs. Just one successful lawsuit against a physician for a missed diagnosis can damage his ability to maintain his credentials, cost him the average income of any two or three Americans in increased liability insurance, jeopardize his financial assets, and even end his career. Why risk our own money when we can use somebody else’s to protect us, even if it costs millions?
And I do mean millions. Not meaning to brag but I am a veritable titan of excessive medical spending. A brawny legend of mythical proportions. Where my ancient Greek ancestors proudly arrayed the sacred hecatomb before the shrines of their gods, I call them base amateurs. My pen casually checks tiny boxes on order sheets that every day effortlessly transfer many times the value of their paltry burnt oxen from the public treasury to the altar of my gods, chief among them being Expediency, Haste, and Fear.
I have ordered, for example, expensive CT scans of the brain by the hundreds, the only purpose of which was to rule out that one in fifty-thousand chance that we’ll find something requiring an intervention, on people who had no neurological deficits, no symptoms of intracranial pathology, and not even a decent mechanical reason why they should have something wrong in their head. This is not to say that every CT I order is inappropriate. A patient who has never been to the Emergency Department before and presents with the dreaded “Worst Headache of My Life” needs to get a CT of the head, even if his lumbar puncture is negative. That’s just reasonable suspicion and due diligence. But an otherwise healthy young adult with normal vitals, normal physical exam, who tripped on the ice, bumped his head, and has been sitting in the waiting room for five hours eating stale vending machine nacho chips and watching the Fresh Prince of Bel Air? Does he really need any workup at all?
I am embarrassed to say that, just to be legally safe and in proportion to the number of times any particular attending of ours has been named in a frivolous lawsuit, we often obtain a five-hundred-dollar CT of the brain even in face of a normal neurological exam and a chief complaint (“I bumped my head”) that didn’t even exist forty years ago when we had less technology but maybe more common sense..
(We actually have a CT scanner in our department you know….and, By The Blood of the previously mentioned Triune God, we’re going to utilize the hell out of it. The only reason we didn’t put it at the ambulance entrance and have the paramedics run everybody through it was their fear of a little ionizing radiation.)Â
This kind of thing is not confined to the head, of course, or to the overuse of CT imaging. The CT scanner is just the most obvious example of Medical Testing Gone Wild.
It is hard to say exactly how many of the laboratory tests and imaging studies that we order are unnecessary. The point, however, of good clinical medicine is to only order a test to answer a question. If a patient complains of vague abdominal pain but has a benign abdomen (soft, non-tender, non-distended) and if twenty dollar’s worth of quick, in-house labs show a normal white count and no electrolyte abnormalities, then the correct play would be to suspect, strongly, some intestinal gas and send the patient home with strict instructions to return for fever, vomiting, or increased pain. Hell, throw in a serum lactate if you’re worried about mesenteric ischemia and a two-dollar pregnancy test if you have even a slight suspicion about an ectopic pregnancy and you’ve pretty much ruled out everything immediately deadly to the patient and answered almost every possible clinical question in the negative. There is no need for the inevitable ultrasound or CT scan of the abdomen with oral and intravenous contrast which not only costs a couple of large ones but also ties up a bed in the department for two hours at a minimum (the time to drink the contrast, transport, and have the study read). We only order these tests out of fear of sending a patient home with something like an early intussiception and having them decide not to return even if clearly told to do so. What does it hurt, after all, to send the early abdominal pain home except that if it turns out to be something and the patient doesn’t come back, all the jury will care about is that you sent somebody home, not that you exercised what seemed like good clinical judgment and a laudable regard for the public treasury?
Thus does the expectation of zero-defect medicine make cowards of us all. I have ordered hundreds of expensive imaging studies and in almost all cases, where the clinical suspicion of anything being abnormal was low, the studies have been negative. Even the studies that I order with solid history, physical exam, or lab abnormalities as a justification and where I expect to hit paydirt are usually negative. I understand that sometimes a negative study is as important as a positive one but if the pre-test probability is low, maybe we should save ourselves the car fare and give the zebra a little more time to cook. Give the problem time to declare itself, I mean, if it really exists. It sounds cold-blooded but you can’t expect everyone to get a ten-thousand dollar workup for every complaint and then complain about the high cost of medical care. Everything is not an Emergency.
If, on the other hand, we remove enough clinical judgment from the medical profession by penalizing it so severely on the rare occasions when it is wrong, we may as well load every patient on a conveyor belt where, despite their complaint, they pass through a full-body CT scanner, an ultrasound station, an indiscriminate lab station, an automatic EKG, and then have cut-rate physicians in India email treatment recommendations to minimum wage technicians at the end of the line.
On another note, the health care system itself, independent of the threat of litigation, is set up to encourage waste. While we don’t actually have a Health Care System per se, just a bunch of independent doctors and hospitals, there are two common threads that run through all of our medical endeavors and which serve as perverse unifying principles. The first is the obvious and inevitable fragmentation of care in our hyper-specialized industry . The second is the sure knowledge of everyone involved that nobody is actually spending their own money.
Consider the typical Family Practice physician seeing his typical panel of thirty patients a day. If he just manages to keep to his schedule giving each patient fifteen minutes of his time that’s a full eight-hour day, not even counting the various patient care tasks for which he receives no reimbursement but still impose an inexorable demand on his time. Unlike lawyers who bill for every minute of their time, a physician is reimbursed for the amount of time the government (and the private insurance firms that follow the government lead) think he should spend with the patient and not how much time he needs to or actually does. Because the reimbursement is so low physicians are forced to substitute volume for quality, running increasingly comorbid patients (the inevitable result of advances in medical knowledge) through their practice at a breakneck speed without the possibility of adequately addressing their many medical problems safely or economically. In their haste to see all of their patients, primary care doctors are forced to refer many of them to expensive specialists for things that they could diagnose, treat, and manage themselves if they had more time. In this manner, specialists are used more as physician extenders than learned consultants who are only brought into the case to help solve thorny diagnostic puzzles or to perform interventions outside the primary care doctor’s scope.
This “gatekeeper” model, where the primary care physician’s chief purpose is to be a clearinghouse for referrals to other physicians, has been a disaster, both from a financial and patient care point of view. A patient being followed by a squad of specialists, none of whom have the time to adequately coordinate care, not only costs many times what it would cost to just let the primary care doctor bill for the time he needs but it leads to a dangerous fragmentation of care where one set of doctors literally have no idea what the other set might be doing. I have seen it many times, often in the elderly patient on a long and bewildering list of dangerous and often medically contradictory medications. When specialists refer to other specialists sometimes even the primary care physician doesn’t know what the hell is going on.
Volume is the problem. Medicine is not like ordering fast food and most of it cannot be automated or standardized despite the best efforts of our friends in the electronic medical records industry, most of whose products are designed more to capture billable activities than medical information. The patients are becoming more complex, not less, and to continue to increase the speed with which we process them will only lead to more fragmentation and expense. Or to put it another way, medicine is not like building an automobile where individual pieces are built off-site, brought together on the assembly line, and efficiently assembled into economical automobiles by reaping the advantages of specialization and division of labor. Our current medical practices are more akin to hauling the chassis of the car to various locations around town, putting on one piece here, another there, none for exactly the correct model and none in any rational order, and then several years later when it is done wondering why the ignition won’t crank and the “engine warning” light won’t go off.
We tolerate this state of affairs because, no matter how much we spend and how fragmented the care, somebody else is always paying for it giving the end user of medical services no incentive and more importantly, no leverage to change things even if they wanted to which most don’t. My demented granny may be followed by a squad of specialists, she may have had every imaging study and intervention under Heaven and Earth ordered for her, she may have hundreds of thousands of dollars spent to extend her life by a handful of months but since I ain’t paying a dime, spend away and the Devil take the hindmost.