Finally, the medical field, in general, is getting its act together. Simply put, Choosing Wisely®, the brainchild of the American Board of Internal Medicine (ABIM), is an initiative to help cut down on unnecessary medical testing. The goal behind the campaign: improve medical care by “cutting waste.” Although I suggest both doctors and patients read up on it themselves, Christine Cassel, MD – president and CEO of the American Board of Internal Medicine and the ABIM Foundation – describes Choosing Wisely® well:
“For every one of these items [on the Choosing Wisely® list of 45 overused tests and procedures], there are times when it is indicated,” she said. “We aren’t saying you should never do it — these are times you ought to have a conversation about whether you need it or not.”
At this point, this looks to be the best thing to happen in the medical field in my lifetime. Everybody benefits!
Say what you want about me: angry, arrogant, controversial, but who I really am, at my core, is a patient advocate, period. In fact, if you want to really know why I am “angry,” I fundamentally do not care for a lot of things that go on in medicine today. I have been doing this long enough to know the difference.
The four reasons why medicine is at the point it’s at today with over-testing:
• Patients ask for it!
• Testing and screening are so widely available and accessible now.
• The current insurance reimbursement structure in America lends docs, over time, to settle with the path of least resistance in dealing with patients.
• Defensive medicine
I was taught in medical school that I could come up with an accurate diagnosis greater than 90% of the time with an accurate history (as in, your story about your problem with a little of my guidance) and a physical exam. I distinctly remember hearing that and thinking to myself, “what a crock.” But today, I know this as truth. These docs today, considering the fact they can readily get that test (the one patients are ASKING for), will often bypass the effort to really learn and too quickly default to the test. As a result, one’s deeper understanding goes untapped.
What does this mean for medicine today? It’s been destructive. Our test-happy culture has the affect of creating DUMBER docs. Yes, I said dumber. I have taught residents for 26 years and trust me, they are definitely not getting better, even though their access to information and medical testing is unprecedented. You see, if one is to consider a test, particularly the correct one for your problem, one must have a really good idea of what your problem is…before the test is ordered.
So then you might say, “Why do we have so much testing?” Because we can, that’s why! (BTW, I hate “because we can.”) But the truth is, we have more access than ever! And, again, it relates back to my first point: the patient may just be the biggest reason why we test so much – because you think getting that MRI, for example, is the best method to arrive at your diagnosis. Sorry, but even though you have the internet, etc., you, as a lay patient, are still not adequately equipped to decide what test, if any, is appropriate. I also recognize that media and medical advertising drive this as well.
Surprising to some is that defensive medicine is probably low on the list of reasons we docs test too much. A quick note on so-called defensive medicine: the best defensive medicine is for me to be a genuine person and sit down and talk with my patients. And I do it everyday; I like it that way (more on this later). Even if that means taking the time to explain why they do not need that MRI they are so sure they do…The good news about all of this: these scenarios are exactly what Choosing Wisely® aims to improve.
As for medical reimbursement – it has changed a great deal over the last two decades – while, at the same time, testing availability and technology have exploded. Thanks to the behind-the-scenes negotiations, docs are being paid less for their services, so they are incentivized to see more patients in less time. In turn, this might equate to more docs sending patients along their way for some testing that patients are expecting – if not asking for.
This logic is exactly the same as when a patient comes into a primary care doc’s office with a cold and insists on antibiotics. We absolutely know that antibiotics will do nothing for a viral cold and their indiscriminate use is not good, but the path of least resistance is to write that script and send you on your way. Good docs take the time and good patients recognize this and listen to them.
Visit the blog soon to read part two.