Sunday, January 9, 2011

Decision Making/Choices in Care

This post started out just focusing on the overuse of medical testing and treatment, but has morphed into something larger. I thought it maybe handy to have a place where a variety of the posts written about choices and decision-making would appear.

Several years ago, my son, an extremely fit athlete, said he had lumps in his abdomen. Away at school, I was not in a position to see him physically and told him to make an appointment with a doctor ASAP. The doctor ordered blood work. Even though the blood work was normal, he was sent for an MRI with contrasting dye at the local cancer center. Again results were normal. When he came home for summer break, he saw a gastroenterologist who accurately diagnosed him as being in such good shape, more so then most Americans, and what he was feeling were in fact his stomach muscles.

Not only did he go through unnecessary painful tests, there was a significant medical bill that insurance did not cover, as well as a great deal of mental anguish on his part and his parents. Was this necessary?

In July 2008 Consumer Reports Health’s wrote For many consumers, good health care means seeing as many specialists as possible. It may also mean undergoing rounds of tests and, if a serious illness is diagnosed, prolonged hospital stays and extensive treatment.

Though the idea that more health care is better seems to make sense, recent research has shown that none of the above necessarily helps you live better or longer. In fact, too much medical care might shorten your life.

Those findings grew out of the 2008 Dartmouth Atlas of Health Care study and almost three decades of research by John E. Wennberg, M.D., and colleagues at Dartmouth Medical School. Their study of 4,732,448 Medicare patients at thousands of hospitals in the U.S. from 2001 through 2005 found significant variations in the way that people with serious illnesses such as heart failure and cancer were treated during the last two years of their lives. Some regions used two or three times the medical and financial resources than others.

Other Dartmouth research has found that patients with serious conditions who are treated in regions that provide the most aggressive medical care—more tests and procedures, more specialists, and more days in the hospital—don't live longer or enjoy a better quality of life than those who receive more conservative treatment.

Patients treated most aggressively are at increased risk of infections and medical errors that come from uncoordinated care, such as doctors prescribing drugs that duplicate or interact with other drugs. They also tend to receive poorer care, spend a lot more money for co-payments, and are the least satisfied with their health care, the Dartmouth researchers found.

According to Dr. Alex Licerman, author of the blog “Happiness in this World: Reflections of a Buddhist Physician, we need to understand why doctors are over utilizing health care resources in the first place:

• Judgment varies in cases where the medical literature is vague or unhelpful. When faced with diagnostic dilemmas or diseases for which standard treatments haven’t been established, a variation in practice invariably occurs. If a primary care doctor suspects her patient has an ulcer, does she treat herself empirically or refer to a gastroenterologist for an endoscopy? If certain “red flag” symptoms are present, most doctors would refer. If not, some would and some wouldn’t depending on their training and the intangible exercise of judgment.

• Inexperience or poor judgment. More experienced physicians tend to rely on histories and physicals more than less experienced physicians and consequently order fewer and less expensive tests. Studies suggest primary care physicians spend less money on tests and procedures than their sub-specialty colleagues but obtain similar and sometimes even better outcomes.

• Fear of being sued. This is especially common in Emergency Room settings, but extends to almost every area of medicine.

• Patients tend to demand more testing rather than less. As noted above. And physicians often have difficulty refusing patient requests for many reasons (eg, wanting to please them, fear of missing a diagnosis and being sued, etc).

• In many settings, over utilization makes doctors more money. There exists no reliable incentive for doctors to limit their spending unless their pay is capitated or they’re receiving a straight salary.

So if we understand what role the medical provider plays in over testing and treating, what’s the consumer’s role? Being informed and asking questions are critical to helping in making decisions and choices.

When it comes to testing, talk about the following with your provider:

• What will the test cost and will my insurance cover it?

• What types of information will test results provide?

• Are there cheaper alternatives to this test?

• How will the information the test provides impact treatment?

• Would treatment be recommended regardless of test result?

When it comes to making treatment choices, be an active participant:
• Check out options, knowing risks and benefits of treatments as well as doing nothing.

• Learn about side effects and weigh benefits

• Discuss your specific situation with your provider. It’s great that medical science knows that three out of four people will have benefit from a treatment. However, the specifics of your condition, may modify that down to a one in ten statistic.

• Discuss treatment options with your provider as well as a close friend/family member.

• Check with your provider about using a “shared decision making” service at your health center, hospital or on-line.

Given the findings of his research, Dr. Wennberg has gone on to help found The Foundation for Informed Medical Decision Making, which helps consumers and providers in determining what type of testing and treatment may be best.

Other Healing Whole Posts on this topic
You’re in Charge/Shared Decision Making: Includes a number of links to shared decision making.

Choices/Decisions Part I

When is it time to say enough?

As far as my initial question, was my son over tested, I think so. There are other cheaper and less traumatic testing that could have been to give similar information. However, I wasn’t part of the examination, so I have no idea how my son presented.

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