"You actually try and avoid ordering a test?" There was an element of surprise, even some incredulity, in the subspecialist’s voice. "Yes," I said.
The case involved a 2-year-old with ... Well, those details don’t matter. The point is that all tests have a downside. There is the discomfort of the test, particularly in pediatrics. This week I had the baby who required four IV sticks and a radial artery poke to get enough blood to work up a potential (though very unlikely) inborn error of metabolism. There are potential complications, especially the risk of cancer with any x-ray or CT scan. There is the potential to be misled. In my career I’ve seen several patients misdiagnosed based on a test with poor specificity. But the biggest issue is the waste of resources in a society where people are dying due to lack of access to affordable care.
I recall a TV series where in each episode a patient arrives at the hospital emergency department and a brilliant young intern rattles off a litany of tests before examining the patient. It makes a good action script but bad medical care. As an attending at a teaching hospital, I’m frequently reviewing the tests proposed by residents. Part of that review is asking whether a test is really necessary. What are you going to do differently if the repeat CBC had a white count of 20,000 versus 10,000? What do practice guidelines say about the utility of a blood culture for a febrile but nontoxic 2-year-old with community-acquired pneumonia? In your judgment, how helpful will another CT scan be for this teenager with chronic abdominal pain who has had three scans in the past 12 months? Given recently published data on the risks of radiation, is a head CT of a child who bumped his head really indicated "just to be on the safe side" or is it harmful defensive medicine?
With an ever-growing bag of tests, modern medicine is as much about what not to order as it is about what to order. The same is true for therapies. Just last week I managed to keep a hospitalized child from getting an IV. I object strongly whenever a resident implies that we need to start an IV solely as a means to justify a hospitalization. Given that the child had already failed a course of outpatient therapy, a different oral antibiotic was used, and the entire hospitalization was appropriately covered by insurance as an observation stay.
Various paradigms have been proposed to rein in the out-of-control increase in the cost of health care. This is particularly true in the United States, where costs continue to rise while life expectancy is below that of many other developed countries that spend half as much. Initially labeled rationing, cost control efforts have morphed into many forms. There have been attempts to align financial incentives through diagnosis-related groups. Gatekeeping by primary care physicians was attempted. Second opinions before surgery became a requirement for a few years. In the 1990s, my office was constantly dealing with a high school–trained clerk at the insurance company with a book that said whether or not a particular test or procedure would be covered.
Lately the push has been less about attempting to limit care and more about simply curtailing waste. Last spring, the Choosing Wisely campaign announced "nine physician organizations that each identified five tests or procedures in their respective fields that may be overused or unnecessary."
It is a variation of the "Think globally, but act locally" paradigm.
Another effort this summer has been a campaign emphasizing "Avoiding avoidable waste." Both campaigns have more appropriate mottos than my sentiment of "Don’t act stupid."
Poor-quality research and defensive medicine have influenced many physicians to overtest and overtreat. Comparative effectiveness research has been inadequate. Yet according to a recent Medscape poll, the plurality of physicians have "no intention of reducing the amount of tests, procedures, and treatments they perform because they believe the quality guidelines and cost-containment measures aren’t in patients’ best interest." Obviously, policy makers, researchers, and clinical ethicists have a long way to go on this problem of professional stewardship.
As I delinquently turn this column in to my editor, a new report has just come out. The Institute of Medicine has released a report asserting the United States wasted $750 billion on health care in 2009.
As we approach an election heavily influenced by health care reform and the fiscal cliff, I suspect this report on waste may be as seminal an event for the next decade as the IOM report on medical error was in 1999.