A major impediment: Patient expectations

Dr. Gabriel Ledger's note on patient expectations:
A major impediment to minimizing patient testing is patient expectation. My patient with a viral chest cold expects a chest X-ray, to prove that his two-week cough isn’t pneumonia (it isn't), and the mother of my three-year-old patient who tumbled off the sofa expects a CT scan, to prove that everything will be fine with the child’s brain (it will be fine, except for the unknown long-term results of the radiation from the CT scan). When the tests aren't done, the patients leave my E.R. dissatisfied and write complaint letters to the hospital. And, in the rare instance that the viral chest cold later turns into pneumonia, the patient assumes that I "missed it" and wants to sue me. Doctors need to be held accountable for over-testing, but let's not forget how patient expectation affects the issue.

Thanks for Dr. Ledger's letter, reprinted from the June 29 issue of the New Yorker.

Seventeen doctors for shortness of breath: Unnecessary services

Dr. Sandeep Jauhar's story:
I recently took care of a 50-year-old man who had been admitted to the hospital short of breath. During his month-long stay he was seen by a hematologist, a endocrinologist, a kidney specialist, a podiatrist, two cardiologists, a cardiac electrophysiologist, an infectious-diseases specialist, a pulmonologist, an ear-nose-throat specialist, a urologist, a gastroenterologist, a neurologist, a general surgeon, a thoracic surgeon and a pain specialist.

He underwent 12 procedures, including cardiac catheterization, a pacemaker implant and a bone-marrow biopsy (to work up chronic anemia). When he was discharged, follow-up visits were scheduled with seven specialists.

Expert consultations had sprouted with little rhyme, reason or coordination.

Doctors are usually reimbursed for whatever they bill. Where doctors are paid piecework for their services, if you have a slew of physicians and a willing patient, almost any sort of terrible excess can occur. As reimbursement rates have declined in recent years, most doctors have adapted by increasing the quantity of services. The culture in practice is to grab patients and generate volume. Doctors are doing too much testing and too many procedures, often for the sake of business.

Advice: Ask, or have your patient advocate ask, about the value of an uncomfortable or painful procedure before it is performed.