Fitness Files: More consultation, fewer medical tests
Years ago, our parents hauled sick kids to the doctor, returning home with an antibiotic prescription. Now we know antibiotics, meant for bacterial infections, did nothing if it was a virus that brought us in.
Still antibiotics were wellness magic for a certain generation, and maybe that perception hastened recovery.
Today, according to Lisa Rosenbaum, writing for the New England Journal of Medicine in March 2013, the lab test, scan and imaging is the palliative for whatever ails us. We feel better cared for if doctors order them.
And feeling better cared for might be significant for healing.
Rosenbaum, a cardiologist, tells this story to illustrate the point. Mr. W. came to her for a second opinion. He said his current cardiologist “didn’t seem to be doing anything to keep me from having a heart attack.” Reviewing his records, Rosenbaum found the cardiologist’s treatment appropriate.
However, Mr. W. was “crippled with worry.” He’d stopped playing sports and felt anxious on long work trips. Rosenbaum observed that he “was overweight, had poorly controlled hypertension, a diet riddled with salt,” as well as a father and brother who had suffered early heart attacks.
Rosenbaum began a discussion of diet, exercise and medication, but Mr. W. asked, “Isn’t there some test you could do?”
Freeze frame right here. Rosenbaum along with her fellow physicians are part of “value in health care,” which I interpret as “let’s spend medical dollars wisely.” Rosenbaum’s says Mr. W’s request for a test was an expensive one.
“In 2006,” she wrote, “the Medicare Payment Advisory Commission identified imaging tests as a leading contributor to rising health care expenditures … growing at twice the rate of other physician services. Cardiac imaging, whose growth rate was among the highest, drew particular scrutiny,” causing Medicare to slash doctor reimbursement rates by 40%.
Mr. W. had had four stress tests, a CT scan to assess his aorta and cardiac catheterization.
“None of these assessments can detect the vulnerable plaque that may rupture with fatal consequences,” Rosenbaum wrote. “Nevertheless, patients are often urged to seek them.”
And studies show that “patients who receive imaging, regardless of whether indicated, are generally more satisfied.”
She points to a study published in 1981 in which patients with low-risk chest pain were assigned no test or two tests. The patients who received tests reported less disability and less notice of chest pain and believed that their care was “better than usual.”
So should Rosenbaum give Mr.W a scan, with the evidence that it might help him resume his activities without worry? Or should she resist the exam, therefore saving money on what she felt was medically unnecessary?
First, let’s look at imaging technology. Rosenbaum says the sophistication of testing equipment “outpaces understanding about how best to use it.” She tells the story of Dr. Sanjay Gupta, concerned about family history of heart disease, announcing to his TV audience that he was going to “heart-attack-proof” himself with a test called a coronary calcium scan.
Well, there’s no evidence this scan extends life in asymptomatic patients — or that it doesn’t. However, it seems obvious that Gupta would feel better having the results.
So how did Rosenbaum walk the tightrope between calming Mr. W’s anxiety with the test he asked for and sending him home just as unhappy with her as with his first cardiologist?
In 71 minutes of consultation with Mr. W., his previous tests were reviewed. He heard why another test he’d discovered wouldn’t give him any new information.
Rosenbaum wrote: “At the end of the conversation, Mr. W. and his wife exchanged looks of relief. ‘No one has ever explained any of this to me before,’ he said.”
Consultation time is the key. Many patients could be satisfied with a conversation including a review of their diagnostic information and an explanation of the current treatment plan. However, Mr. W’s visit took 71 minutes when current medical practice averages 21 minutes per patient.
In New York, value-based medicine includes a rating scale for patients’ office-visit experience. If a doctor can’t spend 71 minutes explaining, yet seeks a satisfactory rating, it would be a temptation to skip the explanation, hand out a lab test and avoid a queue of irritated people in the waiting room.
What if value in medicine paid the doctor for patient consultation and follow-up, developing a partnership where the patient took responsibility to follow lifestyle or medical advice?
What if?
Newport Beach resident CARRIE LUGER SLAYBACK is a 72-year-old marathoner who brought home first places in LA Marathons 2013 and 2014 and Carlsbad Marathon 2015.
