Will Health Reform Drop Your Doctor’s IQ?

Advancing technology has been blamed as a cause of rising health care costs and yet in virtually every other sector of the economy, when technology advances, prices drop.  Witness communication.  It once required manual transportation of documents with the attendant costs of doing so.  Compare the Pony Express to email.   Nowadays, just click “send” and documents are on their way instantaneously.  Look at cars, electronics, food production and photography.  Across the board, prices have dropped and quality has risen in past decades.  So why is medical care an exception?

Two and a half decades ago, when I began my medical training, it was impressed upon me that importance of a solid clinical history in determining the nature of a person’s illness.  Secondly was a careful physical exam.  Lastly, tests were used to verify the conclusions of the history and physical.  I distinctly recall a seasoned family physician telling me that “if you do not know what is wrong with the patient by the time you have finished taking the medical history, you likely never will.”  Sage advice.

Nowadays direct monetary transactions rarely occur between doctor and patient.  Prices are not set by mutual agreement between the two but rather are set arbitrarily by the third parties of government or private insurance.  A doctor’s visit is not like a normal purchase.  Price and value are not weighed out by the consumer/ patient.  The doctor has difficulty providing more health care in a visit than he is compensated for.  Overhead must be paid.  In fact, Medicare and Medicaid often reimburse less than the cost of providing care.  The doctor may lose money under these programs.  Hence, the five minute doctor visit.

A partial solution for the doctor is to hasten patients through with less careful history taking and meticulous examination and more expensive testing and interventions.  Patients have come to expect plenty of testing because they are not directly responsible for costs.  This is exacerbated by an unfriendly legal and regulatory environment that stamps out common sense and the weighing of probabilities.  Careful counseling is now trumped by hasty prescriptions.

As a diagnostic radiologist, I see senseless and expensive testing done every day.  As a third year medical student, I could confidently diagnose normal sized lymph nodes.  These are little islands of the immune system that are common in the neck, armpits and groin.  They are normal structures. They may become enlarged with disease.  It has now become common to evaluate these structures with expensive ultrasounds or CAT scans; the latter of which has an attendant radiation exposure to the patient.  Clinicians lacking in basic clinical judgment, rushed for time and fearing lawsuits defer to technology and the interpretive skills of radiologists like myself to make the decisions for them.  My personal paycheck is enhanced in the short term but I would prefer to work in a medical system that serves patients best, is sustainable and is without intrusive government controls implemented as a stop gap against rising costs..

There is a rare congenital medical condition in which an abnormal collection of blood vessels overgrowing the surface of head and involves the underlying brain.  I have yet to see a case in fifteen years practicing radiology.  Along the same spectrum are common “Stork bites” or strawberry hemangiomas which are common red marks on the scalp or faces of newborns that typically melt away spontaneously in early infancy.   It is becoming a fashion to perform expensive scans on these trivial curiosities despite extreme rarity of underlying brain involvement.  The sense that I get working in diagnostic imaging, is that if a test exists, it will be used with impunity whether actually helpful or not.

Back pain is another area replete with low IQ medical management. Back pain is ubiquitous in the population.  Most people will experience back pain at some time in their lives.   It is the exceptional case where imaging is helpful.  Two-thirds of all asymptomatic people have bulging discs.  Half have outright disc herniations.   Yes, you read that correctly that is people without symptoms!  Expensive MRI tests are therefore not illuminating in the assessment of most cases of back pain.  Radiologists like myself are commonly requested to do x-ray guided spine injections to treat back pain.  Most cases of back pain do not need surgery or injections but careful strengthening of weak muscles and stretching of tight muscles to alleviate abnormal forces that caused the pain in the first place.  Such exercise is cheap.  MRI’s and x-ray guided injections are expensive and yet they are embraced as a first line of management because neither patient nor doctor are accountable for the expenses.

These are some of the more egregious examples of how doctors jump to tests and interventions rather than exercise medical judgment thereby driving up costs.  Prior to the Patient Protection and Affordable Care Act, people could buy insurance with up to a 10,000 dollar deductible.  That is they would directly control their first 10,000 dollars of care motivating an assessment of price and value.  Insurance could be then used as insurance should be.  That is, to protect against large and unexpected financial losses just as automobile and homeowners insurance does.  Incidentally, there has been no cry to reform these types of insurance.  High deductible plans have been a positive step forward in promoting sensible and less costly health care.

Under “Obamacare”, the ceiling on deductibles has been dropped to 2000 dollars.  Expect a commensurate drop in sound medical judgment.


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