Doctors Are Creating Too Many Patients

Hugh Pickens writes "H. Gilbert Welch writes in the LA Times that the threshold for diagnosis has fallen too low, with physicians making diagnoses in individuals who wouldn't have been considered sick in the past, raising healthcare costs for everyone. Part of the explanation is technological: diagnostic tests able to detect biochemical and anatomic abnormalities that were undetectable in the past. 'But part of the explanation is behavioral: We look harder for things to be wrong. We test more often, we are more likely to test people who have no symptoms, and we have changed the rules about what degree of abnormality constitutes disease (a fasting blood sugar of 130 was not considered to be diabetes before 1997; now it is).' Welch says the problem is that low thresholds have a way of leading to treatments that are worse than the disease. 'We are trained to focus on the few we might be able to help, even if it's only 1 out of 100 (the benefit of lowering cholesterol in those with normal cholesterol but elevated C-reactive protein) or 1 out of 1,000 (the benefit of breast and prostate cancer screening),' writes Welch. 'But it's time for everyone to start caring about what happens to the other 999.'"

Comments

Title

[turkeyfish]

Perhaps the title of the article should read lawyers and doctors create too many patients.

Symptomatic

[nuggz]

So we should wait till everyone is symptomatic?
Many conditions can be treated more effectively and cheaply if they're detected early.

Some conditions dont' even become symptomatic until significant damage is done.

The question really is how to balance the best treatment with the financial constraints.

Re:Symptomatic

[Dunbal]

And also to treat the patient and not a set of lab results. This happens all too often in my country.

For example my father in law, who has never been symptomatic, was being treated for gout because he had a uric acid score slightly greater than 7. Since I am also a physician I ordered a few tests to rule out other conditions that could result a slightly abnormal uric acid result, took him off the allopurinol and told him to eat all the red meat he wants. He is still not symptomatic, has no kidney trouble, and will be dead in 10 years from his prostate cancer anyway.

Why label him as a "gout" sufferer and even worse, treat him for it, if he doesn't actually manifest the disease? Doctors must remember that the way we determine what "normal" values are is by fitting large samples to a bell curve, chopping off the ends at 1 or 2 standard deviations, and calling the middle "normal". There are perfectly healthy people on either end of the curve, however. We need to use our clinical skills to figure out who needs treatment and who doesn't, otherwise you might as well not have doctors at all and leave medicine to some giant, complex algorithm.

Doctors Are Creating Too Many Patients

[tverbeek]

You'd expect doctors to know how to use contraceptives to prevent this.

This is just stupid

[rsilvergun]

Study after study shows people with access to more health care live longer. I'll point out John McCain and Earvin "Magic" Johnson as too people that'd be dead w/o the extensive and highly personalized healthcare they receive. This sounds like another conservative shill trying to convince the poor they don't need to see doctors like their rich people do, but than again the author could be another one of those Homeopath loons/Charlestons...

Re:This is just stupid

[Christoph]

I agree.

My late brother's doctor told him his swollen lymph nodes were nothing -- he had no symptoms, and a routine white count showed no infection.

That's how lymphoma presents. The next year he was in the ER due to wheezing, and was diagnosed with stage 3 Hodgkin's lymphoma, which eventually killed him (photos of his last years). He had a bone marrow and stem cell transplant...not looking for lymphoma in someone asymptomatic turned out to be pretty expensive as well as fatal for the patient.

This story is not rare, either. After speaking to a handful of other Hodgkin's patients, they all had similar experiences. And those were the survivors.

Kind of agree...

[Anonymous Coward]

As I understand the current situation:

1) If they don't do the tests and catch a problem, the doctor and hospital will be sued.

1a) The results of a trial may put licenses at risk, depending upon the State Board's agressiveness.

2) If they due the tests either tax subsidized insurance or a Medicare type program will pay for the tests and treatment.

Conclusion: How could the situation any different.......

Re:Kind of agree...

[hedwards]

This.

It's more common in some areas of medicine than in others. But I know that in psychiatry if they don't make a diagnosis then the insurance company definitely won't pay. Whereas if they do suddenly the patient gets crap treatment and most of their medical complaints blamed on mental illness.

What's worse is that the area of psychiatry is hardly one where diagnoses are clearly separable from other options, and doctors usually get the difference between insomnia and depression wrong leading to patients being prescribed antidepressants when bed rest would do more good. Antidepressants usually interfere with sleep leading to often times even worse sleep.

Re:Kind of agree...

[nomadic]

No offense to your girlfriend, but do you really think she's going to say "oh, yeah, we definitely are to blame"?

The Medical Malpractice Myth.:

What do we know?

First, we know from the California study, as confirmed by more recent, better publicized studies, that the real problem is too much medical malpractice, not too much litigation. Most people do not sue, which means that victims—not doctors, hospitals, or liability insurance companies—bear the lion’s share of the costs of medical malpractice.

Second, because of those same studies, we know that the real costs of medical malpractice have little to do with litigation. The real costs of medical malpractice are the lost lives, extra medical expenses, time out of work, and pain and suffering of tens of thousands of people every year, the vast majority of whom do not sue. There is lots of talk about the heavy burden that “defensive medicine” imposes on health costs, but the research shows this is not true.

Third, we know that medical malpractice insurance premiums are cyclical, and that it is not frivolous litigation or runaway juries that drive that cycle. The sharp spikes in malpractice premiums in the 1970s, the 1980s, and the early 2000s are the result of financial trends and competitive behavior in the insurance industry, not sudden changes in the litigation environment.

Fourth, we know that “undeserving” people sometimes bring medical malpractice claims because they do not know that the claims lack merit and because they cannot find out what happened to them (or their loved ones) without making a claim. Most undeserving claims disappear before trial; most trials end in a verdict for the doctor; doctors almost never pay claims out of their own pockets; and hospitals and insurance companies refuse to pay claims unless there is good evidence of malpractice. If a hospital or insurance company does settle a questionable claim to avoid a huge risk, there is a very large discount. This means that big payments to undeserving claimants are the very rare exception, not the rule.

Finally, we know that there is one sure thing—and only one thing—that the proposed remedies can be counted on to do. They can be counted on to distract attention long enough for the inevitable turn in the insurance cycle to take the edge off the doctors’ pain. That way, people can keep ignoring the real, public health problem. Injured patients and their lawyers are the messengers here, not the cause of the medical malpractice problem.

Lawyers

[Anonymous Coward]

In a court of law the question to be asked "Was there a test to determine the problem with my client's husband that would have saved his life if you had done it?" That single question is the reason for all of this, because if the answer is "yes", which is always is even if there were no legitimate reason to run said test, then the doctor is guilty of malpractice. He does that three times, he is no longer a doctor.

Stop blaming the people trying to help you, who have to protect themselves from the lawyers. Blame the root cause.

From a doctor

[deuist]

I'm an ER doctor. I can't create patients as they come to me with symptoms. I will say that people come to me with minimal symptoms such as cough and fever and then demand blood work, X-rays, and antibiotics, even though the majority of the time their symptoms are caused by a virus and will get better all on their own. Somehow, our society has become so weak that every cough, scraped knee, or hangnail requires a visit to the hospital. And somehow we think that physicians can't diagnose anything without a thousand dollars worth of painful tests. Whenever I try to explain to someone, "You have a cold. You're going to be fine," that's not a good enough explanation. I've even had a few people demanding admission to the hospital---which, if you didn't have a life-threatening disease before, you can certainly pick one up during a hospital stay. This problem is societal in nature and has been made worse with television shows such as House and ER where lay think that every problem requires specialists and lots and lots of tests. Don't blame me; I'm just a cog in the wheel.

My wife is a doctor...

[Richard_at_work]

in the UK for the NHS, and her position on this has always been that patients want you to diagnose them with something, and if you do not then they will re-present either to another doctor at your practice very quickly, or at the local accident and emergency room. And last month she was provided with the best example of this ever...

Ever since I met her, she has complained to me (in a friendly way) that people present to the A&E (she was working A&E minors at the time) with conditions that 30 years ago would have been treated at home, but because the home remedy and care experience isn't being passed down these days, current generations of parents do not know how to care for minor conditions any more and are quick to panic.

One example of this is D&V (diarrhea and vomiting - generally any tummy bug that causes you to crap loads and throw up loads) - patients, or the parents of young patients, will regularly show up to A&E with D&V and expect the doctors to do something. If they were to be admitted, it would remove a bed from use for other more serious reasons, and the only thing they would get would be intravenous saline, and thats not even guaranteed. Seriously, would you rather be crapping and throwing up at home in privacy, or in a hospital in public? Do it at home folks.

Anyhow, on with the example - in this case, she was working as a GP at a practice and a mother presented her 3 year old child with D&V, my wife kindly explained that everything was fine, the kid was not in undue distress, they don't tend to worry that the kids not eating or drinking for at least 5 days, and it was just a case of waiting it out. After a lengthy consultation, the mother and child left.

Four hours later, my wife switched to do a locum shift at the local A&E department - and who was her second patient...? The mother and child. The child hadn't presented any more serious symptoms and had not declined in condition, the mother just wanted someone to do something. So my wife, who had suffered the embarresment of calling the patient in and realising why they were here (the parents faces went bright red when they realised who the doctor was that was calling them apparently), had the job of telling them exactly the same thing again.

To put their minds at ease, she called her senior in who explained the same thing. And then just to top it off, had a paediatrics doctor come down to again reassure them that the only things they could do was to allow the D&V to run its course. After a six hour period in A&E, the parents and child left with no treatment, no medication and essentially nothing gained.

And then my wife finds out, a day later, that the parents had driven the twenty miles to the next major hospitals A&E department and done the same thing there - to be told the same thing and sent home in exactly the same manner.

No names and no identifiable information because I don't know any - my wife is very good at venting but retaining the pertinent private details so even I can't identify the patients.

Long story short, the patients are more of an issue these days than the medical carers - patients thing the doctor is there to treat them and damn them if they don't.

Plus, of course, its easier to overtreat for a minor condition than it is to defend the non-treatment in court for the one case in a million that goes from "minor, non-worrying condition" to "death or loss of limb". One of the things my wife is frightened about is the one in a million case where a reoccuring headache is actually the brain tumour that everyone suspects - but she cannot refer all thirty patients a week who come in with that complaint to the specialist simply because the money isn't there.

Re:There's still a lot to do in medicine

[stewbacca]

How would you like to work in an industry where you are told here is what you get paid by the government?

Doesn't seem to be a problem in England, Germany, Belgium, France, Norway, etc. etc. etc.

Capitalism is great an all, but some things (like the health of citizens) are more important than profit.