Research shows that there is tremendous variability in what doctors do. Shannon Brownlee's excellent book, Overtreated - Why Too Much Medicine Is Making Us Sicker and Poorer, provides great background on this as well as work done by the Dr. Jack Wennberg and colleagues on the Dartmouth Atlas. Some have argued that because of the fee for service structure, the more doctors do the more they get paid. This drives health care costs upwards significantly. Dr. Atul Gawande noted this phenomenon when comparing two cities in Texas, El Paso and McAllen in the June 2009 New Yorker piece.
Between 2001 and 2005, critically ill Medicare patients received almost fifty per cent more specialist visits in McAllen than in El Paso, and were two-thirds more likely to see ten or more specialists in a six-month period. In 2005 and 2006, patients in McAllen received twenty per cent more abdominal ultrasounds, thirty per cent more bone-density studies, sixty per cent more stress tests with echocardiography, two hundred per cent more nerve-conduction studies to diagnose carpal-tunnel syndrome, and five hundred and fifty per cent more urine-flow studies to diagnose prostate troubles. They received one-fifth to two-thirds more gallbladder operations, knee replacements, breast biopsies, and bladder scopes. They also received two to three times as many pacemakers, implantable defibrillators, cardiac-bypass operations, carotid endarterectomies, and coronary-artery stents. And Medicare paid for five times as many home-nurse visits. The primary cause of McAllen’s extreme costs was, very simply, the across-the-board overuse of medicine.
Doctors apparently seemed to order more tests. Patients, not surprisingly, agreed. After all, without adequate medical knowledge or experience, how sure would you be if a doctor recommended a test and you declined?
Would doctors do more because they get paid more or would they simply do the right thing and do tests or procedures when only medically necessary?
I recently had a 55 year old healthy woman join my practice. She wisely had brought in her medical records and was fairly educated on the care she received. She told me that her previous doctor had recommended a colonoscopy for this year, five years after her initial colonoscopy at age 50.
For most patients with no family history of colon cancer and a normal colonoscopy, recommendations are to repeat in ten years not five.
Did she have any abdominal pain or change in bowel habits? No.
Did the doctor say anything about colon polyps or growths? No.
Did she have the colon biopsied? No.
Was there a family history of colon cancer? No.
She was pretty sure she was to have a repeat test five years later.
I reviewed her previous doctor's chart which had her colonoscopy report.
Completely normal colonoscopy. No polyps. No growths. No biopsy.
At the end of the report: Recommend repeat colonoscopy in 5 years.
I've read news reports over the years where research has noted some gastroenterologists were doing colonoscopies more frequently than recommended by their own professional medical societies either for routine screening or follow-up of colon polyps and growths. I assumed those stories were outliers and rare. I would never encounter such an obvious case of overtreatment.
But this patient's report and her memory of what her doctor told her could not be chalked up to a typo or a misunderstanding. Would doctors do more because they get paid more? How else to explain this?
After showing my patient the guidelines from the American Cancer Society as well as the American College of Gastroenterology, she was thrilled that she didn't need to undergo the procedure for another five years. No need to do the prep that Dr. Oz did with the gallon of laxative and the loss of a day getting ready and then recovering from the side effects of IV sedation needed for the colonoscopy.
I saved her time and money and unnecessary treatment.
You should always have a primary care doctor review your old medical record, especially if you move or switch insurance plans. Another doctor's opinion and insight can be very important to counter this natural feeling of uncertainty. No one wants to make a bad choice. Patients aren't medical experts and generally don't want to be. Doctors who choose primary care do so because they want to care for the whole patient despite the fact it is among the lowest paid specialties and least attractive to medical students. Medical students are gravitating towards specialty care which are more procedural based and therefore have the opportunity to generate more income.
Unfortunately, this means doctors who can help patients make informed decisions and prevent overtreatment will be in limited supply at a time when we need them the most.