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Too Much Testing And Treatment? Try Superb Primary Care

The Associated Press has been running a fantastic series of must reads with the latest article highlighting the consequence of too many imaging studies, like X-rays and CT scans, which are the biggest contributor to an individual’s total radiation exposure in a lifetime. Americans get more imaging radiation exposure and testing than people from other industrialized countries.

Reasons for doing too many tests include malpractice fear, patient demands for imaging, the difficulty in obtaining imaging results from other doctors or hospitals, as well as advanced technologies, like coronary angioplasty, which have increased radiation but avoid a far more invasive surgery like heart bypass.

Although these are all legitimate concerns, one of the reasons listed was:

“Accuracy and ease of use. Scans have become a crutch for doctors afraid of using exams and judgment to make a diagnosis. Some think a picture tells more than it does. Imaging that shows arthritis in a knee or back problems doesn’t reveal how to make it better, said Dr. Richard Baron, a primary care doctor in Philadelphia.”

Dr. Baron was recently widely cited for his article in the New England Journal of Medicine on the true workload of primary care doctors which gives valid reasons why medical students as well as those in practice are avoiding the specialty or retiring respectively.

It really isn’t accuracy and ease of use as Dr. Baron suggests, but rather a matter of survival for doctors on the front line. The vast majority doctors are paid fee for service. That is the more you do the more you get paid. In the case of primary care doctors, the more patients you see the more you get paid.

It has been argued that if primary care doctors were paid a salary instead of by number of patient visits that more time could be spent on asking the right questions and doing thorough examinations to get to the root of a patients problem. When I train first-year medical students, I tell them exactly the same thing: If there is only one thing you learn from me, then it is how to take an accurate history and a relevant physical exam. Ninety percent of getting the right diagnosis is refining these two skills.

Students often ask how long it takes to be good at this. A lifetime. Professional athletes, artists, and musicians never stop getting better and as doctors neither should we.

Why is this important? Because the latest thought in healthcare is to slow costs by pushing more financial responsibility to patients. A report by the consulting firm PricewaterhouseCoopers found that majority employees will face a deductible of $400 or more, which is in addition to the annual premiums. Will patients really be able to ask or even challenge their doctors on the appropriateness of an imaging study? Do you ever tell your auto mechanic to not service your car when the airbag indicator or the brake light come on? (If you have, please let me know because I certainly didn’t have the courage to do so).

The other thought is to make prices for procedures more transparent as start-up Castlight tries to do. Shop around for the cheapest imaging study. Although this also is a laudable approach to slow healthcare costs, it is also not addressing the root cause. Doctors are ordering too many tests. Though price transparency will make the unit cost of the test cheaper, Americans will still be overdosed with radiation.

Doctors need to step up and lead the way. They cannot until the reimbursement system changes that values primary care for time spent thoughtfully evaluating patients by talking and examining them. As Dr. Abraham Verghese of Stanford Medical School and an outstanding clinician notes, it is the patient’s story that matter not the imaging tests. As he correctly argues in an editorial in the British Medical Journal:

…clinicians who are skilled at the bedside examination make better use of diagnostic tests and order fewer unnecessary tests. If, for example, you recognise that the patient’s chest pain is confined to a dermatome and is associated with hyperaesthesia, and if you spot a few early vesicles looking like dew drops on rose petals, you have diagnosed varicella zoster and spared the patient the electrocardiography, measurement of cardiac enzymes, chest radiography, spiral computed tomography, and the use of contrast that might otherwise be inevitable. And so many clinical signs, such as rebound tenderness, lid lag, tremor, clubbing, or hemiparesis cannot be discerned by any imaging test.

To avoid overtreatment and save money, find a superb primary care doctor will to talk to you about the pros and cons of medications, imaging tests, and procedures. Be thankful he or she did. As the Associated Press series of “overtreated” articles illustrate, sometimes it is best not to keep up with the Joneses and walk away from too many tests while still staying healthy.

Can’t find a stellar primary care doctor? No worries. The truth on how to avoid the traps of overtreatment are found in my book which is available on Kindle, iPad, and iPhone, as well as hardcover. This easy to read book offers the skills I use to keep my patients healthy while thoughtfully ordering treatments they really need to stay well.

*This blog post was originally published at Saving Money and Surviving the Healthcare Crisis*

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One Response to “Too Much Testing And Treatment? Try Superb Primary Care”

  1. Technology has replaced traditional medical skills for many reasons, as you point out. How adept do you think new physicians are with cardiac auscultation, examination of the abdomen or palpation of the carotid pulse? Technology has brought incredible progress, but has also exacted a great cost from our profession. The medical history remains our best diagnostic tool, but it has been devalued. So far as I know, there is no imaging study that can replace it, but who knows?

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Richmond, VA – In an effort to simplify inpatient medical billing, one area hospitalist group has determined that “altered mental status” (ICD-9 780.97) is the most efficient code for use in any patient work up.

“When you enter a hospital, you’re bound to have some kind of mental status change,” said Dr. Fishbinder, co-partner of Area Hospitalists, PLLC. “Whether it’s confusion about where your room is located in relationship to the visitor’s parking structure, frustration with being woken up every hour or two to check your vital signs, or just plain old fatigue from being sick, you are not thinking as clearly as before you were admitted. And that’s all the justification we need to order anything from drug and toxin screens, to blood cultures, brain MRIs, tagged red blood cell nuclear scans, or cardiac Holter monitoring. There really is no limit to what we can pursue with our tests.”

Common causes of mental status changes in the elderly include medicine-induced cognitive side effects, disorientation due to disruption in daily routines, age-related memory impairment, and urinary tract infections.

“The urinalysis is not a very exciting medical test,” stated Dr. Fishbinder. “It doesn’t matter that it’s cheap, fast, and most likely to provide an explanation for strange behavior in hospitalized patients. It’s really not as elegant as the testing involved in a chronic anemia or metabolic encephalopathy work up. I keep it in my back pocket in case all other tests are negative, including brain MRIs and PET scans.”

Nursing staff at Richmond Medical Hospital report that efforts to inform hospitalists about foul smelling urine have generally fallen on deaf ears. “I have tried to tell the hospitalists about cloudy or bloody urine that I see in patients who are undergoing extensive work ups for mental status changes,” reports nurse Sandy Anderson. “But they insist that ‘all urine smells bad’ and it’s really more of a red herring.”

Another nurse reports that delay in diagnosing urinary tract infections (while patients are scheduled for brain MRIs, nuclear scans, and biopsies) can lead to worsening symptoms which accelerate and expand testing. “Some of my patients are transferred to the ICU during the altered mental status work up,” states nurse Anita Misra. “The doctors seem to be very excited about the additional technology available to them in the intensive care setting. Between the central line placement, arterial blood gasses, and vast array of IV fluid and medication options, urosepsis is really an excellent entré into a whole new level of care.”

“As far as medicine-induced mental status changes are concerned,” added Dr. Fishbinder, “We’ve never seen a single case in the past 10 years. Today’s patients are incredibly resilient and can tolerate mixes of opioids, anti-depressants, anti-histamines, and benzodiazepines without any difficulty. We know this because most patients have been prescribed these cocktails and have been taking them for years.”

Patient family members have expressed gratitude for Dr. Fishbinder’s diagnostic process, and report that they are very pleased that he is doing everything in his power to “get to the bottom” of why their loved one isn’t as sharp as they used to be.

“I thought my mom was acting strange ever since she started taking stronger pain medicine for her arthritis,” says Nelly Hurtong, the daughter of one of Dr. Fishbinder’s inpatients. “But now I see that there are deeper reasons for her ‘altered mental status’ thanks to the brain MRI that showed some mild generalized atrophy.”

Hospital administrators praise Dr. Fishbinder as one of their top physicians. “He will do whatever it takes to figure out the true cause of patients’ cognitive impairments.” Says CEO, Daniel Griffiths. “And not only is that good medicine, it is great for our Press Ganey scores and our bottom line.”

As for the nursing staff, Griffiths offered a less glowing review. “It’s unfortunate that our nurses seem preoccupied with urine testing and medication reconciliation. I think it might be time for us to mandate further training to help them appreciate more of the medical nuances inherent in quality patient care.”

Dr. Fishbinder is in the process of creating a half-day seminar on ‘altered mental status in the inpatient setting,’ offering CME credits to physicians who enroll. Richmond Medical Hospital intends to sponsor Dr. Fishbinder’s course, and franchise it to other hospitals in the state, and ultimately nationally.


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