Throwing the baby out with the bath water

June 6, 2012 — At least she doesn’t place most of the blame on patients.

Usually, articles or policy papers imagining that Americans are getting too much medical care focus on a population that, heedless of cost, is supposedly eager — startlingly so — to see the doctor. The magic bullet: crimp insurance benefits still further so that those health care “consumers” will think twice before engaging in the casual pursuit of medical services.

When Elisabeth Rosenthal, an outstanding reporter for The New York Times joined the less-doctoring craze this week with Let’s (Not) Get Physicals, she, at least, began with some sound premises.

It can be true that, in the U.S., “most doctors and hospitals profit more by doing more.” Screening procedures — especially those, like CT scans, that expose patients to significant radiation — can be and are overused. The tendency of some specialists to “find what they know” — if your only tool is a hammer, you see everything as a nail — exists. And the “cascade” problem — an incidental finding on a routine test that leads down a path of ever-more invasive (and riskier) testing, often for what turns out to be a harmless anomaly — is real.

But then Rosenthal, who is herself a physician, went on to prescribe a one-sided regimen of dispensing with annual physical examinations and cutting back on routine testing of both invasive and non-invasive testing, all without appreciating the potential costs to patients.

Rosenthal boasts of having “not gotten an annual physical examination since around the time I finished my medical training in 1989.” But perhaps she is significantly more aware than the average civilian of potential causes for medical concern, and, surely, she is distinctly less inhibited than most people in discussing openly with a doctor the concerns she does have.

As many physicians (or, at least, many of those interested in yielding data from what their patients have to say) will tell you, lots of patients are often remarkably unforthcoming about either concerns or symptoms. An annual physical examination at minimum opens a forum that provides a possibility for communication and the opportunity to build an ongoing relationship.

Yes, it’s true that a blood pressure check could, as Rosenthal points out, “be performed in a pharmacy.” But the fact that you can slip your arm into the cuff of an automated blood pressure machine hardly means that you’re likely to confide in the machine.

And the annual physical, properly performed, remains the least rushed of doctor-patient interactions, and the one where the doctor isn’t focused on one specific complaint to the exclusion of a broader examination. Is an hour or so a year to physically examine a patient, talk to him, and gather laboratory data really too much to ask?

Perhaps Rosenthal’s readers will take her up on the idea that, as long as you think you’re basically healthy, you really don’t need that annual physical. Some of those people will find that they wished that a doctor had spotted a tiny — and to the patient, innocuous-looking — skin lesion and had sent the patient to a dermatologist (yes, the dreaded specialist) to have a melanoma removed at a sufficiently early stage.

Some young people, following the advice, won’t bother to have any medical care while they are feeling healthy — even though they’re silently developing plaque in their coronary arteries, a progression that could have been prevented, arrested, or reversed with changes in diet, increased exercise, and, perhaps the introduction of statins or other medications, if they had only seen a doctor.

What would have followed if they had made that first appointment would likely have been a benign cascade: the internist, upon finding high cholesterol through routine testing, might have followed up with advanced lipid testing to confirm the existence of a problem, and, thereafter, with an entirely appropriate referral to a cardiologist (another specialist) for a carotid artery ultrasound (an entirely non-invasive procedure). Care tailored to that patient could then knowledgably be recommended. 

The irony, of course, is that Rosenthal herself acknowledges that “Americans have far fewer doctor visits on average than patients in places like Japan and Denmark,” that “50 million people are uninsured and receive little medical attention,” and that “[m]ore than half of uninsured adults in the United States did not see a doctor in 2010.” In short, part of sensible public health policy would be to get more Americans to see primary care physicians more frequently, increasing some front-end costs, but reducing substantially the cost and hardship of suffering that comes with chronic diseases that are allowed to get hold.

I think that Rosenthal’s analysis is also marred by two errors of conflation. The first confuses the desirability of obtaining medical data (through routine testing) with the undesirability of how the data yielded can be misused.

Of course blood tests and other screening methods can return a falsely positive result. And, as mentioned earlier, follow-on procedures can carry risks (it’s the scenario of an incidental finding of something that appears to be mildly suspicious on a x-ray, followed by a series of CT scans, followed by a lung biopsy, where the initial suspicion is allayed, but where the radiation doses cannot be undone, and a hard-to-treat infection develops from the biopsy).

But that just means that both doctors and patients have to use judgment — indeed, both groups need to be taught how to use better judgment — in utilizing the results of tests, not that doctors should endeavor to minimize the information they have available to assess a patient’s condition.

Another conflation is between different types of tests. It seems misguided from a quality care point of view to treat non-invasive or low-risk testing (like blood testing, ultrasound scans, or colonoscopies) in the same way that one would evaluate testing that carries greater risk.

Lurking in Rosenthal’s analysis, like that of virtually everyone thinking about the provision of health care, are cost concerns. She cited a researcher that “has estimated that unneeded blood tests during physical exams alone cost $325 million annually.” Assuming that number were true, it needs to be put in context. First, one should note that it’s about $1 per American (or, perhaps, $2 if we assumed that twice as many Americans could be getting such testing than are actually doing so).

In any event, these costs are tiny when compared either to overall health expenditures or to the dollars paid for private health insurance that don’t go to patient care.

According to data from the National Health Statistics Group of the Centers for Medicare and Medicaid Services, published earlier this year, overall health expenditures in the U.S. in 2010 totaled almost $2.6 trillion, and the “net cost” for private insurance (the amount in premiums not paid out for medical services) was $102 billion, more than 300 times the cost of the blood testing characterized as unnecessary.

A genuine conversation about quality health care would not exclude the substantive concerns that Rosenthal raised, but would consider alternatives to simply doing without, and would be prepared to discuss various kinds of testing that are underutilized (as, for example, transvaginal ultrasound, a relatively inexpensive procedure, generally entirely without risk, that can detect more readily than customary gynecological exams the presence of ovarian cancer or other pelvic abnormalities).

We’re not going to being able to have that conversation unless we’re able to put to the side — at least for a few minutes — the question of cost, and make sure to begin and end with what is best for patients.

Then we can discuss whether we’re a society that is prepared to pay for what is needed.