Fear, Greed and X-Rays
Fear and greed are potent motivators. When both of these forces push in the same direction, virtually no human being can resist. And doctors -- despite many expectations to the contrary -- are human beings.
This is one reason why medical costs in the U.S. have spiraled out of control, yet we are among the least healthy people in the developed world.
On the fear side, consider this email I got from a physician friend who had read galleys of my book Why Our Health Matters: A Vision of Medicine That Can Transform Our Future which will be released September 8, 2009:
"You should spend some time with me in our ER, which is totally typical of what is going on all over the U.S. Incredibly expensive, unnecessary, and potentially harmful X-ray scans are ordered with gay abandon on all patients to make sure that 'nothing is missed' that a lawyer might later use against the ER. Patients with the most ridiculous complaints are admitted to the CCU [critical care unit] just to make sure that an MI [myocardial infarction, a.k.a. heart attack] is not missed. I would guess that $10,000 dollars per day or more of wasted X-ray radiation studies occur in our ER everyday. Multiply this times 365 and times the thousands of ERs in the country and you come up with billions and billions of dollars of pure waste in our system."
Along with over-scanning, over-biopsying, over-blood-working and other diagnostic excesses, fear propels over-treatment. Anytime a physician diverges from standard U.S. treatment protocols, nearly all of which skew toward expensive drugs and surgery, lawsuit-fear looms. "Defensive treatment" strips physicians of clinical judgment, costs billions and leaves patients less healthy, but it's hard to blame physicians who practice it. As one wearily told me, "You never forget your first lawsuit."
Physicians like to discuss the fear side, because it shifts the blame to lawyers. The greed side, however, deserves just as much scrutiny and reform. Consider "The Cost Conundrum: What a Texas town can teach us about health care," a must-read New Yorker article by Atul Gawande, M.D. Gawande visited McAllen, Texas, to discover why per-capita health care expenditures there are the highest in the nation. He found that many physicians in high-medical-cost cities such as McAllen have a diversified "revenue stream," the result of what one hospital administrator termed "entrepreneurial spirit." This "spirit" often manifested in physicians owning their own medical testing equipment, which meant the more tests they ordered, the more money they made. A 2002 University of North Carolina study showed doctors who own imaging equipment sent patients for roughly two to eight times more imaging tests than those who don't own.
In Gawande's article, a McAllen doctor who refused to hop aboard this gravy train had a more sensible take on the local "spirit." "Medicine has become a pig trough here," he said. "We took a wrong turn when doctors stopped being doctors and became businessmen."
Lest you think the only drawback of over-scanning is wasted billions, note that from 1980 to 2006, per-capita radiation dosage from medical testing more than quintupled. A controversial study published in the November 29, 2007, New England Journal of Medicine estimated that computed tomography (CT) scans -- the type of imaging that has grown most explosively -- administered today could eventually cause up to 2% of cancer deaths.
As with fear, greed also propels expensive, inappropriate treatment. If a clinic loses money each time it counsels a patient to control type 2 diabetes with diet and exercise, but makes a hefty profit when it amputates a foot riddled with diabetic ulcers, how long will it continue to emphasize the former?
Because these problems have two causes, the solution is twofold.
To quell the fear that drives physicians to over-test and over-treat, we need vigorous legal reform to cap malpractice payouts. Staunching the greed motive requires a more dramatic change. Since a single CT scanner can bring in $400,000 a year in profit, it's vital to sever the link between ordering tests and making money. Restricting ownership of testing equipment to nonprofit, government, or independent private entities is crucial.
As for popularizing less lucrative -- but often better -- low-tech treatments, putting physicians on salary can also help. Whether the paycheck comes from a nonprofit organization such as the Mayo Clinic or some variety of single-payer national health care, stabilized incomes would let physicians more readily focus on the health of their patients rather than on their own finances.
Until both of these corrective measures are in place nationwide, it's up to you to ask your physician if the tests or treatments ordered for you are truly essential. You might get an honest answer about the test's potential risks and benefits. Then, together, you can arrive at a decision that satisfies both of you.