Preventing what?

pills1My father was a master diagnostician who had an uncanny knack – honed over many years of personally examining and interviewing patients – of making the correct diagnosis of a patient’s medical problem without the assistance of expensive and often time-consuming tests.

However, my father’s way is not the preferred method of modern preventative care, which often tethers patients to their doctors with a dizzying array of tests.

Dr. H. Gilbert Welch and his colleagues at the Dartmouth School of Medicine aren’t convinced that the modern way is better than my father’s approach. This Abigal Zuger, MD/NY Times review of Dr. Welch’s new book – Over-diagnosed: Making People Sick in the Pursuit of Health (Beacon Press January 18, 2011)  — sums up the core issue well:

As the world is currently configured, the authors point out, doctors are never punished for over-diagnosis, no matter how much havoc may be wrought by untrammeled over-testing. It is perceived under-diagnosis that arouses legal and moral wrath.

Is that the way it should be?

An intriguing question, indeed!

7 thoughts on “Preventing what?

  1. tom,
    i think your dad would tell you three things have contributed to your accurate point. legal threat is one = “more tests”.
    younger docs now have “too much” to learn in four years of school and emerge with less respect for and talent at history and physical. (back in the day, we were taught if you take the history and do not know what is wrong you are in trouble and if the physical doesnt then tell you, you are in REAL trouble because carefully selected tests are only used to confirm or clarify what the H&P suggested–i find this as true today as it was when taught.)
    lastly, today’s payment leaves most doctors with too little time to conduct a proper history and physical and they can escape the room faster via vain efforts to compensate with an overabundance of tests–WE ARE ALL IN TROUBLE, doctors AND, more importantly, patients.

  2. Very well said, both of you – now what suggestions
    do you have for how to get back to a primary reliance on differential diagnosis, rather than on expensive tests?
    It may not have started with gw’s “no child’s behind left” corporate welfare scam to benefit one of the bush boys who was/is? CEO of a testing software company – but who knows, maybe it did.

  3. I simply do not understand why we, as a nation, are having such a hard time reforming our medical care delivery system. If the problems is that health care costs are out of control and threaten to bankrupt families who need catastrophic care, then sell high premium catastrophic care policies ($5k deductibles), allow people to build up their flex spending balances over time (forcing people to ‘use it or lose it’ at the end of each year is silly) and put the responsibility for building a relationship with a primary care provider and finding a value proposition for routine care providers in the hands of the consumer. Low income families could still be provided for under such a system. Enact tort reform, and we have a vastly reformed system.
    If an individual were responsible for paying out of their flex spending account for dozens of tests and were forced to bear direct costs of unnecessary tests, it would take about a week for that individual to start asking around to find a better value for their health care dollar. No one permits auto mechanics to run dozens of tests to diagnose car troubles, simply because the direct cost imposed on the consumer would force the consumer to seek better value for the money they pay. The imposition of direct costs upon consumers ensures information is available to consumers so they can assess the value received for payment and imposes costs of lost business on practioners who fail to deliver resonable value or seek to impose additional costs of unnecessary tests.
    By imposing government control of the health care system, the connection between those who pay for health care and those who must evaluate the value received for each health care dollar is further muddled. We can solve the problem of catastrophic care costs quite easily. We can just as easily restore the ability of consumers to seek the highest value for health care expenditurs while also forcing health care providers to offer greater value for their services. Why our current approach fails to achieve these goals is not surprise to me – When large pools of money are involved, we can count on politicians to exert control and direct as much money as possible toward their cronies and friends.

  4. Bill –
    What I set forth was a program identical to how auto insurance is run. Buy insurance to insure against catastrophic loss and self insure against common, expected events. Not even close to a single payer system. In fact, under what I suggested, the government isn’t even involved in health care decisions. The idea is to remove bureaucrats from any health care decisions.
    Only when determinations concerning the value received for services rendered are placed in the hands of the consumer will the market become more efficient. One doctor may charge $150 for a given test and another $200 for the same test, but the doctor charging $200 may offer better value (by not bundling other tests in with the one that is truly needed, by faster analysis or by a number of other methods).
    If i am a healthy individual in my 20’s or 30’s, the only reason I would buy health care is for catastrophic illness. If I’, in my 40’s or 50’s, exercise and don’t smoke, I should be able to receive benefit by choosing higher deductibles and paying lower premiums. (If I am a safe driver, don’t speed and don’t drive drunk, I gat the opportunity to choose higher deductibles for my car. The theory is similar).
    People need a financial incentive to eat sensibly, exercise regularly, stop smoking and drink only in moderation. Continuing to allow people to make bad personal health choices and then shifting the costs of doing so to others isn’t going to lower overall health costs. Allowing medical practioners to run every test imaginable to raise their billings isn’t going to lower overall health costs. Putting value decisions in the hands of consumers and giving incentives to lead more healthy lifestyles will lower overall health costs.

  5. Very interesting.
    I was an HIV-Educator for several years and, after a decade of study between the correlation of HIV-AIDS and AIDS-diagnosed ‘diseases’, your term “over diagnosed” can be applied to the problematic history of HIV-AIDS prophylaxsis, which many of us in the AIDS dissent community believe.

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