Medical Tuesday Blog
Medical Gluttony: Unnecessary Medical Testing-What is Ultimate Cause?
When I was in the US Air Force in the 1960s in charge of the Pulmonary Clinic, Pulmonary Function Lab and the Allergy Testing program, I was called to the Operating Suite to help manage a cardiac arrest that occurred during surgery under anesthesia. When I arrived, the chest was wide opened and the surgeon had adequately compressed the heart to restore circulation to the brain. We managed the respirator, measured the blood oxygen, adjusted the ventilator appropriately and kept the oxygen level normal. The Electrocardiogram was normalizing.
The operating surgeon began to close the pericardial sack, began to close the thoracic cage mending the lungs as needed, and brought the chest wall with its ribs and muscles together and place the final wire sutures that could withstand the force of breathing or coughing. The veteran survived and was even able to return to flying status inasmuch as he was a pilot and had his own airplane.
As we were running into the noon hour, I called back to my clinic to have them reschedule all the non-urgent or elective patients. I would see those with an urgent problem during my lunch hour.
I was somewhat taken aback at the type of patients that waited more than two hours to see me. I expected a number of severe diabetics, cardiac or respiratory failure patients. They had all been rescheduled. But, lo and behold, the half dozen patients that thought they had an urgent problem that needed to be addressed that day were the patients with back pain of 10, 15, 20 or more years duration. They had charts three to five inches thick which recorded every possible test and x-ray that could be performed. Every indicated test had been done a number of times and they still thought that something serious had been missed. Attorneys would pay me a thousand dollars to review a chart that size. This could take most of one day; an impossible task on a lunch time urgent appointment. Even though they may have come in monthly or quarterly for many years, with no measurable change in their condition, their pain that day was a crisis in their lives. Some just told me they would like to start over from scratch—just order a bunch of x-rays and tests and they would be back for the results.
Perusing the charts, I estimated some had had over $100,000 to $200,000 worth of testing done and they still felt something major had been missed. What possibly could their physicians have missed? What did the patients think was missed?
I saw the same phenomenon when I entered private practice after my USAF experience. Patients didn’t want me to see their prior medical records. They thought that would dampen my interest in checking out all possibilities.
The attitude was basically, “What does it matter if it costs another $100,000. Isn’t it free? Yes, I know someone else is paying for it. But it’s free to me.”
Where is the disconnect?
Didn’t the prior doctor explain the mechanism of the pain and that some pains are permanent but can be controlled with medications?
Hospitals, HMOs and insurance carriers had nurses on call for evening, night, and urgent daytime calls. The patients were generally equally unhappy with this arrangement. They couldn’t understand how a nurse who didn’t see them could possibly understand their problem and provide an explanation. This administrative mechanism was thought by those in charge of the hospital, HMO or insurance system, to be a way to save money. The person in charge could in fact be a physician administrator. Patients, in general, hold the physician responsible for not fixing the health care system. Meanwhile, HMOs and insurance programs penalize doctors for not seeing patients fast enough which doesn’t allow time for an adequate Doctor/patient interaction—which would solve most anxiety related problems.
It is hard to fix a system when you are the scapegoat and fixing it would put your job in jeopardy. Physician unions and the medical associations do not appreciate this change as having anything to do with doctors not being in-charge of their service; in charge of their medical business; and having become employees subject to dismissal or firing.