Getting Medical Care That Makes Sense  

Good medical care doesn’t necessarily mean more or less medical care. Good medical care makes good sense and you can help make sure that’s what you get.

By: Dr. David L. Katz*

 

The Institute for Health Policy and Clinical Practice at the Dartmouth Medical School publishes a periodic Atlas of Health Care. In a recent edition, the costs and quality of care delivered to patients during the last two years of life were compared with surprising results.

Some of the best care, at premier institutions such as the Mayo Clinic, and the Cleveland Clinic, involved spending only about half as much money as similar care at other institutions. The differences related mostly to procedures, tests, and treatments that drove up the bill -- but did little to improve outcomes.

While the Atlas’ findings -- and their implications for Medicare -- are about the health care system at large, I believe there are important messages for the individual patient, too. In my experience, it’s often the individual patient, or family who most determines what kind of care is delivered.

Case in point: Some years ago I was working as an ER doctor while completing my training in Preventive Medicine. During an evening shift, an older gentleman came in on a gurney after a minor, “fender bender” car crash. I examined him carefully, and determined no bones were broken. The patient said, fine, while his 30-something son felt I was shortchanging his Dad by not ordering fancy tests. Minimally, he felt, his father “deserved” an x-ray!

I tried to talk him out of it, but as one of two physicians handling the ER where patients in adjacent rooms were trying pretty hard to die, it was my primary job to try just as hard not to let them! So there was no time for debate, and I gave in and ordered a battery of x-rays. Sure enough, no fractures -- although I suspect the poor gentleman may have glowed in the dark for a week!

I also recall the case of a medical student who saw me some years ago when I was working as a primary care physician at the Yale University Health Services. This young woman in her late 20s had felt a small and seemingly innocuous lump in her breast. She saw a doctor who thought it was nothing, but just to be sure ordered a mammogram. The mammogram showed nothing at the site of the lump, but raised a question about another area entirely. This prompted an ultrasound, which suggested that nothing much was wrong – but only a biopsy would prove that fact definitively.

There is a macabre humor shared among medical students and practitioners that keeps us sane through long, painful hospital shifts. With a tongue-in-cheek attitude, we refer to the odd but generally unimportant anatomical variants picked up by various scans as “incidentalomas” – findings that are not about anything we were looking for, but, nonetheless, commonly occur.

The trouble with incidentalomas, as in the case of the medical student, is that they often set you on a conveyor belt toward more and more testing and treatment you may not have needed! And if somewhere along the line you develop a complication from treatment, the cutting edge of modern medical technology has managed not only to find – but to create – a medical problem you didn’t have in the first place!

These two examples – and there are plenty more – highlight the fallacy that more care is better care. We also know, however, of serious instances in which insurance companies have denied care that should have been provided. What should you do?

The sweet spot in the middle is good for you and your family, and for the health care system as a whole. That’s when the care provided is the care that makes sense. To ensure such care, make sure everything done offers a greater likelihood of benefit than harm. When considering any test, procedure, or treatment, ask the following:

How will doing this likely change my outcomes, or choices?

What is the best – and worst – possible outcome associated with this, and what are you expecting?

Would you do this if you were the patient?

Is there an alternative that is more likely to do good, or less likely to do harm?

Is the result of this test definitive? The answer is almost always no, meaning the test should be interpreted in context. For example, if a 99.9 percent accurate pregnancy test were done on a million men, as many as one thousand positive results would all be wrong! In a million women, almost all of the positive results would be right. Same test, but different people! This principle is always important to consider.

Really good medical care is not about more, or less; it’s about the right stuff at the right time for the right reasons. Care that makes sense, and saves dollars, can be left to the health care “system.” But it can also begin by you speaking clearly to your health care provider and making GOOD sense with regard to the care you ask for – and insist on receiving.

* David L. Katz, MD, MPH, FACPM, FACP; Director, Prevention Research Center, Yale University School of Medicine and medical contributor for ABC News. He may be reached at www.davidkatzmd.com.)