How can patients voice discomfort with excess services?

The cabdriver pulled up to take me to the community hospital where I work several weeks each year. Settling into the back seat, I made my request before he reached the intersection: “Could you please take 93 South?” He was quick to ask me why, and I hesitated. I had taken this route dozens of times and had usually found it to be faster than the alternative, I said, but what if there was something he understood, with his superior highway smarts and his advanced navigation technology, that eclipsed my knowledge? He nodded at my explanation and took the right onto the highway.

A few minutes into our ride, I picked up my cell phone and my mother opened with her usual dramatic flourish. This time: “Ishani, you’re never going to fix your health care cost crisis.” Earlier that day, she had gone to her annual physical with her primary care physician (PCP) of more than a decade. As in the previous year’s visit, her doctor ordered an electrocardiogram (EKG, or heart tracing) even though my mother has no history of heart disease. She gave my mother a lab slip to check her blood counts and electrolytes – tests that have limited value when performed routinely and not for a specific medical issue. She referred my mother to a gynecologist for a pap smear even though she is older than 65 (the guideline-recommended age to stop this screening for cervical cancer).

As patients, we tend to equate doing with caring. We feel nurtured when we get more – more tests, more treatments. We like doctors who are thorough and pull out all the stops for us. (To this point, my mother tells me that her PCP gets only the highest reviews on doctor rating websites). But more isn’t always better and can be harmful to us as individuals (by way of unnecessary side effects and anxiety-producing diagnoses) and as a society (by way of soaring health care costs).

In the relatively few areas of medicine in which there is good research to point us to the right amount of care, it is absolutely the doctor’s responsibility to adhere to evidence-based guidelines and spare her patients the burden of doing too much. But what can patients do? Even my mother, a relatively savvy patient primed by her daughter’s frequent rants on these issues, had a hard time voicing her discomfort with excess services. She tried to bypass the EKG: “Do you really want me to get this?” Not surprisingly, the answer was yes. She got the blood tests because she wasn’t sure which ones were necessary and which weren’t. She let the gynecology referral slip, at least, because who hasn’t?

I don’t think the solution is to accost one’s doctor about a questionable offering (let’s be honest, it’s hard for us not to get defensive; and in many situations, our years of training and experience may provide a legitimate rationale). But it is perfectly reasonable to raise the question and to use a credible source to support it. I’m encouraged by a slow but noticeable trend in the media and in public outreach efforts toward acknowledging the harms of over-testing and over-treating while giving patients tools to guard against these ills (The American Board of Internal Medicine Foundation’s Choosing Wisely Campaign is a great example). Like that cabdriver, the doctor may just nod and acknowledge a point well made.

Ishani Ganguli is a journalist and an internal medicine-primary care resident who blogs at The Boston Globe’s Short White Coat, where this article originally appeared. 

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  • Guest

    They can voice with their wallets. Want me to have this test of limited value that I will pay a portion of out of pocket? Explain why exactly. If I’m not satisfied with the explanation, I won’t do it, and no one makes any money. If more of us start doing this we might start to see things change.

    • azmd

      An excellent suggestion. People appear not to recognize that in the vast majority of cases, PCPs who order unneccessary tests and studies do not earn extra money by doing so. Rather, they are seeking to protect themselves from the potential liability that could result from failing to discover an obscure medical condition. If the doctor makes the suggestion and you refuse the test, the doctor is still covered and you saved the money. It’s a win-win.

      • Guest

        Correct. I did not mean to infer that the docs recommending the test made any money off the test; as you stated that large majority is defensive. Thanks for clarifying.

  • Jean Oliver

    How about people quit going in for annual physicals. Recent studies have shown that they do nothing to improve longevity. If a person has a chronic condition, like diabetes, heart disease, etc., they can surely be monitored by a doctor on an as needed basis but as far as healthy individuals going in to be checked every year I think it is a big oversell. If people got more involved in their “care” and kept up with the recommended screening guidelines they could surely visit a doctor every 3-5 years to stay current with these if they choose to do them. Actually cancer screenings are purely optional and should be presented to a patient by not only stressing their benefits but also their risks and limitations and that includes PAP tests, mammograms, PSA tests. I think one of the reasons our health care costs have skyrocketed is because the health care industry as well as the media have done a lot of disease mongering and oversell of tests with little balance on the downside of it all. You almost can’t blame patients for not questioning it all or for buying into the whole scenario. Now that we are all looking at costs its like trying to backpedal against the previous over testing, over screening machine. It will take many years to turn the tide, if ever.

  • rtpinfla

    It is extremely hard to decline tests.

    I am a physician and my wife has a masters degree in nursing with a heavy dose of statistics in her training so we understand the risk/benefits of all tests and procedures. She is polite but firm and has very good, informed reasoning behind her decisions, but she still gets A LOT of push back. This was the case when we declined the “quad screen” when she was pregnant-our reasoning was the risk of a false positive and the fact that we would not terminate the pregnancy regardless of the test result- More concerning was the when the recommendations she receives go against published guidelines. (e.g. recommending a colposcopy rather than a repeat pap for ascus. After a hard fought battle, she had a normal pap 3 month later, and even then they wanted to do another pap in a month “just to be sure that is wasn’t a false negative”).
    Knowing what I know about my wife’s experiences, I don’t see how a patient without a medical background stands a chance, especially when they are being told how important these tests are to prevent cancer, strokes, heart attacks, and all manner of bad things. To be sure, some screenings and tests are appropriate, but we as physicians need to take the lead on this issue and make sure we are making the appropriate recommendations for the right reasons.

  • Michelle

    I find that the doctors who are least confident order the most tests.

    A while ago my husband had bad pain in his jaw and headaches, and he went to visit the PCP he had used when single. I was wholly unimpressed, but waited to see what the doctor had to say. After examining him the doctor was at a loss, so he wrote prescriptions for a battery of tests, including an overnight sleep study at a clinic with which the PCP is affiliated.
    I insisted that before running any tests he visit my PCP. My doctor took one look and said, it’s referred pain from your tooth. Go to the dentist. My husband needed a root canal.
    I’ve since learned to question the most those who order excess testing.

  • southerndoc1

    Your mother’s PCP doesn’t do Pap smears? That alone is reason enough to find a new doctor ASAP.

  • meyati

    The peripheral services at the hospital have contracts with hospitals and clinics. The more tests they perform, the more money everybody makes. A grandson had a serious head injury. They kept taking X-Ray after X-Ray. My grandson was in agony and I begged them to stop. The reply was that they had a contract to do so many a month and procedure-and they had to do this, or the rural hospital would lose their services and all patients would suffer. The doctor told them to take X-Rays of him. That the air ambulance was coming to transport my grandson to the regional trauma center, where he’d have CAT scans-and these were really worthless. That’s one reason for over testing-like bone density on older women. The fancy calcium supplements cause many bad to severe side-effects. Many people actually seem to expect their doctors to be like witch doctors or faith healers- run a test and thou shall be healed. I tell my doctors that if I fall and don’t break a bone- my bones are fine-if they break-they aren’t-unless it’s something extreme like having a horse fall on you while in the mountain or a bad car wreck. I drank lots of milk and ate cheese in my formative years, did weight bearing exercises and hobbies-like pushing wheelbarrows full of manure or bricks, etc. I do lift weights- light-small ones, but they do me well.