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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