Saturday, March 13, 2010

Too many medical tests, too little doctor time and what is the poor patient to think or do?

The Star Leger reported in its article reprinted from the Associated Press from Lindsay Tanner ( that we are over tested, over doctored and the rationale for what we do is truly broken.  More and more are being written about how the current model, especially the cancer screening models are coming under fire for over promising and under delivering when it comes to life expectancy.  Statistics do not lie although because health reform will likely affect our current ways of doing things, there will be winners, losers and hopefully in the end the patient benefits.  Some of our patients have heard me say that right now, our cancer detection methods are like whack a mole because we have people and do tests that may detect a problem and then do more tests or interventions (hit it) to try and see if they get it or if it moves (either are wrong in our assumption - found a breast lump for instance that is normal but had a biopsy to determine this for example) with the implied idea that if it is cancer and it is not too aggressive, we can poison you with chemo and radiate you until the cancer cries uncle (hopefully).  I hope you get the analogy which I use because until we actually understand what cancer really is (see my prev post for some possible ideas on this), these tests and their interventions may be harmful or helpful and may disfigure you for life. Cancer is just one example but it all starts with the primary care model and how we use it.

Primary care heavy states (fewer specialists) statistically show lower costs, fewer specialist referrals with therefore fewer interventions and overall, the same or better outcomes.  One HMO in Illinois uses a chiropractic primary care model  which has shown to cost the system up to 50% less overall with high satisfaction from the public (yes, primary care can be drug and vaccination free).  The chiropractors understand the musculoskeletal system better which comprises of many of the complaints and I have always said that one of the primary reasons our health care system is a monopoly is that we have the disease based model  feeding the disease based model where in other countries, acupuncturists, natropaths and other styles of primary care do primary care well and cost effectively.  In our current model, most regular family practitioners do not know musculoskeletal very well and so they sent it out.  From a chiropractors perspective, we can very well save the system millions by being the primary specialists in this realm and since many symptom complexes that are diagnosed with a disease differential diagnosis are actually musculoskeletally based, these patients often endure thousands of dollars of unnecessary tests and end up on drugs that may relieve their problems but do not solve them.  Conversely, chiropractors and other non disease based model practitioners are more capable to rule our musculosleketal and enlist disease based model practitioners like our family doctors and internists who can likely manage or co manage these patients.  The co management idea is likely one we will probably see more of in the future.

The incentives are perverse.  Why does a primary care doctor get penalized financially for spending time (a complaint of geritricians who need to spend time with their elderly patients).  If we paid them for their time and allowed them the opportunity to get paid well for it, there would likely be fewer tests.  We also should have some tort reform to limit payouts for pain and suffering but also, if we had fewer specialist referrals and fewer procedures, the patient would benefit and it would overall cost less.  On the other side, if we made fewer referrals to fewer specialists, are all those disease specialists necessary and what will happen to our hospitals if fewer people were admitted because the new model just did not do this as much?  Surely, super high paid specialists and facilities would suffer but as our needs change, so must the systems that feed off of it.  If we had less testing, many of these companies who do these including the many MRI centers would now be forced to consolidate.  As you can see, real reform is not rationing, but better doctoring which includes primary care doctors who are compensated for patient time and care and other types of primary care that work together to help patients and their needs.  The losers unfortunately would be those that benefit from the over testing and the unnecessary testing which is fear mongering at its worst.  The problem is why our health care system is the 6 largest force in our economy.  Does anyone in congress have the political nerve to put a dent in this overpriced and under achieving system?

The insurance companies are not the innocent victims of this because in our office, they ration care by using outside companies that pervert the word medical necessity for chronic patients with chronic problems.  In their world, if someone has used our services alot over the past couple of years as we problem solved their situation and improved their quality of life, they abuse us and the patient by asking for their notes, wanting appeals and concentrating on cost, rather than the patients wellbeing.  Quite honestly, we are not the cost drivers in the system and are just a blip on the screen of a much bigger healthcare ocean.  Since our office handles many difficult chronic pain cases, we are often subjected this this more commonly.  The insurance models are why specialists are paid more and generalists are paid less.  Like the government, when they have poorly managed their pool, the pass the cost on to us giving us less but charging us more each year. Somehow, they still manage to make billions and reward their management.  Shouldn't we just pay the doctor better instead since they spend 30% on saying no.  This is why I believe we need a public option because they do indeed ration our care making sure to turn a profit and as capitolism goes, make money for their investors (  Why is insurance company rationing ok and government rationing bad? If it is ok for them to say yes or no to cancer treatments or other treatments supported by research, they are not the boogey man but if the government does it and it does cost us less without the profit motive being the real reason, ultimately, we will have a cleaner and better health care system that makes more sense.  I actually believe that if government without a profit motive did our cancer research, we would likely find the common link faster because finding the reason behind the problem is indeed the solution we need and is like minting money, since true prevention does not seek a cure and the game of whack a mole is not the game of prevention which is the key.

My future vision of healthcare should be true prevention based, without the marketing (drug ads on television for every symptom you have), with a healthier public (healthy food promotion without subsidizing farmers to grow certain things and not grow others but raising demand for fresher and better foods and subsidizing this way).  Changing the publics ideas about things like our current model will take years but if we start now, it will assure us of living better, longer and the end of life needs to be embraced as part of the (disney said it best)  great circle of life.  We are born, we live out our lives and then eventually we go.  The quality of life is paramount (not the quantity, the quality) and it is not necessary to be on drugs like lipitor if it helps you live an additional year with tons of problems the drug creates since it is not really preventative).  When we are in school, we will screen not only for scoliosis but for postural problems and body asymmetry which will help children grow into adults with fewer problems in the musculoskeletal system.  Perhaps our video games will be built in the future on an exercise bike so we can sit and play only as long as we pedal assuring better fitness.  At the beginning of life, we will make wiser decisions on when we use technology to prolong a life that has little change, and at the end of life we will accept the inevitable, and rather than throw technology at it, have a more humane end point.  Doctors will be allowed to be doctors and there will be fewer lawsuits because fewer drugs will be needed and fewer procedures will injure fewer patients.  We will leave with the same body parts we came into the world with because most knee and hip replacements can be prevented if in school, we found the problems early and something as simple as an orthotic could have changed our future.

Wow, this is alot to think about, isn't it.  I welcome your comments.  Check out our web site at and join our twitter feed.  Thanks for reading.