More isn't better

Every day I see doctors, physicians assistants, and nurse practitioners relentlessly ordering medication after medication and test after test. Since I work in a closed and managed system, I can monitor and direct these providers to some extent. It seems, though, that the more I restrict/control the referrals, the more the providers order inappropriate laboratory tests and prescribe inappropriate medications. Those are harder to track and harder to put the brakes on.

Many people believe there is no harm to “a little blood test.” And many patients find comfort in getting lots of tests. Ordering tests must mean the doctor is thorough, is “looking for everything.” And if the patient gets a prescription doesn’t that mean the doctor knows what is wrong and is DOING SOMETHING for it?

Let’s look more closely at these suppositions. Say a patient comes to the doctor because he’s worried about some pain and burning in his upper abdomen and under his sternum. Many doctors would do a quick history and poke a bit on the patient’s stomach. They might order a bunch of lab tests, thinking they are being thorough. They might order a test, like an EGD (looking through a long tube at the patient’s esophagus and stomach), or a CT scan. Maybe they’d order a stress test to look at his heart. And an EKG. Maybe a chest x-ray. They probably would prescribe some medication.

So what is so wrong with practicing like this? In the medical field, it is called a “shotgun approach.” You just order every test to assess every possible diagnosis so as not to miss anything. After all, the blood work might suggest hidden bleeding or liver disease. And cardiovascular disease is extremely common. And what harm can there be in ordering a CT scan or in prescribing a pill?

In reality, talking with the patient, looking into his medical history and risk factors, should determine whether or not he is at risk of less obvious problems, not the blood work or other tests. There are risk tables published which doctors can use to assess whether a patient has a cardiovascular risk, for instance. Unfortunately, doctors rarely are trained in their use and don’t use them. Ordering lab tests is not a benign choice. The more lab tests done, especially in patients who are at low risk of a disease, the more likely the tests will not be accurate. Then the abnormal test results lead to more testing, more expense, more worry, more interventions.

These problems with laboratory testing apply to radiologic and other testing as well. Many doctors might do testing for our guy with heartburn, just to “rule out” more serious pathology. Again, in a patient with few or no suggestive symptoms, this testing is unlikely to be productive and often causes harm. For instance, a significant proportion of people who get CT scans of the abdomen have small tumors found in their adrenal glands. This finding is so common these tumors are nicknamed incidentalomas. The vast majority of these are benign, but you can’t tell if they are benign or cancerous on the CT scan. So then what do you do? You can repeat the CT scan in a few months to see if the tumor is growing. That doubles the patient’s already high exposure to radiation. You could do some other test, an MRI perhaps, at exponentially increasing cost, without much improving the quality of the information obtained. Or you could get a biopsy by doing surgery. That gets you a definitive diagnosis, proving, probably, that it is indeed, not cancer, but at a cost of $10,000 or more, and exposes the patient to all the side effects and risks that go with surgery. Yikes. All because of heartburn.

So doctors need to go back to being doctors. Since each diagnosis has a typical set of symptoms, a doctor should be able to match up his patient’s symptoms with the spectrum of symptoms that goes with a particular disease. In this case, if the patient eats fatty foods and gets pain under his lower right rib cage, that goes with gall bladder disease. If he gets heartburn after he eats a big meal and lies down in bed, that suggests acid reflux. If he gets upper abdominal pain after a drinking binge, that is probably gastritis. If he gets heartburn or pain under his sternum after eating spicy or acidic food or drinking coffee, that is probably acid reflux. If he gets crampy, lower left abdominal pain with alternating diarrhea and constipation, he most likely has irritable bowel syndrome. Of course you can’t count on patients having all the classic symptoms of a particular disorder, but when they do, there is no reason to do tons of testing to make the diagnosis. Taking the time to ask careful questions goes a tremendously long way towards making an accurate diagnosis.

So in our patient above, let’s assume he eats certain foods or lies down after a heavy meal and gets heartburn or pain under his sternum. There is absolutely no reason at that point to draw lab tests or order xrays or CT scans. The proper, safe, cost effective, and correct approach is to teach the patient about what is causing his symptoms (acid from the stomach sloshes into the esophagus and causes pain or spasm), and how his diet and behavior makes these symptoms worse (fatty foods and a full stomach cause the sphincter at the bottom of the esophagus to relax so the acid can slosh up there). Then you teach the patient what to do about these symptoms – like avoiding big meals in the evening, cutting down on fatty foods, avoiding caffeine, spicy foods, or acidic foods that may be aggravating his symptoms.

So why not start right out with medication and not waste time with all the diet change stuff? He’s probably not going to do it anyway. It would be a quick fix. The patient never needs to come back and the doctor has cured him. Perhaps the major down side to relying on medications rather than behavior change is that once the patient’s symptoms are relieved by a pill, he has no motivation to change the behaviors, like his diet choices, that lead to the problem in the first place. The doctor feels better writing the medication; the patient feels better taking it; but the cause of the problem is never addressed. His stomach contents still slosh into his esophagus but now they are not acidic enough to cause symptoms. Stop the medication, the symptoms start right up again.

And what if the patient is already taking four or five other pills for his diabetes and blood pressure and cholesterol? It is clear that the more medications you take the more likely it is they will interact in adverse ways. The more medications prescribed, the more difficult it is to be compliant with taking them all. And while the consequences of missing his medication for heartburn might not be serious, missing the blood pressure or diabetes medications could be disastrous.

But if the doctor doesn’t opt for the quick fix, it is imperative that the patient is followed over time. An older family doctor at my residency program taught us that we should never let the patient leave our office without a plan for him to come back. That is really important. If the initial diagnosis was wrong – the patient gets worse, his symptoms change, the behavioral approach didn’t help – the doctor will be able to reassess the case. A change in treatment might be in order. Or a change in diagnosis. Often as the patient learns more about potential diagnoses, and pays more attention to his symptoms, the picture of what is wrong changes. Maybe then a test or medication may be justified.

While heartburn may seem like a trivial diagnosis here, a slower, deliberate, thoughtful approach to diagnosis and treatment applies to many, if not most, patient complaints. In the practices I supervise, many doctors, nurse practitioners, and physicians assistants order blood tests for everything from aches and pains to rashes. They order MRIs for chronic headaches; radionuclide cardiac stress tests for stable angina; and prescribe lotions, creams, laxatives, anti-inflammatory medications, aspirin, Tylenol, stool softeners, cortisone cream, etc, for chronic use with refills that go on forever. One provider alone has managed to generate $100,000 a month in excessive prescribing. Just think how much money is wasted nationally, as this practice is repeated millions of times over.

Fixing the habits of doctors will be difficult. Our current medical system provides no incentives to doctors to change their ordering and prescribing habits. Patients are influenced by drug company advertising that suggests every problem should be treated with a pill. Patients also have misperceptions that tests are infallible and necessary. Many medical providers who are employed by hospitals are tacitly encouraged to order expensive testing, as the hospital provides these services and makes a solid profit on them. And the systems that encourage doctors to see 30 or more patients a day drive the over prescribing as well. It takes less time to write a prescription than to carefully identify the problem and work with the patient on effective management. The patients get seen but very little gets solved.

My job enables me to chip away at these practices, to question doctors’ assumptions, to develop logical and cost effective approaches to diagnosis and treatment. Hopefully, as financial pressure in the health care realm escalate, this kind of supervision will become more common. I think it already is necessary.