Preventing Patients From Feeling Trapped by the System

When a patient is ill, they come in to see you so that you can help them get well. Some patients demand tests, others demand medications but all patients seek quality care. Over 70% of patients stress that they value and trust doctors’ integrity; however, research shows that a large percentage of patients withhold information that is important to their own recovery. What is this so? Some patients may lie out of fear of being judged, while others may want to present themselves in a positive light. More and more often, patients are not only withholding information, but they are scared to go to the doctor for even the most minor issue because they fear of what it might lead to – unnecessary tests and procedures.

Between the years 1996 and 2010, over 70% of patients with acute bronchitis were prescribed unnecessary antibiotics and an increased exposure to CT scans was associated with increased rates of cancer. Moreover, over 25% of Medicare patients underwent unnecessary imaging test for uncomplicated lower back pain. Today, patients who visit the doctor for a headache or minor skin condition are recommended invasive biologics as the first course of treatment. Needless to say, unnecessary doctor visit and services account for over 10% of healthcare spending in the United States – nearly $300 billion dollars a year. Not only is this expensive, it can also lead to severe patient harms and risks. In an excerpt taken from “When Doctors Don’t Listen: How to Avoid Misdiagnoses and Unnecessary Tests”, the story told of 20-year-old Danielle’s experience is a clear indication of the risks of patients being forced into unnecessary procedures. Danielle is an example of a young woman who felt frightened and trapped by the medical system.

“Danielle is a 20-year old college student at the New England Conservatory. She came to the ER because of a headache. When she woke up this morning, her head hurt badly. Her mouth was dry, and when she tried to get up to go to the bathroom, she felt like she was getting faint.She attributed all of this to drinking too much the night before—normally she has one or two drinks when she’s out with friends; last night, it was her roommate’s birthday, and she did three or four shots and had a few beers on top of that.” “The last time I had a hangover was a couple of years ago, and I think this was how I felt then,” she says. “My roommate Jackie told me to drink lots of water.” “Throughout the day, she felt too nauseous to eat or drink. When the headache didn’t go away in the afternoon, she called her mother. She doesn’t have a doctor in Boston because she doesn’t have any other medical problems and still gets her yearly check-ups over the summer when she’s back home. Her mom convinced her to go to the ER to make sure everything was OK. Every provider who saw the Danielle knew exactly what she had: a hangover headache. She received some IV fluids and was texting away on her phone. However, her doctors were following a “pathway”, a cookbook recipe for what happens when someone comes in with a headache—they needed to “rule out” a bleeding in her brain”

“Danielle got ordered for a CAT scan of her head. It was negative.This was good news—or was it? Soon, she was being told that she needed to stay for a lumbar puncture: a spinal tap. The doctors began pulling out needles to put into her back. At some point, she excused herself to go to the bathroom. That was the last time she was seen: as far as we can tell, she escaped out the window of the bathroom. She left all of her clothes and shoes, and ran out in her hospital gown” – written by Leana Wen, emergency physician and co-author of “When Doctors Don’t Listen: How to Avoid Misdiagnoses and Unnecessary Tests.”

The reality is that over half of the doctors in the United States believe that patients cared for in their own medical practices receive too much medical care. Today, more than 1/3 of healthcare services are not making patients any healthier, but rather they are exposing them to harmful, unnecessary care. “I am seeing more and more patients who are told to have operations they don’t need. If patients have operations they don’t need, they risk having major problems – infections, paralysis, heart attacks, strokes” said Nancy Epstein, neurosurgeon. She went on to add “nobody reports the complications, so finding the real morbidity and mortality of these procedures is extremely difficult”. As a doctor, how can you do your best to prevent your patients from anticipating this?

Most recently, the “Choosing Wisely” campaign, associated with the American Board of Internal Medicine Foundation, was launched in order to bring forth attention to the dangers of healthcare overuse. The campaign focuses on professional and public education through means of videos and brochures in order to raise awareness and guarantee new advances towards quality management. Nowadays, more than 60 healthcare organizations have identified over 300 recommendations that should be addressed and the campaign continues to encourage both doctors and patients to discuss the issue of “overuse” or rather the use of unnecessary tests and treatments. Yet, before the launch of “Choosing Wisely”, researchers at RAND developed an approach to sorting healthcare into 4 categories – all the way from necessary services (where the benefits outweighed the risks for harm) to inappropriate services (where the risks for harm outweighed the benefits). Over the last few decades, the healthcare system has taken a turn towards reducing overuse of medical services by making multiple attempts on local and national levels in order to change the behaviors of doctors. For instance, the Centers for Disease Control and Prevention has recommended antimicrobial stewardship programs in order to improve patient care and efficiency, as well as reduce hospital costs. Moreover, The US Food and Drug Administration (FDA) has launched a proposal to reduce unnecessary exposure to radiation. Further improvements need to be made on a more national level; however, active research is continuously being practiced in order to overcome challenges of medical care overuse and provide solutions for coordinating care.

Millions and millions of healthcare decisions are made on a daily basis – from seeing a doctor and getting a medication prescribed to getting an annual physical and undergoing an invasive procedure. All of these decisions come with their own benefits, risks, and financial costs. Although most of these decisions are driven by medical research and expertise, there are too often those that are driven out of habit or improper incentive. Today, medical care in the United States is characterized by “overuse”, which in turn leads to direct and indirect harms to patients across the nation. Confronting such an immense issue requires substantial strides in individual doctor efforts as well as systemic transformations. Fortunately, most doctors are willing to limit access to expensive tests that are considered unnecessary and to waiver excessive costs. Still, there are those who continue to recommend testing and procedures out of fear of lawsuits and clinical uncertainty.

Being a doctor in today’s modern age of technological advancements, you have the chance to use such tools to your advantage, all the while ensuring patient safety. Better yet, you have the chance to raise awareness among patients about how to take better care of themselves. Too many Americans feel trapped by the medical system because even though they are receiving care, their health-related needs are not being put first but rather they are subject to unnecessary tests and procedures. Therefore, by continuously supporting campaigns such as “Choosing Wisely” and working together, both doctors and patients can make better decisions about when care is considered necessary and when it is considered unnecessary.