Have you ever seen a doctor for a simple complaint and been subjected to a plethora of blood tests, scans, x-rays, urine screens and other investigations, only to be told that you had something obvious that could have been diagnosed without a single test being performed? Perhaps you were sent home with a prescription, or maybe you were just told to go home and see if the symptoms resolved on their own? Many people would feel relieved to know that their doctor ruled out every possible diagnosis with all the various tests. Some people might feel frustrated that they had to be poked and scanned so many times, only to be told that they just needed to wait and see if they felt better in a few days or weeks.
An article recently published in the New York Times touched on this very topic. The author describes how medical testing has been on the increase for a while. He suggests that because of reductions in Medicare payments and the decline of reimbursement rates, doctors have to subject patients to many unnecessary tests just to break even. In addition, many people demand that doctors perform as many tests as possible. There’s a perception that more tests equals a more thorough investigation, and a higher quality physician.
I think there is some truth to his argument, but I think the problem is multifactorial. The number of medical investigations that can be performed has increased substantially over the past few years, for many different reasons. Part of the problem, however, is that many of these tests don’t necessarily rule in or rule out any diagnoses. While I’m not arguing that these tests aren’t important, I’m just saying that they don’t always aid in diagnosing a patient or even lead to a treatment plan.
All of these tests come at a hefty price. According to the article, the overuse of healthcare services probably cost hundreds of billions of dollars last year. And the data suggest that this increase in services is not causing a concomitant increase in the quality of healthcare in the U.S.
The question of whether or not to pay for expensive medical testing was really drilled home with me during the past two months. I’ve been rotating at a hospital in Dominica with much fewer resources than U.S. hospitals. In addition, the average patient is not wealthy and does not have health insurance. Not long ago, I met an elderly gentleman with obvious signs of a stroke. Unfortunately, he could not afford a CT scan, nor an MRI, for which he’d have to be sent off island. We ended up doing the standard interventions with the assumption that he did in fact have a stroke. He ended up faring about as well as he would have if he had the proper diagnostic tests. Obviously, it might not have turned out this well. It’s possible that he could have needed a surgical intervention, but since we don’t have a neurosurgeon on the island, he wouldn’t have been able to get the surgery anyway.
I’ve been amazed at how well the hospital here runs, even with very little means. Patients still get a good quality of care. Of course there are exceptions, but many patients are successfully treated at very low costs. The clinicians at the hospital are all too aware of the deficits, but they use low-tech methods of good history taking and physical examination to diagnose patients.
Because of the current structure of the healthcare system in the States, I don’t predict that rising healthcare costs and the misuse of diagnostic testing will decrease any time soon. But I think that as doctors and future doctors, we should all do our best to not add to the problem. The next time a patient comes in and we consider performing a huge barrage of investigations, we should ask ourselves how much information we really stand to gain, and whether or not it will actually benefit the patient.
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It’s true. I’ve lived on this island for 589 days. Now, I only have 16 more to go before I return to the land of excess milk and honey, processed food, pollution, big cars, and bad health. I have very mixed feelings about the whole thing. Anyway, today I have my very last practical exam ever!! It’s going to be the most difficult one to date, but by now, I kind of feel like a pro at them. Thursday is my last written exam of the semester. I can almost taste the sushi!
My name is Kendra and I am a newly minted doctor about to begin my residency in Psychiatry at 
