The first day of medical school, the class was told to "Read Reader's Digest; your patients will and if you do not know what's in, they will lose confidence in your competence as their physician." That was in 1968. Today, keeping up with medical information in the lay media is more important than ever and the sources of information include not only Reader's Digest, but TV news, papers, Medscape, WebMD, Wikipedia, Google, etc., etc., etc. As a means to controlling medical costs, the government is trying to identify and limit unnecessary medical testing and in this quest, there have been an escalating number of articles concerning the validity of testing. A few examples are:
• A Consumer Reports article noted that in the last five years, 44 percent of healthy adults with no heart disease risk factors had a heart-specific screening test other than routine blood pressure monitoring and blood work, e.g., an electrocardiogram (EKG) and an exercise stress test.
• A research report funded by the National Cancer Institute that claims women who have a screening mammogram every other year are substantially less likely than those who opt for annual screening to experience false-positive results and biopsies that turn out to be unnecessary.
• A recent report stated that women should wait until 50 to get a mammogram, while in the past it was recommended that women start receiving regular mammograms beginning at age 40. Chest X-rays also face scrutiny.
• A study revealed that annual lung cancer screening with a chest X-ray doesn't reduce deaths from the disease as it offers no benefit for early detection. In addition, the United States Preventive Services Task Force recommended that men no longer receive a PSA blood test to screen for prostate cancer since it has not been proven to save lives.
• There have also been recent investigations reporting the risk of Vitamin D on the heart and that taking too much can make it beat too fast and out of rhythm, a condition called atrial fibrillation.
Research is critical to understand, treat ailments and save lives. However, research findings can also be preliminary and confusing. It is like the Woody Allen movie "Sleeper" -- hindsight is needed to confirm what works and what doesn't. In addition to the above, the media have bombarded the public recently, to name a few:
• Take vitamin E -- don't take vitamin E. • Take selenium -- don't take selenium it may increase cancer risk. • Take medication for osteoporosis -- medication for osteoporosis can increase the risk of fractures. • Take vitamins supplements -- vitamin supplements are useless.
The new ACO model rewards physicians for a reduction in costs to diagnose and treat a patient. There are financial incentives to perform less medical testing provided, of course, the outcome is satisfactory. These published investigations are causing physicians and patients to question everything from mammograms for identifying breast cancer to PSA testing for identifying prostate cancer. Physicians are given guidelines and algorithms. If they follow the guidelines they will be reimbursed and if they do not, they are required to document why. Either way, reimbursement will be linked to the patient outcome.
Treating patients requires satisfying payers in addition to (if not instead of) satisfying patients. What must be remembered, both by physicians and patients and particularly by oversight agencies, is that treatment plans cannot be based only on the underlying condition. Patients differ as to their ability and willingness to comply with suggested treatment and, therefore, individual treatment plans are required.
Physicians are being asked more and more to make decisions based on published studies and guidelines, as well as insurance authorizations for testing, sometimes in lieu of actually taking care or their patients. This "cookbook" approach is resulting increasingly in physicians delegating initial and follow up patient visits to their PAs and nurse practitioners (NP). These physician extenders are usually more comfortable with "listening" to patients, providing the required "documentation" and following "guidelines." While the skill set and knowledge of these educated individuals is excellent, it would be unfortunate if the patient-doctor relationship is eventually compromised.
The Internet, like the Reader's Digest of the past, plays a role in this patient-doctor relationship. It is possible that all this medical information available to the patient is contributing to the rising health care costs. Patients are much more educated than in the past and with access to this vast amount of medical information, they are prone to self-diagnose. Patients come to their doctor's visit armed with information gleaned from the Internet. They feel entitled and in need of every test available.
Physicians must listen to their patients' concerns and complaints. However, the physician is obligated to do what is right for the patient. Some physicians, interested in volume and bottom line, often oblige the patient's request for specific tests, e.g., heart exam, an MRI, an EKG, etc., as it is more expedient and allows them to move on to their next patient. Some of the tests being requested, however, may not be indicated or validated or even helpful. Hopefully, the tests are not harmful, although, sometimes the results, especially when equivocal, can lead to anxiety and angst and probably further testing.
In some instances, the results of research reach the media, prematurely. Typically, initial research is based on a small and select patient group and the results and conclusions often have a "disclaimer" about the sample or method used. For instance, one mammogram study cautions that "the small number of women in the study who received a diagnosis of invasive breast cancer prevents firm conclusions about the effectiveness of one screening schedules' effectiveness over another." The Consumer Reports article states, "In some cases, people had tests that have little evidence of benefit; in other cases, the tests might have been beneficial in older patients with a history of smoking, for instance."
Research results are based on specific parameters. Conclusions of these studies must be carefully considered when applied to a specific patient. Research is just that, research, preliminary observations on which further investigations are based. These initial results inform and educate the medical community on what tests may be beneficial, what will or will not help a specific condition. It is up to the physician to determine appropriate next steps, including what tests or interventions are indicated based on a patient's signs and symptoms. These decisions to test or not to test should be based on good medicine, not whether the test is desired by the patient or if the test is reimbursable. This is where the physician-patient relationship is essential. Research should guide decision-making but not be the end all. Physicians need to know how the "research findings" might be applied in a patient's individual circumstance. Patients must be informed to understand how their personal history might affect medical decision making, e.g., family history of breast or prostate cancer.
Published medical information and research results must be balanced with patient expectations and with the knowledge that medical education and physician experience provides.