Q: What Scares Doctors? A: Being the Patient

What insiders know about our health-care system that the rest of us need to learn

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But their innate resistance to treatment carries a message for the rest of us as well. It requires almost a stroke of luck to enter a U.S. hospital and receive precisely the right treatment--no more, and no less. A landmark Rand Corp. study published in 2003 found that adults in the U.S. received, on average, just 54.9% of recommended care for their conditions. Average blood sugar was not measured regularly for 24% of diabetes patients. More than half of all people with hypertension did not have their blood pressure under control; one third of asthma patients eligible to get inhaled steroids did not get them.

Even more insidious is the danger of overtreatment. With well-insured patients inclined toward hypervigilance, doctors afraid of missing something and a reimbursement system that rewards testing over talking, there is embedded in the system a dangerous impulse toward excess. Specialists are typically paid much more to do a procedure than the family doctor who takes the time to talk through the treatment options. A doctor who does a biopsy may be paid as much as $1,600 for 15 minutes' work, notes Dr. Jerome Groopman of Harvard Medical School. "If you're an internist, you can easily spend an hour with a family where a member has been diagnosed with Alzheimer's or breast cancer, and be paid $100. So there's this disconnect between what's valued and reimbursement."

And yet sometimes, talking is the more important and certainly the safer treatment. Ten more minutes spent taking a family history can reveal clues that prevent a misdiagnosis or an unnecessary test; that childhood injury, that illness during a trip abroad, that family history of excessive bleeding. When the orthopedist hears that Mary broke her leg when she was 2 years old, he can hope that the dark spot on her tibia may not be a deadly bone cancer but something more benign, like a Brodie's abscess. He may still remove the abscess but not have to do a whole invasive tumor workup. Doctors talk privately about the cost--economic and physical--of the bias toward overtesting. They are less beguiled by flashy technology, more aware of the risks of even simple procedures and thus more willing to trust their doctor's instincts. If everything in his experience tells your doctor that the lump on the back of your hand is a ganglion and not a malignant tumor, it may not make sense to run the risk that goes with surgical excision. If your baby is born after a very long labor but shows no sign of infection, then agreeing to a spinal tap just to be sure may not always be worth the risk.

Doctors will argue privately that there is not enough watchful waiting and re-examination anymore, partly because patience literally doesn't pay. "The areas in the U.S. with the highest rates of use of hospital beds, intensive-care units, specialist consultations and invasive testing don't have the best quality of care and outcomes," says Berwick. "In fact, they often have the worst. It would be a great advance in both quality and cost if somehow the American public came to understand that 'more care' is not by any means always 'better care,' and that new technologies and hospital stays can sometimes harm more than they help."


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