Wednesday, June 24, 2009

Patients' rights

I went for my routine physical last week, not that I believe in routine physicals. But I bit the bullet and went, largely to appease those around me who believe in their usefulness, and to make sure that my doctor still remembers me. After a thorough clinical examination and a lovely chat, my doctor asked me what labs I might be interested in checking. Knowing the US Preventive Services Task Force's recommendations for screening a patient like me, I opted to get no lab studies. I further informed my physician that my reading of the literature has convinced me that, given my risk factor profile, I do not wish to have any more screening mammograms until the age of 50. I also had to apologize to her, knowing that the pay-for-performance rules of my insurer will withhold a certain amount of her quality care bonus payment for not obtaining annual screening mammography.

I tell this story because it illustrates a couple of important points. First, since I am an uber-informed consumer, I have the wherewithal to make educated decisions at every step of my encounter with the healthcare system. An additional societal benefit is that, as a responsible consumer, I can help drive down costs by personally promoting efficiency. Of course, it took not only 10 years of post-graduate schooling and training, but also an additional decade of researching to develop the skill to navigate this complex and convoluted environment. What follows is a realization that the politicians' call for healthcare consumer empowerment is more political posturing than a credible policy directive. As a very competent physician friend of mine pointed out to me, you cannot become a medical expert on Google -- the information and decisions are esoteric and specialized to the point where even physicians are not always aware of their intricacies. Not too comforting, hey?

So, what are the choices? A peer review system is something to advocate for, but more on this later. I guess the inevitable conclusion is that, at least to a degree, patients have to allow for substituted judgment by their healthcare providers. And this brings me to my second point. The practice of medicine has become defensive. What I mean by this is that every patient to a certain extent represents a potential law suit. And this is certainly a direct result of egregious misuse of our tort system, intended to be an equalizing instrument within our society. I know this is a worn justification for runaway healthcare costs and dysfunctional physician behavior, but it is not entirely imagined. Our culture deplores risk, and we as consumers have been conditioned by clever marketing that to protect ourselves from such risks, real or imagined, as burglaries and kidnappings, all it takes is more spending on the latest gadgets. We have also adopted this attitude in the way we think about healthcare: if a mammogram is good at detecting an early cancer, an MRI or anything digital must be even better, right? We worship at the shrine of technology and use our children's future as the sacrificial lamb to bargain for a disease-free passage into old age. And so, if a physician uses her judgment to recommend against a mammogram, and, against all known odds, a cancer is subsequently discovered, a law suit usually results, even if the decision was not due to negligence, but rather because of understanding the patient in the context of what is known about her risk.

People who know me well, including my students, know that I love to think in threes. So, in that spirit I am going to make a third point. This is something that eludes not only the lay public, but also government agencies, insurers and practitioners alike. I am of course talking of the risks and consequences of a false positive result. As an example, I am talking about getting a "routine" urinalysis in a healthy woman, discovering what we call an asymptomatic bacteruria (bacteria in the urine not causing an infection), treating her with an antibiotic, which in turn results in a serious intestinal infection with the bacterium Clostridium difficile requiring a surgery to remove her colon in order to save her life. This is but a small illustration of how doing more, although well-intentioned, can derail not just a sensible way of practicing medicine, but indeed a person's entire life. A similar scenario can be imagined with, yes, you guessed it, mammography: a lesion detected, resulting in an invasive procedure, resulting in an infection followed by multiple complications and further interventions, while the lesion proves to be entirely benign. And then, of course, the same insurance company that may be dictating a screening mammogram as a quality measure to determine the physician's reimbursement, subjects the said patient to a rescission (withdrawal of insurance coverage due to a pre-existing condition).

So, as with everything else in life, the adage "everything in moderation" applies to your dose of healthcare. It is your right as a patient!

1 comment:

  1. Marya,
    Just read this--truly eloquent. I have yet to establish with a PCP after 2 years here, wince at my probably needless mammogram (emotionally, not physically), and surprise my gyn when I push back against her suggestion that I get yearly CA125 and pelvic u/s. Jeanna