Tuesday, April 6, 2010
Why peace of mind is so expensive in health care
The cost of medical care is high because the body is complicated and doctors and patients hate ambiguity. The cost is high because a missed diagnosis can lead to death and a large lawsuit. The cost is high because we have many specialists who view the body in tiny pieces and want to feel 100% correct about their piece. Let me give you a real life example:
My patient, Rick, is a brilliant attorney. He has insulin dependent diabetes and heart disease and he takes good care of his health. He pointed out that his lower leg (around his shin) was red and swelling and then forming a painless hard lump. The exam showed a little redness, a tiny puffiness and a small firm lump in his leg tissue. I ordered some blood tests to make sure his diabetes was under control and to look for infection.
Because I couldn't put a name on it and I was unwilling to say, "Let's watch it; I don't think it is anything serious," I told him to ask his dermatologist, who he was seeing anyway. The dermatologist said it wasn't in the skin, it was deeper, so he was referred to an orthopedic specialist. The ortho doctor said he wasn't sure and did an X-ray. Since the bone was fine, he ordered an MRI. The MRI showed no tumor or vascular problem.
After several months of doctor's visits and spending $2,626.40, we have no diagnosis and I realize I should have said, "Lets watch it; I don't think it is anything serious." Rick has high deductible health insurance. He pays $4,800 annually out-of-pocket before insurance kicks in. He usually hits his deductible because of the diabetes medication and tests. None of his doctors own imaging centers or labs. We don't make any money on ordering tests. We all wanted to help the patient in the only way we were trained to do.
I asked him if he would have been satisfied with me saying, "Let's watch it; I don't think it is anything serious," after that first visit. He said, "Yes, I trust you." But he still has a leg that is swelling and a lump that forms daily. The symptoms are mild but strange.
Now we will watch it, and it will probably go away and we'll never know what it was. That happens more often than not. We can all rest better knowing it is not serious, but achieving our collective "peace of mind" is one reason medical costs are so high.
Toni Brayer, FACP, is an ACP Internist editorial board member who blogs at EverythingHealth, designed to address the rapid changes in science, medicine, health and healing in the 21st Century.
Labels: Diabetes, health care cost, health insurance
posted by Toni Brayer, MD at
1:00 PM
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Members of the American College of Physicians contribute posts from their own sites to ACP Internist and ACP Hospitalist. Contributors include:
Albert Fuchs, MD
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.
David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.
DrDialogue
Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.
Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.
Everything Health
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.
FutureDocs
Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.
Glass Hospital
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.
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Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.
I'm dok
ACP Member Mike Aref, MD, PhD, ACP Member, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.
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William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.
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Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.
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Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.
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Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.
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Elaine Schattner, MD, ACP Member, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.
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Rob Lamberts, MD, ACP Member, a med-peds and general practice internist, returns with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind).
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David M. Sack, MD, FACP, practices general gastroenterology at a small community hospital in Connecticut. His blog is a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.
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Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.
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Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.
White Coat Underground
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.
Other blogs of note:
American Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.
Clinical Correlations
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.
db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.
Interact MD
Michael Benjamin, MD, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.
PLoS Blog
The Public Library of Science's open access materials include a blog.
White Coat Rants
One of the most popular anonymous blogs written by an emergency room physician.
2 Comments:
I am in this position all the time. Back in the day I guess all you could do was watch and wait. But now we have MRI's! And we have been trained to come up with a diagnosis. And it's just human nature to want to know exactly what's causing things!
This is so true. If you watch and wait and it turns out to be a serious problem that could have been diagnosed earlier with a test...you are toast in the courtroom. "Failure to diagnose" is the most common malpractice claim against Internal Medicine.
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