American College of Physicians: Internal Medicine — Doctors for Adults ®

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Monday, June 10, 2013

The grueling request for 'more'

I remember going to see the movie "Oliver" in the theater when I was a kid. Since this was my first movie in a theater, my mom made me a treat: a bag full of raisins and chocolate chips (Raisinets for Dutch people) and sent me there with my sister. It was a fine film, with Oliver getting kicked out of the orphanage when he wanted more gruel, the dastardly Bill Sykes threatening Oliver and sweet Nancy, the funny and clever artful dodger and Fagan teaching Oliver about life on the street, and with (spoiler alert!) good overcoming evil in the end Oliver getting adopted by a rich dude so he can get all the gruel (or real Raisinets) that he wanted. And though my memories of the movie are still vivid, my strongest memory was the look on my sister's face when I walked out of the theater covered with melted chocolate chip goo. It went into family lore (and wouldn't have happened if they had sprung for Raisinets, I might add). I think they still don't trust me with chocolate chips.

The key line in the film comes when Oliver loses a bet and goes up to the gruel-master and says: "Please, sir, I want some more." Which, as I am sure Oliver expected, causes the gruel-master to break into the song, "Oliver! Oliver! Never before has a boy wanted more!" and the whole dining hall to pull out musical instruments and singing harmony to the gruel-master's admonition.

I can see why Oliver was scared. A whipping is welcome compared to his whole world breaking into song and dance.

Asking for "more" has caused trouble over the ages. Adam and Eve wanted more food choices, the people of Pompeii wanted more mountain-side housing, Napoleon and Adolph Hitler wanted to spend more time in Russia, and America wanted more of the Kardashians. We can all see what destruction those desires reaped.

Americans have been viewing health care the same way, always wanting more: more antibiotics, more technology, more robots doing more surgery, more expensive treatments for more diseases. The result: Health care costs more in America than anywhere else. Some folks think that our "more" approach makes our health care "the best in the world," after all, where else can you get so many tests just by asking. MRIs for back pain, X-rays for coughs, blood tests for anyone who dons the door of the ER. "Tests for everyone!" shouts the bartender. "Tests are on the house!"

They aren't, of course, and we are paying the price for "more." This hunger for "more" is fueled by the media's fascination for the "latest thing," the long disproved idea that technology will solve everything, and docs who aren't willing to take time to explain why it's actually better to do less. It's hard to do, when we are paid more to spend less time with patients, and when the system is willing to pay for more and more.

There is a voice against this: the "Choosing Wisely" campaign, which argues against unnecessary treatments and tests. This is a welcome voice of reason in the cacophony of cries for "more." Yet the battle goes against the irresistible tide of our payment system. The root problem is this: there are a whole lot of people whose jobs depend on America's addiction to "more." The payment system has created an ecosystem that thrives off of waste (of which I once wrote an allegorical fantasy). True health care reform will be catastrophic to many who work in health care, with many very nice and hard-working Americans losing their jobs at the ACO factory, at Meaningful Use Inc., and even at Stents-R-Us hospital here in my home town.

This is what you get when you make disease more profitable than health, when we treat problems instead of people. The simple fact that our system would be destroyed if everyone got healthy should tell us something is terribly wrong. Doctors want their offices full, not empty. The goal of every patient, to be healthy and to stay away from the doctor, goes directly against the economics of "more."

I have always tried to be a non-test orderer. I was trained well by docs who believed it weak-minded and bad care to blithely order tests and prescribe medications without a well-defined reason. This has always made it harder for me, as it's far more time-consuming to explain why a drug or test is not needed than to simply order it. But in my new world, one in which an empty office is a good thing, I've found my patients much more open to my aversion to "more." The main reason for this is that I am giving them more of me. More of me means they can call if they don't get better, or if their symptoms develop. They know I won't force them to take more of their time and spend more of their money to get my attention.

Ultimately, I want my patients to see as few doctors, be sick as infrequently, and be on as few drugs as possible. I hope to wage an all-out assault on "more."

Here are my rules to battle "more":

1) Never order a test that doesn't help you decide something important. Ordering tests "just to know" does much more harm than good.

2) Use consultants only to do things you can't. Orthopedists will always give an NSAID and physical therapy for problems, so I don't send patients to them unless they've failed those treatments (where appropriate). I am just as good at ordering physical therapy, and am more careful with NSAID prescriptions than they are.

3) Don't give a patient a drug without explaining to them why they need it. If I can't make a good case for a drug, I shouldn't be giving it. This is not simply "to lower your cholesterol," or "to treat your blood pressure," but because doing so will raise your life-expectancy.

4) Remember the number that really matters: how many birthdays a person gets to celebrate in health. I don't care about blood pressure, LDL, or even A1c if treating it doesn't raise the birthday total.

5) Don't forget about another number: how much money patients have in their wallets. There's no point in ordering a drug they can't afford, or making them pay for a test they don't need (even when they ask for either).

I hope my new world of less overhead, less regulation, and less antacids for me continues on this trend toward less sick patients, less drugs, and less tests. Perhaps I need to break into a song and dance number whenever my patients ask for "more."

That would teach them.

After taking a year-long hiatus from blogging, Rob Lamberts, MD, ACP Member, returned with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind), where this post originally appeared.

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Blog log

Members of the American College of Physicians contribute posts from their own sites to ACP Internistand 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.

And Thus, It Begins
Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.

Auscultation
Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.

Zackary Berger
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.

Controversies in Hospital Infection Prevention
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Richmond, Va., with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).

db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.

Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health 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.

Gut Check
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
Mike Aref, MD, PhD, FACP, 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.

Informatics Professor
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.

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.

Just Oncology
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.

KevinMD
Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.

MD Whistleblower
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.

Medical Lessons
Elaine Schattner, MD, FACP, 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.

Mired in MedEd
Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.

More Musings
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).

Prescriptions
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.

Reflections of a Grady Doctor
Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.

The Blog of Paul Sufka
Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.

Technology in (Medical) Education
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.

Peter A. Lipson, MD
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.

Why is American Health Care So Expensive?
Janice Boughton, MD, FACP, practiced internal medicine for 20 years before adopting a career in hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling.

World's Best Site
Daniel Ginsberg, MD, FACP, is an internal medicine physician who has avidly applied computers to medicine since 1986, when he first wrote medically oriented computer programs. He is in practice in Tacoma, Washington.

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.

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.

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