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Doctors: Over-Testing and Over-Writing

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"Written-by-a-real-doctor" articles and books about the medical profession are today's literary and journalistic gold. Perhaps spurred along by the incisive and thoughtful work published in recent years by The New Yorker's Jerome Groopman and Atul Gawande, an increasing number of articulate M.D.'s are clamoring for a chance to show off their writing skills. It's an interesting trend, for the most part: Who doesn't find it fascinating to hear tales from inside the O.R.? To learn about a doctor's thoughts concerning hypochondria, insurance scams, or mysterious diseases?

Unfortunately, however, this week's most recent example of the smart-doctor-writing trend -- Dr. Sandeep Jauhar's essay about how many extra tests and doctors so many of us endure -- proves that doctors aren't just over-testing, over-billing, and over-referring: they're also over-writing. And about the most obvious issues, too.

Jauhar's essay tells us about an older man who had been referred to a cadre of specialists as well as medical imaging doctors who find the need to schedule as many scans as possible. He also chalks some of this medical-billing waste up to patient demand (you know you want more blood tests!) even if he ends up concluding: "Doctors are doing too much testing and too many procedures, often for the sake of business."

Who would disagree? Yet from the standpoint of a Hodgkin's Disease and stem-cell bone-marrow transplant survivor with many secondary health issues happening twelve years since my so-called "cure," I have a more important point to make. Over-testing and over-referring happens, and greed is certainly a part of the problem, as well as the occasional hypochondriac. But the real issue no one discusses is that many doctors have become so super-super-specialized, large amounts of them now refuse to take responsibility for a medical issue that doesn't fall into their microscopic niche. Or they're so worried about lawsuits, they do every test in the book.

It's gotten to the point where a neurologist with plenty of general training who sub-specializes in peripheral nerves won't even look at a head MRI. One even once admitted to a family member that he flat-out shouldn't read such a film: he hadn't looked at one in 20 years. Fair enough.

But how about oncologists that specialize in, say, lymphoma? Try asking yours if he or she would like to help you understand an issue that arose because of the lymphoma or prescribed treatment--say, a hormone imbalance that can be easily fixed with one daily pill. You will likely be told no by a host of doctors working in the new corporate hospital model. That is, if you even get a chance to speak. You'll then be sent to an endocrinologist who will then probably see you at least twice before deciding what dosage of a particular drug that you need. Seldom will you be sent to take a blood test without having a very short follow-up appointment that costs hundreds of dollars and rarely results in anything other than a prescription. And seldom will the oncologist receive a phone call about the results--or care to receive such a phone call, even if the condition is related to the lymphoma. But: You have the best specialists!

Of course we all want the best doctors on the case for each of our medical issues. And thankfully scientific advancements made by fantastic researchers and practitioners have allowed new doctors to sub-sub-specialize in some of the most odd and rare little corners of medicine so that we may actually find someone who always knows how to handle every diagnosis. We hope. But with this incessant sub-sub-specializing and the Mayo Clinic-inspired model of putting group practices with super-specialists all in one actual corporation has come a new generation of doctors that: a) Doesn't want to take responsibility for any condition in which a professional hasn't received multiple fellowships, and b) Has no problem sending you around to others and never following up with the referred physician because his or her job is done. Which only leads to more billing and more testing, and sometimes even more referrals along with patient dissatisfaction.

It's such a vicious cycle, in fact, that the primary care physicians--many of whom want to understand what's happening to their patients--end up out of the loop and helpless from specialists referring to other specialists, and so on.

I'm all for calling doctors out for over-testing, but find me one who wants to follow more than just the specific work-order sent to his or her fix-it shop, and I'll believe that the only issue here is greed and doctor-shopping.

Oh, and why all the doctor-shopping? Maybe it's not because a particular physician doesn't over-test as a hypochondriacal patient may request. Maybe it's because some physicians didn't show care or curiosity--or have or the time to look into mysterious or complicated issues for which he or she could be held accountable to fight. Maybe it's because some sub-sub-specialized physicians are literally looking for a way out of having to treat particular patients because their cases aren't cut-and-dried. Or because they may blur the boundaries of clearly defined specialties.

Years ago, I had an internist and gastroenterologist (thankfully, two specialties in one!) who wouldn't perform an upper endoscopy on me until I had asked him for one. And guess what? He performed the procedure and found bacteria that could lead to an ulcer and as well as other problems. He was a suburban quasi-intellectual who writes books, too, and loved to chat with me about the latest issue of The New Yorker. He had recently delved into mind-body medicine. (Helpful, of course.) But he thought that a cancer survivor with suggested gastro issues and serious pain didn't really need a test. After all this patient had been through, he thought, the kid just had some worries.

Well, good thing I left this doc. Four years after last seeing him, I've learned there are a lot of things going haywire in my system because of the disease and treatments I weathered. If I had stayed with him, he would have continued to waste my time, patronizing me, when I really needed the care of a curious, multi-talented doctor who thought outside the box. And this was a doctor who didn't want to "over-test!"

The other real problem? Doctors aren't racking their brains anymore for every possible diagnosis--their "sub-specialist" roles have absolved them of this. If I could be ensured that doctors would treat patients the way they would treat their children, I wouldn't be interested in looking beyond the first top doctor I see. But I haven't met very many of these professionals, and I've been through the ringer.

Other, more down-to-earth and caring professionals with the ability to listen and think beyond the next national newspaper essay clearly exist, to be sure. But it's a population that's dwindling as medical school becomes more about finding an area of exacting super-expertise (never mind all the "required" symposiums on "bedside manner" put on by psychologists who often have to clean up the messes.)

In fact, it's not that sub-specialties are problematic; it's that there's a rampant lack of communication between sub-specialists and primary docs. So much so, there's rarely someone in control of a patient's total health anymore.

Interdisciplinary cooperation is one thing. But simply referring people to a bunch of different specialists is not a comprehensive, interdisciplinary approach. The Mayo Clinic model--see a bunch of specialists in one facility for total care--would be wonderful, in theory. But it usually just results in more appointments, scans, and bills. Rarely does a doctor pick up the phone to call another anymore--even if they work in the same hospital. And do you have a copy of all the reports they write about you?

Of course we need to clean up all the over-testing and over-referring. But we also need doctors who spend more time and look more carefully at their patients.

How about one of our famous, wordsmith doctors with a giant book deal finally writes about how so many people in his profession are no longer interested in looking at the big picture? I know brilliant oncologists--I know how much they understand beyond just their sub-specialty. But I have only ever met a handful who have cared to discuss beyond a mere mention the other issues that come along with cancer such that you wouldn't have to make the rounds for unnecessary tests.

"You see too many doctors," one such doc actually said to me. I was relieved. I wasn't the kind of patient who wanted more appointments. I just wanted someone who wasn't thinking about the dollar value of his every minute, about how he could be sued for discussing something with me, about getting me in for more scans so he could pad his bills. This was a doctor who actually communicated via e-mail and was happy to give out his cellphone number. Because he knew it wouldn't be abused: the majority of patients weren't coming to him for nonsense or to cause problems. He knows his world is devolving when it comes to patient care, and that that's a huge reason for all the medical waste. In fact, he talks about it. Behind closed doors. He just doesn't plan to write a book.

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