Just recently out of medical school (and the Kennedy School of Government as well) Dr. Neel Shah has a particularly keen eye for medical culture and its tendency to overlook what things cost. He founded the Boston-based non-profit Costs of Care last year to try to change that culture. We wrote about the group’s essay contest yesterday; for today, we asked Shah, currently a resident in obstetrics and gynecology at Brigham and Women’s Hospital, for his top 10 reasons that doctors might over-order tests or treatments. What do you think? Would you add or subtract anything from this list?
- How we’re taught: Doctors are taught to consider whether a procedure is safe and whether it’s likely to work. We’re almost never taught to consider cost — it’s considered taboo.
- Trying to do our best for the patient: We’re worried. Often we over-order because of our personal risk aversion.
- Pre-emptive ordering: For residents, who do much of the ordering of tests in hospitals, it may be more efficient to order tests now rather than later. Standard practice might be to order a relatively cheap screening test and then if it’s positive, order other expensive tests. Instead we sometimes just order everything at the same time so we don’t have to wait.
- Covering all bases: In medical culture, doing more is equated with being thorough. If there are five possible conditions that may explain a patient’s symptoms, and it’s probably going to be one or two of them, we might order tests for all five conditions right away.
- General unawareness: We just don’t know what things cost. When you talk to people and say, ‘Do you know a magnesium level is $70?’ it blows their mind.
- Broader ignorance: It’s not doctors' fault for being unaware. Health care costs tend to be very opaque, and many costs are very difficult to determine.
- Not realizing how much setting affects costs: An MRI in an emergency room setting can be twice the cost of an MRI for an outpatient.
- Defensive medicine: Doctors do fear malpractice claims, but the cost issue is far more complex than malpractice alone.
- Patient requests: Ultimately, we believe that good doctors should be at the service of their patients. Many patients, however, are not rational decision-makers. For most people, the current status of our health distorts how we value health care. Those of us who are healthy undervalue care and are less likely to see our primary care doctor. By contrast, those of us who are sick can overvalue care, sometimes even assuming significant debt for very marginal benefit.
- Lack of oversight: When administrators or insurance companies impose oversight of any kind that tries to limit doctors’ ordering, everyone tends to push back. Both doctors and patients are uncomfortable with the idea of a third party deciding how health care resources should be used.
This program aired on September 14, 2010. The audio for this program is not available.