Recently, a physician panel with representatives from nine different specialty boards, developed guidelines for patients and physicians, which question the current delivery of health care.
These boards represented nearly 375,000 physicians and underscore the growing need for educated medical partnerships between physicians and patients.
In the past, the physician’s role was such that they dictated patient care and patients rarely question the course. Today, however, a more balanced relationship is the norm with an emphasis placed on matching ones care with a more holistic approach. That being said, the majority of the guidelines proposed by the panel related to the overuse of tests and procedures which are being pushed by physicians and patients alike.
By some estimates, unnecessary treatment makes up one-third of medical spending in the U.S. Each year approximately $2.6 trillion dollars are spent on health care or almost 20 percent of our gross national product. Medical spending has been met with increased scrutiny as we try to build a more sustain medical delivery system.
Some blame incentive structures, which inflate the number of tests order due to ease or profit. For instance, studies have shown that practices which own their own radiologic equipment are more likely to order imaging studies, then those who refer their patients to outside facilities. As a result, many of the recommendations by the panel reflect decreasing the number of radiologic studies that we order.
Even my field, urology, is not immune to the over-prescription of imaging. The American Society of Clinical Oncology specifically recommended against the use of CT, PET, or bone scans in patients with early stage prostate cancer in their suggestions to the panel. This is congruent with multiple evidence-based guidelines which specify that imaging studies are unnecessary for low-risk patients.
Previously, my research team has published on the overuse of preoperative imaging in the prostate cancer patient. The majority of my patients are referred from other urologists and as such have already undergone clinical testing prior to arrival at my practice. By looking at patients who were identified as low risk, we found that at least 48 percent of these patients had underwent at least one imaging procedure despite no evidence to support their utility. These studies increase the patient’s radiation and contrast exposure, while placing an unnecessary financial burden on the patient and health care system.
Some argue that litigious concerns motivate the overuse of tests as well. As more physicians practice defensive medicine, imaging and blood tests are order as documentation of care not necessarily to determine a treatment plan. Furthermore, as patients become more active in their therapy they might request specific imaging and testing. Here is where I believe the practice of medicine is truly an art. After having completed decades of training, I am in the unique position to filter the myriad of information and come to an educated and evidence based practice decision. For instance there are some patients, who regardless of being classified as low risk I still order imaging due to other clinical factors.
It is my responsibility to work with my patients so that they understand why certain tests are needed while others would be irresponsible. Ultimately, I believe that this approach leads to a balanced utilization of resources and when widely implemented could prevent the need for rationing.
Dr. David B. Samadi is the Vice Chairman of the Department of Urology and Chief of Robotics and Minimally Invasive Surgery at the Mount Sinai School of Medicine in New York City. He is a board-certified urologist, specializing in the diagnosis and treatment of urological disease, with a focus on robotic prostate cancer treatments. To learn more please visit his websites RoboticOncology.com and SMART-surgery.com. Find Dr. Samadi on Facebook.