| I am a physician in the US. I think the article has valid points (esp. inpatient glucose control) but it also oversimplifies and glosses over some of medicine's more arcane aspects. To give a tangible example I'll start with the unnecessary ankle x-ray. There is a set of guidelines called the Ottowa Ankle Rules[1] which we use to justify ordering plain films for a suspected fracture, but there are plenty of reasons why a doctor would still get them if the criteria weren't met. One reason is clinical judgment and experience. Guidelines are just guidelines. Ultimately the doctor is the one making the call, as well as suffering the blame for that call if things go sideways. If everything were as simple as following algorithms and checklists, medical training wouldn't take 7+ years of post-undergraduate work. But probably the most important reason has to do with the "patient satisfaction" (customer service) aspect. Ideally medicine wouldn't be a business, but it is and there's not much we can do about that. Patients who present to an urgent care center or ED generally carry an implicit "something is seriously wrong with me or I would have just made an appointment with my PCP" vibe. These patients often don't like it when you explain that based on your history and exam, they most likely have a sprain/strain injury and an xray is not appropriate since we want to avoid unnecessary costs/radiation exposure-- as opposed to being relieved that they only suffered a minor injury. Even when spoken in a compassionate, straightforward manner, this explanation can come across to the patient as "nothing is wrong with you / you are malingering / your concerns aren't valid / I don't care about your symptoms", etc. Sometimes patients outright demand tests, or worse, they'll say nothing but then complain to your employers that you medically neglected them, or you are incompetent, or what have you. Now if they had the audacity to file a malpractice suit, you'd (ideally) have no problem justifying your actions in a courtroom or deposition. But say they complain to the MBA (or some other person with no medical training) who runs the clinic or care center employing you. Your argument will likely fall on deaf ears, and be countered with some diatribe about how you're causing them to lose money. In that case it's a lot easier to just order the unnecessary xray. Basically, the squeaky wheel gets the grease. There are plenty of other examples like this, and they all come down to choosing your battles wisely. I think it's kind of hard to blame the over-worked and behind-schedule doctor who orders something like an xray or lab test rather than taking an extra 10-15 minutes discussing the pros and cons with the patient, after which the patient might still not be convinced. Having said that, there is a problem with superfluous testing in EDs, especially ones that rely on "standing orders" where e.g. virtually any patient presenting with abdominal pain might get a CT scan before the physician even sees them (something I strongly disagree with and can't think of a legitimate excuse for). [1] http://www.theottawarules.ca/ankle_rules |
For instance, there was a with E.U. doctor referral for ultrasound and blood work. The reply was if it bothers me to consider painkillers or wait for it to get worse and come back. (Why should I take painkillers if we are not certain of the cause to begin with?) On the other hand, walking a friend into urgent care for their leg leads to a full checkup.
With the above I want to complement your view, that there is some extreme behavioral gap in how doctors' react that is not related with the patient's ailment.
And there is a lack of a middle ground between urgent care and making a personal doctor appointment. I find it surprising that if I break my leg I need to go to urgent care. There is no contagious disease, and I am not going to die if left untreated, but it is an event that requires time sensitive treatment. Yet, there is no concept of walking into a doctor's office, or at least it is not that easy.
Example case 2. Eye pain etc. After failing to get an appointment with any doctor, K is instructed to go to urgent care. K called ahead and asked if they could handle their case, yet there was no actual ophthalmologist there. K got a full "checkup" and got a "it's probably an infection"; they were prescribed antibiotics. Next day K's eye pain worsens with new symptoms. K gets an appointment with an optometrist so as to be referred to an ophthalmologist. It is the protocol to have an optometrist check you first apparently. Another half a day later, an ophthalmologist actually checks K and comments "thank god you came in this fast." That was after my wife begging several times on the phone with several doctors, that we need an appointment today and not in 2 months. Yes, patient K is I. (I could not make any phone call or walk at this point, I was for all intents and purposes blind and in pain.)
Thus, the system in place from my experience assumes that the patient i) is stupid ii) if not dying does not need a checkup within the next 2 months, or else has to go to urgent care.
Thus is it really the patients' fault when they are used to walk into urgent care to get any sort of timely treatment? Why would a person with a broken leg take the invaluable resources from someone actually in need of urgent care? I argue the system somewhat enforces this over-treatment. You have to go through the urgent care for any timely treatment, it is rightfully instilled in you that perhaps there is something serious going on. You would not pay urgent care prices for a strain right? Thus, it must not be a strain.
My E.U. experience: As a patient,you walk in to a doctor you consider appropriate (You can also make an appointment ahead of time and ask if uncertain). One might wait for a few hours. If it is deemed urgent, the doctor will make sure to see you first, or send you to urgent care/emergency room or hospital. If the doctor is not of the appropriate specialty, they will refer one appropriately. Paying everything out of pocket, costs extremely less compared to my copay for urgent care -- this is a simple doctor appointment, no urgent care.