This http://www.newyorker.com/magazine/2015/05/11/overkill-atul-gawande is a long, but very well written essay. My preceptor, who is very cost conscious, could have written this himself. The topic of ordering tests that won't contribute any value has been a theme we have revisited often since I started my clinical hours there in January. In his career, he has seen endless waste like the kind described here in this article. After I read a little bit of the article while waiting for our first patient to show up today, I said to my preceptor, "For sake of playing devil's advocate, what do you say to people who fervently believe that we do all this unnecessary testing in order to avoid being sued." He said he really didn't buy it.
Though he is quite supportive of my efforts to become an NP, he doesn't pull punches in explaining that he believes NP and PAs, because of a thorough lack of actual clinical training, refer people out for these tests because it is what they are taught to do. Unfortunately, I have to agree strongly here that this is the case. On the other hand, he has been presented countless examples of MDs who were no better. A question he constantly asks me, as well as his patients is, "What difference will that test make, and if we find a particular result, how will it change what we are already doing?"As the author of the article points out, there are many discoveries of cancer that would likely never become fatal to a person in their lifetime. Further, despite diagnosing more cancers, we aren't doing anything meaningful with the knowledge, like reducing death rates from cancer.
My biased experience as both an ICU nurse and hospice nurse, is that we provide an avalanche of unnecessary testing and procedures primarily because people demand it. In the ICU I worked in back in Chicago, there was one doctor on staff there who was willing to say to no to patients and families. He wasn't a jerk about it, but he took the time to explain why a particular test or procedure would add nothing to the treatment plan or more importantly, to the patient's quality of life. Admittedly, I have a lot of shit to say about the idiots who came up with term death panels, but honestly, a much bigger problem to me is our consumer mindset mentality. People have insurance and believe that if they receive anything short of extensive testing and treatment, they are being shortchanged.
If we collectively want to stop spending so much money on healthcare, there are some obvious measures. Taking responsibility for healthy behavior is certainly at the top of that list. However, the next big thing, IMO, is to really listen to what the author of this piece is saying. A stark reality that Americans need to accept is that we will not live forever. With that in mind, it seems reasonable to start having honest discussions on when to say enough is enough, especially when it comes to surgeries. On my end, I feel fortunate that I am working with a doctor who is really willing to tell his patients when he believes a particular test or treatment is of no value. I hope I can someday practice like he does because if I work in an HMO driven office, I know this won't be the case.