I've mentioned this before, but as I have completed my clinical hours this year, I have been blessed to work with an MD who is very, very cost conscious. He has been in medicine for over 30 years, he has taught in hospitals, he has done research, he has provided expert testimony in malpractice trials, and he has run his own practice. It may surprise some, but he is fully in favor of a single payer system, and though he admits he might chafe some at changes he believes should be made, he fully believes that the way current doctors practice has a lot to do with why medicine is so expensive.
I asked him directly if he really believed tort reform is that answer, and further if he really believed that doctors order a lot of unnecessary test to just cover their ass. His response to the test part of it was that he really didn't believe that doctors did it out of covering their ass legally, rather, at least in his case, he has a fear of missing something. He also sheepishly acknowledged that providers tend to have big ego's and like ordering a test that confirms what they have already figured out. As for tort reform, he told me that in most of the cases he gave testimony in, he felt there was a clear lack of due diligence. It wasn't a matter that a test wasn't ordered as much as it was a matter that a doctor didn't really make much of a case in their notes for why they did or didn't do something. He has also said to me a few times, "You can be wrong, but you need to have a rational for why you did what you did"
This week, he showed me an awesome article in JAMA that I can't link because those bastards won't let you read anything for free on their site. In a nutshell, a patient started to develop chest pain that was basically a stable angina, IE his chest pain stopped when he sat down and rested. He was told at first he needed to go for a stent. When he asked if it would lower his risk for heart attack and whether he could be treated with just medicine, he was given a "take it or leave it" ultimatum. He went for a second opinion, and was told again to get a test without being given any real rational for what this test would do for him. In the office of a third MD, who wrote the short submission, the patient relayed his story and the third MD addressed his questions and admitted that the research is not there to support getting an aggressive procedure like a stent for his condition. So, the patient diligently worked to lose weight, change his diet, and also started a statin and an aspirin and did just fine.
The moral here, that my preceptor has been drilling into me is that the system orders and pays for countless tests and procedures that have little science to show they improve outcomes. Some maybe to cover their ass legally, but not enough to fully explain the problem. A big part of the problem is that patients are not medically literate, and countless MDs simply don't have the time to explain anything. Just this week, we saw a new patient who has had atrial fibrillation for 15 years, after I explained what that meant, she and her granddaughter said that no one had ever explained that to them. I found an interesting link I wanted to share http://www.choosingwisely.org/about-us/ This link talks a little more about this. For some, I understand that a single payer system will merely be a horseman of the apocalypse that indicates the end of freedom is neigh. For me, I see it as something that is long overdue if for no other reason to start to wring out the enormous inefficiency our system has. On that link, there is a section called "lists" that I think has really good information for patients.