The Doctor’s Pen


What is the most dangerous piece of technology in a doctor’s arsenal? It’s her pen.

As doctors stand above you, they look down on your expectant features. Because you are rarely at eye level with your docs, your eyes, by necessity, are cast upward to look into their all-knowing orbs. Your skyward gaze is misinterpreted. You appear as a supplicant beholding ‘they who are the arbiters of your well-being’; the experts upon whom your health depends. And many of you do acquiesce, becoming passive seekers of ‘truth’.

Boxes Yearning to Be Filled
As your physician contemplates this lofty role, she turns to a pre-printed page. It contains every test at her disposal. Dozens of blood, body fluids and radiographic studies beckon, each box awaiting the anointment with her Bic or Mont Blanc. They are aligned alphabetically in columns. Myriad consultants are also lined up in rows –like the good soldiers they are. One check and you are gonna be checked out… by them  We have doubled the number of referrals to these test-meisters in the last decade. They too, if chosen, will be referring to their own set of specialty-specific boxes. These little squares each await only a pen’s check or a mouse’s click. A flick of a doctor’s wrist is all it takes to send you off on an epic medical Homeric odyssey.

And remember, while every journey begins with a single step, they never end that way. The cascade effect means that many, even most tests, lead to more. And as they multiply in number they increase in risk while decreasing in benefit.

How many of those boxes will be checked? Will a clump, a cluster or a collection of these clinical cauldrons receive your provider’s nod? To doctors, too few of those inky imprimaturs threaten a missed opportunity at diagnosis. If missed, he will be held accountable. And checking that box never is the basis of a lawsuit. But not checking them may prove him! And it’s so easy!

To you, too many checked boxes portend unnecessary, unproven, unaffordable journeys often right up to the ‘final frontier’. These voyages will explore strange new worlds and force you to boldly go where no neighbor has gone before.

Rosemary Gibson is a writer and leader in U.S. health care. She is section editor for the ‘Less is More’ series in the Archives of Internal Medicine. She is the author of The Treatment Trap. Her most modest claim to fame is that she left a very nice review of my book. She argues that one of the major obstacles to achieving better care is that treatment too often causes more harm than good. “Too often, she says, health care services and professionals don’t know when to stop. Clinicians are often “so busy doing,” she adds, that they don’t recognize the “burden of treatment…“.

Physician payment systems reward incomes when we do things to you rather than when we talk things over with you. Medical consumers themselves (uh, that’s you) equate testing with better care and are overly impressed with technology.

Sharon Begley is the science columnist and science editor of Newsweek. In The Daily Beast she nicely summarizes the situations when saying ‘No’ to a test or procedure can potentially save your life.

In the Annals of Internal Medicine this week, Dr.Christine Laine, its Editor in Chief acknowledges the recognition that too much care offers little or no benefit to patients.

Where’s Your Pen?
The doctor’s pen is mighty likely to lead you to the sword. But ‘know what? You have a pen too. And you are expected to wield it when signing consent. So either with your pen, or a respectful, “Not until you tell me why!”, you are the final pathway to medicine’s excesses or it’s successes.

From the Annals Dr. Laine published a table for doctors’ reference. They were questions that the author suggested be asked before ordering tests.

Rather than trusting your doctors, let’s have you ask the questions of THEM.”Data suggest that unnecessary testing abounds.

The Congressional Budget Office has estimated that up to 5% of the nation’s gross national product is spent on tests and procedures that do not improve patient outcomes.” So you take charge and you won’t be charged, while charging off on a stretcher adventure based only on a doctor’s whim.

Did I have the test previously? Many times it’s easier for doctors to order tests again rather than to get copies of old results. This happens every day in every hospital and every office. It just happened to my sweetheart Annie’s dad. He had a CT 5 days previously. No one knew or no one cared. It was easier to re-order it than to find it. This all happened under my nose. I told Annie’s dad…”don’t sign a thing until we talk about it”. No luck.

Will the test change my care? How? Are the purported changes important to you? Are the changes backed by evidence?

Will the doctor profit in any way by what he orders. If so, you need to know. How? Ask, damn it! “Hey doc, I hate to ask but I’m reading a lot. Will the office profit by this recommendation?” See, you didn’t ask if he profited. You asked if the office will profit. That phony one degree of separation you just manufactured will be better received by your doctor.

What are the chances of false positive results and what might they lead to?

What are the dangers of doing it? What are the dangers of NOT doing it?

Are we doing this test just to reassure me? “I don’t need reassurance. Is it being done to reassure you? I don’t need you to be reassured unless you tell me why you’re really fearful that something is wrong. Being fearful of a malpractice suit doesn’t count. Keep doing a good job and we’re all okay.”

If the test was ordered, did your doctor discuss it; or was it done without consulting you? This means he didn’t take into account circumstances he might best be aware of. It means your priorities are being ignored.

What tests have been acknowledged as being unnecessary? Tune in.


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