Less is more. I think

I visited my physician today for a minor complaint. It’s probably nothing serious, but then again there’s a small chance it could be something bad. My doc is an older internist, Harvard affiliated. He keeps up with the literature and knows what he’s doing. He’s also pretty modern –using secure messaging for example.

Unlike many of his colleagues, he’s pretty conservative in ordering up tests and meds. This isn’t a guy who gives out antibiotics to people who come in for a cold.

In my case he was at pains to tell me it was probably benign and might resolve on its own. There’s no pill for it, he said. He could refer me to a specialist but the specialist would just tell me the same thing –but would have more credentials. I hadn’t asked for a pill or a referral (and wasn’t going to), so this seemed to be a pre-emptive move.

I’m generally fine with this approach. It’s the kind of thing they do in Canada and Europe I’m told, and why their costs are lower.

On the other hand, when I spoke to a close friend who’s an internist  and told him my situation he was a little surprised I wasn’t referred to a specialist or sent for an advanced test.

I’m not sure how I feel about it myself. Although I’m generally a believer in “what you don’t know can’t hurt you” –or more accurately, “what you find out if you look might hurt you” I’m thinking of asking for that referral anyway.

July 17, 2009

9 thoughts on “Less is more. I think”

  1. Good points. Although you describe a slightly different situation, your post reminds me of something Paul Levy wrote a while back on how his PCP needed to protect him from being overtreated.


    Lately there has been a lot of discussion about how financial incentives may cause physicians to order unnecessary tests. But I wonder how much of the test-ordering is also patient-driven? As someone who is data-oriented but sees that too many tests might not make sense medically or economically (and could be harmful), I am not sure how I feel about it, either.

  2. I’m thinking of asking for that referral anyway.

    And THAT is why American health care costs are so out of control.

    I agree completely that the patient-driven aspects of the problem have been woefully under-appreciated. That’s what my next book is about.

  3. Had you waited weeks for this appointment regarding a minor but worrisome thing?

    My theory is that the more accessible health care is the easier it is to be relaxed about it.

    If it didn’t break your budget to see someone so you weren’t trying to maximize your bang-for-buck, if you know that if whatever doesn’t resolve and you call back they’ll see you again without another long wait, if you enjoy good health to begin with – those kinds of things make it easy to chill.

    If you feel that resources are scarce then the natural human reaction is to grab as much as you can right now!

  4. How long did your doctor tell you to wait to see if it resolved? Can you waiit that long?

    In general I find that asking patients to wait for more advanced testing is one of the more difficult things that I try to do. It’s fraught with medicolegal risk (What if it gets worse while they wait and they blame me? What if they take my reassurance as a final diagnosis and fail to follow up in a week as I have asked them to? If they don’t call me am I obligated to call them and if so, how do I track all those patients out there I am waiting to hear from? You get the point…) Not to mention the patient’s anxiety, worsened by internet searches and conversations with well meaning friends and family. So in the end, I often find myself ordering the test, then calling the patient with the good results, only to have them say that the whatever-it-was went away in the interim.

    Welcome to American healthcare.

  5. I’d want a few things from my PCP:

    1) Some insight into what the condition(s) could possibly be, and the stage and severity, based on my signs and symptoms.
    2) What signs and symptoms should I expect were the possible condition(s) to become more severe?
    3)What further diagnostics could I expect a specialist to do under reasonable circumstances?

    Just those basic facts could help you research a little more into these possible conditions and help you prepare for what a specialist would do with you, were you to go that route.

    Hopefully, you got that info from your PCP. But just imagine if a physician was taking boards and for one of the questions, just answered “It’s probably benign, don’t worry about it,” without any explanation or guidance.

  6. That’s what the vet said about the teeny tiny itsy bitsy moveable lump on the head of my brother’s dog. “We’ll watch it.” They did. It grew. It is cancer. It was removed and had spread requiring a huge incision to remove it. They are treating a very sick dog right now, sitting up nights with him, and will probably have him euthanized. But I’m guessing that’s an option your family won’t have. But it does save health care dollars.

    And my husband’s dentist notice a spot in his throat during his last check up and cleaning. “Probably nothing, but have your internist look.” Our MD, like your doc, is very conservative. He took a look and said, “It’s probably nothing, but let’s have a specialist with different equipment and training take a look.” And it will probably be nothing, but when something grows that wasn’t growing before, I think it best to know what it is.

    On the other hand, the first professional to spot something before my daughter’s thyroid cancer was known was her hair dresser. All the tests were normal.

  7. Thanks for all the feedback.

    Lily/#1 Dinosaur: I agree that much overuse is patient driven, but don’t consider myself the cause here. I waited 3 weeks before going in, and I communicated w/my doc via secure messaging and tried an OTC remedy first.

    I’m also remembering a time a few years ago when I had a problem with my leg that kept bothering me. I went to him, he said all seemed fine but if I really wanted to go to a PT he’d refer. I went to the PT and he isolated the problem (hip flexor) in about five minutes. I then had PT for 3 months and it’s better. Sure it cost the system a few thousand but it was worth it.

    Margaret: He was explicit in offering reassurance that “it isn’t some dread disease” but I know he can’t have ruled it out definitively. He didn’t give me a timeframe, though he said to let him know if it didn’t get better.

    In terms of well-meaning friends and family I’m lucky to have an internist brother but I try hard not to bother him about my medical issues. In this case I did speak with him after my appointment and he was surprised I hadn’t been referred, based on my account of the visit. (I know it’s possible he would have agreed with my doc if he’d heard his side.)

    Jay: I agree w/your 1, 2, 3. I didn’t get those fully.

    Norma: Dentist and hairdresser points are well taken. My dentist is like that, too. Unfortunately the dental specialists I’ve seen are a little trigger happy.

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