In numerous articles and blogs in the last decade, the overuse and misuse
of some medical procedures, lab tests, and diagnostic studies have been
identified as a problem in US healthcare. I have written and spoken about
this issue for the last two decades. In the last several years there is
mounting data that are moving some providers, and the associations representing
them, to say that this is not only true, but may be significant reaching
as high as 20% of the cost of care. A greater concern is that this overuse
or misuse could result in harm. In an article recently published in the
British Medical Journal, the authors’ research indicated that 1
in 20 diagnoses made by US physicians are incorrect, causing significant
harm in many cases, including some deaths. And, of course, the article
indicated that such poor outcomes are also a major cause of the rising
costs in the industry because of the need to “re-work up”
many of the patients.
This overuse is now verified in some laboratory studies, like the PSA;
diagnostic studies, such as mammography; and some surgeries, including
knee replacements, prostatectomies, and some “benign-acting”
lesions of the lungs. The drivers of overuse can be directly related to
three factors:
- Driven by a competitive model, US healthcare now has an overabundance of
technologies, often high priced, and just because they are available,
they are often used without clear indications;
- Revenues are declining, so some practitioners who are seeing patients with
borderline symptoms, that ideally deserve further observation, proceed
with immediate surgical intervention; and,
- The presence of a strong medical liability system drives providers to perform
studies just to enhance the medical record in case they are sued.
In reflecting on these drivers further, we would propose that there is
perhaps another more important one. Many physicians today do not have
thorough training in the physical diagnostic skills. Such skills require
learned and careful observation and actually touching the patient! Findings
from a proper, thorough and competent physical exam are a major part of
and driver of the treatment plan. The competencies, which we clump together
under “human touch” can do much to lessen the overuse of technologies,
and, in fact, are much preferred by most patients.
This premise was recently verified when we were working recently with a
client in Mexico. Here the medical school prepares primary care physicians
who learn the four human touch techniques and practice them often:
- Inspection – looking at the patient and observing behavior, skin
tone, etc,
- Auscultation – using the stethoscope to listen to the heart, lung,
and bowel sounds,
- Percussion – using two fingers to “drum” over the chest
and abdomen to listen for solid and hollow reverberations, and
- Palpation – pressing on various parts of the body to identify anatomical
abnormalities, such as abdominal tumors.
These students, along with their faculty, have limited access to CAT scans,
MRIs, and other sophisticated technologies, so they must combine these
“human touch” findings with basic lab and x-rays to make their
diagnosis, which, of course, drives the treatment plan. By following the
patient carefully over the next weeks, the physician can verify that the
diagnosis and treatment plan was correct. For the occasional patient who
does not significantly improve, then they can be exposed to a higher level
of more technologically sophisticated diagnostics. By developing and utilizing
the four “human touch” competencies physicians are less likely
to overuse more sophisticated studies. This process is also helped by
an environment in which there is not an excessive supply of diagnostic
equipment or a great prevalence of medical liability.
If we are to achieve a higher quality and safer healthcare delivery system
in the US, which is also cheaper and more accessible, it makes sense if
the “human touch” competencies could, again, be given high
focus in medical education. Medical graduates in the future, hopefully,
will have the opportunity to work in places where tort reforms have been
adopted. Additionally, incentives must be realigned so those who have
the capability to do better with less will be appropriately rewarded.