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.