Just Say "No"

Steven R. Peskin, MD, MBA, FACP

A visit to my dental hygienist this week began with a conversation about diagnostic tests. Before the dental x-rays, I asked Dottie if I needed x-rays, and she replied that it had been 18 months, and, based on my age and past dental history, every year to two years was a reasonable interval. Not wanting to debate this point before confronting the Cavitron, I accepted that rationale.

Before Dottie began her assault on my plaque, she described her own interactions with physicians. She said that she sometimes questions her physicians or those of her children about the need for x-rays, blood tests, and antibiotics. She said that simply asking “Do I — or does my child — need this test or antibiotic?” led to the physician often not ordering the test or prescribing the antibiotic.

A favorite tech term, “convergence,” might be applied to our overuse and misuse of diagnostic testing and antibiotic prescribing with concomitant adverse economic, and sometimes adverse health, consequences. The convergence of forces or factors includes ready availability of tests and antibiotics, the relative noninvasive nature of most tests, patient expectation (Dottie being in the minority in my estimation and in my experience), defensive medicine, expedience (using tests to substitute for more questioning in greater depth, examination, time spent thinking), and reimbursement.

One recent estimate of the cost of unnecessary testing, by a former Congressional Budget Office director, was staggeringly high — $700 billion.

It’s a tough problem. “Just say no” is the contentious, no-win position that payers were asked to take by purchasers beginning in the 1980s. Part of the health care reform that we need, that can work: reshaping consumer attitudes and understanding toward the Dottie healthy-questioning orientation, reforming reimbursement methods, and reforming tort statutes. This will help to provide a framework for clinicians to best use their training, time, and judgment.

Steven R. Peskin, MD, MBA, FACP
is executive vice president and chief medical officer
of MediMedia, USA, which publishes Managed Care

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