We bought a new car recently. Shopping for it was a challenge as complicated as any clinical decision I've ever faced. There were countless options for fuel (gas, diesel, electric, hybrid), configurations (minivan, sedan, hatchback, station wagon), sound systems, interior decor, and transmission. It all boiled down to balancing what was important to us (our values) against how much we were willing to pay (the cost).
We all go through this same process on a smaller scale many times a day (usually unconsciously) when we choose what to buy, eat, read, or watch. These decisions are rational only to the extent that we know how much we're paying and for what we're paying. Marketing firms are well paid to mold our values and perceptions of their products and to hide the true costs. We all know as a result that skepticism is a necessary survival skill in our consumer society. We learn to scrutinize the fine print and to gather as much information from as many unbiased sources as possible. One of the many flaws in our market-based medical system is that those who buy medical services — patients and third-party payers — have no way to measure the value of what they are buying or its cost. Consider Mr. Nelson.
Mr. Nelson was a trucker on a run to a city three hours away when he developed diffuse epigastric pain that gradually changed to a sharp crampy periumbilical pain with urgent diarrhea. He pulled into the next ED when he noticed blood in his stool. He said the doctor there saw him right away, but “didn't seem to listen” when he tried to describe what had happened that morning. “They hooked me up to oxygen, started an IV, and did a heart tracing while the doc looked at his laptop. He did ask about my parent's health. I didn't see him again until the lab and x-ray were done two hours later.”
The discharge report he was given described a comprehensive cardiac workup. It included electrolytes, LFTs, lipase, amylase, PTT, PT, troponin, CKMB, CRP, d-dimer, CXR, UA, BNP, ECG, and CBC. The recorded vital signs were all normal as were all the test results except for a minimally elevated d-dimer. A CTA “to rule out PE” was negative. The discharge diagnosis was “epigastric pain-noncardiac.”
Mr. Nelson was reassured when he was told that “his heart and lungs were fine,” but frustrated when he was told that the pain and bloody diarrhea “must have been something he ate.” He drove home and came to our department to find out what to do about the diarrhea.
The doctor who saw him in our ED took a focused history. Mr. Nelson had had several less severe episodes of crampy pain and diarrhea over the past few months but no chest pain or dyspnea. None of his immediate family or friends had similar symptoms. He had had nothing out of the ordinary to eat. His abdomen was soft and nontender. Vital signs were normal. He had passed only a small amount of blood since he had been seen that morning, and his Hgb was unchanged. The doctor told Mr. Nelson it was unlikely that there was anything dangerous going on, but that further investigation was necessary. He arranged a colonoscopy for the next afternoon, and set up an appointment with a gastroenterologist. He discussed symptomatic treatment of the pain and diarrhea and possible return to the ED. Mr. Nelson was later diagnosed with Crohn's disease, and was doing well a week later. His main concern was the bill he had gotten from the first facility.
Several obvious differences are seen between the practice styles of these two physicians. The least important is that one steered the patient toward the right diagnosis and the other didn't. The first doctor was valued by hospital management as energetic and productive. His care of Mr. Nelson generated thousands of dollars in revenue for his hospital and justified a charge code of at least 90515. The second doctor spent more time with and on the patient's behalf but generated much less income. The important difference is that the first did nothing to lower Mr. Nelson's risk of a bad outcome, nothing to decrease his suffering or uncertainty. He provided nothing of real value to the patient. In fact, many of the tests he ordered (to rule out conditions with near zero prior probability) exposed Mr. Nelson to the risk associated with potentially harmful tests or interventions (the CTA).
The second physician listened, thought carefully, and made recommendations that lowered Mr. Nelson's risk, a very real value. Any thoughtful clinician will immediately recognize this difference, but Mr. Nelson, his insurance company, and hospital administrators do not have the eyes to see it. Our challenge is to make it obvious to all concerned.
We add value to the extent that we thoughtfully engage with patients and make decisions that decrease their risk and uncertainty. This is not a subjective stylistic distinction. Our understanding of the incidence of disease and of the predictive value of tests is incomplete, but they are well known for many clinical situations. We know that certain tests or interventions in some cases are of no value or are potentially harmful. The same tests and treatments in other instances are potentially life-saving. The risk reduction (or increase) that results from our choices is real and measurable. Our specialty will be undervalued, our patients will be harmed, and our medical system will continue to be the most wasteful on the planet until we as a profession define, measure, and teach the real value of what we do.