Rx for medical overuse: treat less, talk more

For years as I practiced medicine, I worried we were prescribing too many pills, ordering too many tests and performing too many procedures. But even I failed to appreciate the scope of the problem until I saw the data.

Experts believe that at least 30 percent of our health care dollars are spent on overuse and unnecessary care -- care that does nothing to improve our health and may actually harm us.

Last year, the United States spent $2.3 trillion on health care, the highest in history and more than twice the amount spent by any other country. And although we spend a lot, American health care is not the best.

The United States now ranks worst among 19 industrialized countries on deaths that could have been prevented with timely and effective care, according to the 2008 National Scorecard on U.S. Health System Performance.

Why is there such a disconnect between the quality of our health care and the amount of money we spend on it? Although there are many reasons, overuse and unnecessary care are key culprits.

When a patient comes in with new low back pain, we order an MRI scan rather than explain that most back pain goes away within six weeks. Or when a worried patient comes in with classic heartburn, we order a series of expensive heart tests rather than talk about the real diagnosis.

I recall a conversation years ago with colleagues who were prescribing antibiotics for a simple cough and runny nose. I questioned this practice and was stunned by the response: The doctors didn't have time to talk patients out of the antibiotics they wanted. Often it's faster to just write a prescription or order a test and send people on their way.

When it comes to health care, time has become our enemy.

Patients are now expected to be more involved consumers. They are bombarded with complex health information from multiple sources, and are paying more out of pocket for their health care.

But as patients attempt to understand this information and apply it to their health care situation, they have less time to question and discuss options with their provider.

Doctors and other health care providers are now driven by a business model that pushes them to see lots of patients quickly. Patient in. Patient out. The pace itself can jeopardize quality, thoughtful discussion and sound decisions.

Although I have no data to prove it, personal experience has convinced me that when we spend less time with patients we are more likely to order tests and medications.

During medical training we are taught that 90 percent of the diagnosis comes from a good history, asking the patient questions before diving into action. When we fail to obtain a comprehensive history, we resort to something we can do quickly -- prescribing a medication or ordering a test.

Meanwhile, we have created a cultural expectation that more is better. And if something is new and expensive, it must be great.

Many people believe their care is better when tests are done, medications are prescribed and they have access to the newest procedure.

Sometimes that is undoubtedly true. But if we all take the time to discuss the risks, benefits and rationale for alternative approaches, overuse will start to decrease and patient satisfaction and health will improve.

Patients must have time to discuss their needs, questions and concerns. Providers must have time to listen, explain and advise. Only when our health care system acknowledges the need to do this will we reduce overuse and begin to improve quality.

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Kay Schwebke is a physician and a health journalism graduate student at the University of Minnesota's School of Journalism and Mass Communication. She is medical director of the Hennepin County Medical Center Coinfection Clinic in Minneapolis.

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