I was furiously tapping on the computer when he asked: “Doc, what happens if I don’t have the procedure you are recommending?”
Glee spread through my body. I grinned and nearly jumped up from the stool to hug him. I enthusiastically answered.
Few patients ask this vital question.
I tweeted about the encounter:
An older pt asked me: "what happens if I don't have this procedure" / I nearly jumped up to hug him! <Please, people, ask your doc that
— John Mandrola, MD (@drjohnm) July 7, 2017
A number of people noted my error:
Why aren't docs telling their patients their options and explaining them?
— Holly, MSN, RN (@Ozzwoood) July 7, 2017
1/Alarmed that isn't already part of the conversation! The Hippocratic Oath obligates Drs to discuss pros & cons of any medical intervention
— Informed Consent (@BZarebad) July 8, 2017
These people are correct.
I should have explained the expectations of not doing the procedure. My patient should not have had to ask.
In this case, I hadn’t described what would happen without the procedure because he had come to me for a problem that was causing him to feel poorly, and the fix I offered was easy, elegant and low-risk.
My enthusiasm to help got in the way of offering the option of not having the procedure.
It turns out that my lousy job of providing informed consent was not the only criticism of this encounter.
Dr. Ajay Kirtane is a thoughtful and prominent interventional cardiologist. He tweeted another line of criticism:
John – I get (and actually feel) your passion to avoid unnecessary procedures. But don't you think it's gotten a little one-sided lately? https://t.co/U6pNlytA3o
— Ajay Kirtane MD SM (@ajaykirtane) July 8, 2017
Dr. Kirtane’s comment highlights the problem of underuse.
I suspect he sees many suitable patients who have not been offered cutting-edge therapy.
Of course, inequity is a fundamental flaw in US healthcare. It’s an ugly blemish for our nation.
Once a month, on Saturdays, I see underserved and low-income patients in the Have-A-Heart clinic. The difference between this clinic and my regular job is stark.
In my regular job, in a well-endowed private hospital in a rich suburb, the challenge is improving decision quality and reducing harm from over-diagnosis and over-treatment. In the Have-A-Heart clinic, the challenge is simply to deliver basic medical care.
I am not a policy expert, but I think our enormous waste of medical resources–created mostly by fear-mongering, disease creation, over-diagnosis and over-treatment–causes, or at least exacerbates, underuse.
So to my colleague, Dr. Kirtane, I respectfully propose that over-diagnosis and over-treatment is the disease and underuse is a symptom. If we treat the disease, symptoms will likely improve.
The bottom-line for patients:
If you are well; if you have no complaints, be damn suspicious of any medical intervention, especially screening. Take this paper to your doctor and have her/him explain how you would benefit from screening. Although some (high-risk) people might benefit, the real beneficiaries of screening are hospitals, doctors and industry.
If you have a problem, and your doctor proposes an intervention, be sure to get answers to the four crucial questions. Enthusiastic doctors may forget to give you all the scenarios.
If your healthcare experience is lacking; if it’s hard to get an appointment; if it’s hard to find time with the doctor; if it’s too expensive; then it may be time to ask public leaders to address two core problems in US healthcare: waste and inequity. Absent from the debate in Washington now is any reform of these core problems.