At lunch yesterday, I was the guest of a group that contained several retired physicians (all male). We listened to a talk by a board member from a large non-profit local hospital system. The speaker, knowledgeable and well-prepared, talked about the cost drivers of health care in America, which he listed as an over-reliance on technology, the practice of defensive medicine because of law suits, heroic measures at the end of life, lack of transparency as to the true cost of procedures, non-standard reimbursements, and a few others.
He pointed out that while we might have reformed health insurance, we had done little to cut costs, because we hadn’t changed the delivery system. And he went on to say that we had to move toward outcomes-based medicine, which he thought would convince doctors to prescribe fewer MRIs, mammograms, and other procedures that had proved to have little effect on patient outcomes.
During the discussion that followed, the comments from the physicians were not at all what I expected. Many were heated but not over the need for higher reimbursement, more tort reform, or loss of power to insurance companies.
No, instead they said we would never reduce costs until we taught physicians to make a diagnosis by taking a complete history and talking to the patient, rather than by opting out and scheduling tests. They said the art of diagnosis has all but vanished from medical school teaching and that students don’t know the simple principle of looking first for horses when hear hoofbeats, and not for unicorns. To these men, the race to adopt new technology hasn’t made the practice of medicine better, it has merely made it more expensive. Many of them are still reading their grandchildren’s X-rays to make diagnoses younger physicians miss. These guys saw diagnosis as an art, now a lost art. Many med students don’t even know how to listen through a stethoscope. Perhaps that is because doctors don’t get paid much for listening.
Personally, I think the introduction of DRG (diagnosis related group) codes has done as much as anything to discourage the art of diagnosis. A DRG code is generated after every patient visit, and allows the doctor to get reimbursed. More complicated codes get higher reimbursements, and some medical staff assign codes according to the profit motive, while others simply code incorrectly out of ignorance. But the standardization of patient codes turns every patient into a statistic. We might as well pick a code that approximates what the patient might have and give him/her some tests instead. The doctors also pointed out that their colleagues who are still in practice will not give up their MRIs easily, because they are in the habit of relying on them, and even tort reform won’t change that.