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tive system, we may miss an occasional item of importance, but with the present routine we sometimes do so, anyway.
We don't have to follow this routine. When we must hospitalize a patient, we should weigh our reasons for doing so—and resist the hospital's battery-of-tests policy. If the diagnosis is uncertain or if we're suspicious, we should explain to the patient why we must investigate further and then go ahead and do so. In testing, we ought to be guided by the golden rule, paraphrased thus: Do unto your patient as you would have him do unto you.
TOO MUCH TESTING? THE PROS AND CONS
At least one physician agrees with the idea that Dr. George B. Markle proposes in the accompanying article. Reduce the expense of a patient's hospitalization by discarding some routine tests and examinations. William A. Volen, a general surgeon in Litchfield, Minn., would go a step further and eliminate routine lab work entirely. The physician and the patient, says Dr. Nolen, benefit most from lab work that's ordered for a specific purpose. But when it's done routinely, as is often the case, the attending physician probably doesn't even check the report. What if the hospital is strongly opposed to the elimination of this fixed procedure? Then, he says, each doctor could at least determine if his patient needed such tests, instead of making them a necessity by virtue of hospital law.
"Sometimes, in an attempt to prevent an extremely rare disaster,” Dr. Molen continues, "hospitals adopt policies either voluntarily or because accreditation boards compel them to do so—that aren't statistically valid. Such policies, once they've become routine, are blindly continued and rarely if ever questioned by those who use them. In fact, once adopted, it's almost impossible to modify them, and the tired We've always done it this way comment is usually given as an explanation for their continuance."
With medical expenses at an all-time high and with medical personnel in short supply, Dr. Yolen concludes, “it's high time doctors refused to accept such an explanation as adequate for the continuance of illogical and expensive routines."
A number of other physicians who read a prepublication draft of surgeon Markle's art disagree with his recommendation to do away with routine hospital tests. Dr. Charles C. Letourneau, a hospital consultant in Chicago, calls it "not very good advice. I hope I never fall into his hands!" Says Forrest P. White, a pediatrician in Norfolk, Va.: "Dr. Jarkle has a bone to pick with a record committee that is simply trying to get him to practice good, modern medicine. As a record committee chairman, I can't go along with the examples of ‘unnecessary testing that he cites. As I see it, there's absolutely no excuse for any physician not doing a complete basic testing and physical exam on each of those patients."
This need for complete care of the patient is emphasized by internist Walter E. O'Donnell of Gloucester, Mass., who writes: "Dr. Markle apparently feels that his responsibility in the case of the patient with the two crushed toes begins and ends right there. The rest of the patient doesn't seem to come in for much attention unless there's something grossly wrong. Actually, the tests Dr. Markle describes as 'costly and unnecessary include the simple blood, urine, and chest X-ray package, the actual cost of which is less than $25 and has long since been accepted as a reasonable minimum by most physicians and hospitals."
Another internist, Alfred P. Ingegno of New York City, points out that "certain routine tests have been found advisable from bitter experience, and the bitterest experience comes from sloppy routines all too common on surgical services. A minimum of a decent history and physical, plus urine, blood count, blood sugar, and chest X-ray are certainly needed to prevent carefree major surgery on, say, a decompensated diabetic. If only we could get our surgeons to understand the need for such reports! Do they think that 'routine' evaluation of the bloodclotting status in a T. & A. patient is a frivolous procedure? Instances of uncontrolled bleeding after such omissions in the past may give them pause.
"Such 'routine' tests,” Dr. Ingegno continues, "are easily done by the staff that's usually available in any well-run hospital. These tests can give valuable information, and their cost is reasonable. I suspect that the major problem is the other way around: not enough indicated tests by attending physicians who as. sume too much."
The value of low-cost testing is stressed by Irving M. Levitas, director of rehabilitation medicine at Hackensack (N.J.) Hospital. “When tests are inexpensive, as they are in mass screening," he says, “they're worth what they cost for case findings. At 10 cents a test, why not have them?"
Mass health screening is seen as a solution to the problem by Richard C. Bates, an internist in Lansing, Mich. "The answer to Dr. Markel's dilemma probably lies in the computerized exam," Dr. Bates writes. “When each citizen goes through such a routine yearly, the need for all these expensive hospital test batteries will largely disappear. But until that time, I think the Joint Commission is wise to use the hospital admission as a means to insure a fairly thorough going-over for everyone who considered sick enough to be hospitalized.”
One needless hospital expense that Dr. Markle overlooked, according to Curtis D. Benton, Jr., an ophthalmologist in Fort Lauderdale, Fla., is the routine pathology report. “All surgical specimens," Dr. Benton says “must be sent to the pathologist, who charges $3 to $10 to report that the penny the attending physician removed from a child's throat is 'a coin.' We have to send the pathologist cataracts, foreskins, bullets, and all sorts of obvious foreign bodies. This costs money.
“But there's one point that Dr. Markle doesn't mention," Dr. Benton concludes. "When certain tests and procedures are considered routine and standard and a physician fails to do them, he won't have a leg to stand on should a lawsuit follow and the case go to court. Most physicians are willing to go along with some 'unnecessary tests' for our patients because we can't accept the legal risks of not doing so."
EXHIBIT B: SPARE THE PURSE AND PLEASE THE PATIENT
[From Medical Economics, Aug. 5, 1968]
(By George B. Markle IV, M.D.) The high cost of medical care today is, like the weather, something that everybody talks about but nobody does much about-except politicians and bureaucrats busily preparing new rules and restrictions for hospitals, the drug industry, and the medical profession. I think we doctors had better do something about it-soon. Sure, many of us do make some effort to spare our patients' pocketbooks, but too often we overlook the little ways to same them needless expense.
Some of the suggestions I'm about to pass along will save only a few dollars. But to many of our patients, $3 represents the income from one, two, or even three hours of work. It may never occur to the affluent doctor that so small a sum is worth saving. But it means a lot to a low-income worker, and a doctor's thoughtlessness can easily multiply the patient's cash outlay manyfold.
Let me give you an example, Jim Martinez, a laborer who supports a wife and four children on the $2 an hour he earns when he has work, came to the office of a colleague one day with a painful abscess in his axilla.? The surgeon, recognizing the need of incision and drainage, admitted him to the local hospital and scheduled him for surgery the next morning under a general anesthetic. Following hospital policy, he got a routine c.b.c., urinalysis, V.D.R.L., and chest X-ray. That evening the surgeon did a fairly thorough physical exam and dictated his findings. The anesthetist talked with him and ordered the usual pre-op medications. An orderly shaved his axilla and half his thorax and arm.
Next morning he was taken to the operating room and anesthetized. The O.R. aide donned sterile gloves, carefully draped off the area with sterile towels, and prepped the axilla, taking about 10 minutes of anesthetic time. Then the doctor, scrubbed and gowned, draped the wound. This required four more sterile towels, a half sheet or two, and a full-sized laparotomy drape. The O.R. nurse had opened up enough instruments for an appendectomy, and the circulating nurse was prepared to supply more.
Then came the moment of truth! The doctor stuck a scalpel into the bulging mass, drained out an ounce of pus, took a culture, and stuffed in a bit of gauze. The anesthetic time was 15 minutes; the operative time one minute. A dressing was applied and the patient taken to the recovery room and thence to his room. He had a little pain before dismissal and was given a tablet. He was discharged with a prescription for $8 worth of an antibiotic.
The surgeon sent Jim a bill for $30—an amount the doctor felt was quite reasonable. Because Jim had no health insurance, the doctor hadn't charged for the first office call nor for the two postoperative visits, and he'd done a history and physical, not to mention the bother of scheduling surgery and going out to the hospital to do it.
Jim's bill from the hospital was $140, which the administrator assured him was very reasonable when broken down: routine lab, $13; culture and sensitivity, $17; X-ray, $10; room, $25; medications (four), $6; prep of area, $2; anesthesia, $30; and O.R. fee, $35. There was a $2 charge for the recovery room.
By an odd coincidence, Jim's cousin, Pedro, came to me not long after with an identical abscess in the axilla. I quickly shaved the area, wiped it with alcohol and Merthiolate, and with a very fine needle infiltrated a little 2 per cent procaine. Then, without gowns, gloves, or drapes, I made the same sort of incision and tucked in some gauze with a hemostat. I gave him an injection of long-acting penicillin and half a dozen capsules for pain. I had him return once, and after that he dressed the wound himself a few times and got well.
Pedro's total bill was $15, against $198 for cousin Jim! It took me only a few minutes, against an hour or two for Jim's doctor. Timewise, I was the better paid, and Pedro was 20 hours ahead of cousin Jim.
Thus, No. 1 on my list of ways to save patients money is to do in the office those procedures that can easily be aovie there. Some insecure doctors, I know, insist on hospitalization not for the patient's sake but for their own. They're afraid they might need help in an emergency or become the target of a malpractice suit if anything should go wrong. But it's amazing what you can safely do with a modest little setup. A manual such as “Surgery of the Ambulatory Patient," by L. Kraeer Ferguson (J. B. Lippincott Company), will open your eyes to numerous possibilities. I know many doctors who give pulmonary or other therapies in their offices; many urologists do cystoscopies. You can probably think of more.
My second suggestion is, of course, to use a local rather than a general anesthetic whenever this can readily and safely be done. This not only permits surgery in the office, but it will save money and time when the patient needs to be hospitalized. For example, I do ganglion cysts under local in most cases, sometimes in the office and sometimes for a hospital outpatient, who is then charged only the O.R. fee. I find that, with a little premedication, all but the most nervous patients can tolerate an arm tourniquet for the half-hour it takes.
I've reduced a great many Colles' fractures ? under local, with or without premedication. This is especially convenient when the patient has recently eaten and I don't want to have to return to the hospital several hours later. And, of course, with rare exceptions, local anesthetics are safer than general anesthetics are.
In addition to office and hospital savings, we can materially lighten our patients' expenses at the drugstore. We tend to forget how drug bills can add up, since we habitually douse our own families' minor illnesses out of the sample drawer. Woe to anyone in my family who comes down with a condition that isn't treatable from my sample collection. I just won't allow it!
Seriously, though, that sample drawer can serve a good purpose. Perhaps your patient has a temporary diarrhea, a bit of a cold, or a little muscle spasm. You surely have some samples that will get him by. If you do some office procedure or minor surgery that will be painful for a day or two, you can find a few analgesic pills to give him. You might even keep a bottle of them on hand just for such small but frequent demands; there are several good analgesics that don't require narcotic accountability. For my very poor patients, I keep and dispense vitamins and iron, too. It costs me almost nothing, and it pleases the patients no end.
If a poor patient must continue on a medicine for a long time, why not call his pharmacist and arrange for the patient to get a large supply for just a bit above the wholesale price? This is only one of many good reasons for getting to know your local pharmacists. Most of the pharmacists I know are glad to help in this way--or in other ways they themselves may suggest--for needy cases.
Another way we can make the patient's medical dollar go further is to use oral medications instead of injections whenever possible. Most menopausal women get along quite satisfactorily with oral estrogens or stilbestrol instead of injections, and aren't daily oral vitamins really better than a weekly injection? One old doctor I know says, “Yes, but shots keep the patient coming in regularly, so I can follow him better." I happen to know that such patients rarely get past his nurse, who gives practically all those routine shots.
· Colles' fractures are the common type of wrist fractures of one or both bones.
We also add to medical costs when we don't give our patients credit for ordinary common sense. Most of them have it, and we can save them money by letting them take some responsibility for their own care. After I've dressed an uncomplicated wound a time or two, for example, I let the patient dress it himself with only an occasional check by me. I simply tell him that if it should get red or drain, or in any other way look or feel as if it's not progressing well, I'll be glad to see him.
If your patient needs some physiotherapy, he may be able to do at least a part of it at home if you or a therapist will show him how. Most doctors have diabetic patients check their own urine, thus saving a lot of visits. Instead of waiting for such vague signs as fever blisters or a dry mouth, most patients can learn to take their temperatures so they'll know if they need to see you for a respiratory infection or other condition. Many doctors help chronic patients take some responsibility for their care by giving them appropriate pamphlets or by recommending books. One overburdened G.P. has found he can save much of his own time and his patients' money by preparing and distributing brochures containing his standard instructions on a topic like "Your Child and You."
We can save more money for our patients by avoiding "nuisance" consultations. I know some specialists who, when treating a fracture, for instance, won't treat the same patient simultaneously for a common cold. Some surgeons won't treat a catheter cystitis but will call in a urologist who has better things to do. A little myalgia doesn't require an orthopedist, nor a little anxiety a psychiatrist. When you call in another specialist you put him on the spot. You've made an issue of the problem, and he feels he has to be thorough. So the patient's little sniffle will cost him at least $10, and sometimes a lot more. It shouldn't be beneath our dignity to treat the simplest things, even if we don't treat them ordinarily. It's a way to show concern for the patient and his pocketbook, and I've found it's appreciated.
When you do refer to a consultant, be sure to tell him whether the patient has limited means. Since the consultant presumably hopes for more referrals from you, he may be spurred to effect some of the economies I've mentioned and will try to keep his own fees modest.
Remember that time is money, for both you and your patient. If he needs hospitalization, make it as brief as possible. Do what work-up you can while he's an outpatient, and get him out of bed and out of the hospital as soon as it's safe. Then get him back to work. Loss of income from not working may be a bigger financial blow to him than the medical costs. Furthermore, mental as well as physical rehabilitation is usually faster when the patient is back trying to lead a normal life. Oversolicitous delay can make a patient a semi-invalid for months.
Those are just some of the ways I've found to cut medical costs. No doubt you can think of many more. They're not likely to hurt your income because, as I've shown in some examples, your productivity will increase. And who knows, such savings may enable or even inspire-some otherwise nonpaying patients to pay your fees.
EXHIBIT C: MORE WAYS TO SAVE YOUR PATIENTS' MONEY
[From Medical Economics, Aug. 5, 1968) Among the physicians who read and commented on the preceding article before publication were three MEDICAL ECONOMICS contributing editors. They volunteered some cost-cutting tricks of their own.
Richard C. Bates, internist in Lansing, Mich., is down on medical tubes. He writes: "Avoidance of tubes of all sorts—I.V., nasal oxygen, and catheters, not only permits the patient more freedom and comfort, but it cuts costs. I'd guess that over half the cases with such tubes that I see are being treated unnecessarily. When a patient is dehydrated and able to take oral fluids but won't. I give him a teaspoon of salt out of the shaker. For each teaspoon of salt he takes, he'll crave two glasses of water, which will give him the equivalent of 500 cc. of normal saline I.V. Taken intravenously, that would cost him $5."
Forrest P. White, pediatrician in Norfolk, Va., writes: "When I prescribe clubfoot shoes and a Denis Browne splint for an infant, I have the mother bring the whole apparatus to me when the baby has outgrown it. She's usually glad to sell it for about 60 per cent of what she paid. So when the next baby with the same condition and shoe size comes in, I offer the used shoes and brace to that mother. If she accepts, she writes out a check to the first mother, and we mail it. The transaction never goes through our books; I'm just an unpaid middleman. Both mothers are happy—the first because she got some of her money back, the second because she got something she needed at a substantial discount. And when her time comes, she'll probably be able to sell the apparatus for 60 per cent of what she paid for it.”
Curtis D. Benton Jr., ophthalmologist and pediatric otolaryngologist in Fort Lauderdale, also passes along certain temporary appliances from patient to patient, such as plastic shields to wear after eye surgery. But Dr. Benton's chief cost-cutting enthusiasm is for reducing the time that his younger patients spend in the hospital for T. & As. “Last year.” he writes, “my surgical patients were spared the expense and inconvenience of 300 unnecessary days—or more precisely, nights-in hospital beds. Most hospitals have regulations requiring patients scheduled for elective surgery to be admitted the night before their operation. But the period of hosptialization for T. & A.'s on children under 14 in this community has been cut to just 24 hours.
"We've been able to accomplish this by pre-admission preparation. When surgery is scheduled, the history and physical are done in the office. All necessary lab work is done in the hospital O.P.D. the day before the operation. Pre-op and post-up orders, plus the typed examination results, are in the hands of the admitting clerk when the child arrives at 6 A.M., with empty stomach and eyes wider than his mother's. Johnny goes straight to the children's ward, gets his sedative shot, and is on the operating table by 7:30 A.M., before he has the time to start thinking and sprout nervous second thoughts.
"I haven't yet convinced the hospital authorities that the same procedure would work just as well with adults. But my 300 younger patients last year were saved about $10,000 in hospital costs by not spending an unnecessary and probably sleepless night in the hospital awaiting surgery the following
ITEM 9: MATERIAL SUBMITTED BY DR. RUSSELL B. ROTH, VICE
SPEAKER, HOUSE OF DELEGATES, AMERICAN MEDICAL ASSOCIATION
EXHIBIT A.: THE PHYSICIAN AS A GUARDIAN OF HEALTH CARE Costs
(By Russell B. Roth, M.D.) The concept of the physician as a guardian of anything other than the health and immediate best interests of his patient is, I believe, a relatively modern development. Certainly in those less turbulent Oslerian days at the turn of the century there were at best only minimal and incidental ways in which the physician was called upon to dilute his concern for his patients with consideration for the community, for hospitals, for third party payors, for goyernment, or for the tax-paying public.
Times have clearly changed. Janus, the God of gates and doorways, needed only two faces—for looking in and looking out. The physician today, in his role of guardian, needs to be more Hydra-headed in order to keep primary focus on his patient, while casting a wary eye on the hospital to be sure it is not over-utilized, on the insurance company to be sure it is not over-charged, on the community to be sure it is well serviced, and on Medicare and the rest of the tax-financed programs to be sure they are not abused.
Nonetheless, it is the thesis of my presentation that the competent, ethical physician is indeed the only able guardian of the public interest in the area of consumer expenditure for medical care. As an aside. I should note that, despite my published title, I do not intend to deal with Health Care Costs, since, in the language of the economist "cost" is overwhelmingly a matter of the price-tag on labor, materials, supplies, utilities-elements generally apart from the influence or control of physicians. The area of physician concern, quite obviously, is that in which he influences expenditures by or on behalf of his patient for the goods and services of the Medical Care Industry.
It is important to recognize that the guardianship to be exercised by physicians is one dealing chiefly with specific services involved in individual cases. It is concerned with professional medical decision making. Is it necessary to hospitalize this patient? Do we need extensive laboratory and X-ray studies? How about private-duty special nursing care? What medications will do the job? Is