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There are now some ways to do a lot of this testing less expensively. Machines which larger laboratories can afford can now automatically do a dozen different tests on one blood sample that are quite reasonable, and so, even if you are not interested in half of the results, the total cost is fairly cheap. For a long time some hospitals have had miniature X-ray machines that take small films of the chest (a common requirement) as a screening procedure. The use of mobile, free chest X-ray units is standard in some communities, using this inexpensive method, and is a good thing.

The biggest variable in medical costs is up to the individual doctor; how he manages each case. I have illustrated this in another article published in Medical Economics, Aug. 5, 1968, “Spare the Purse and Please the Patient”, a reprint of which I enclose. The savings our profession could manage, if we were all as cost conscious as I am, are enormous, certainly hundreds of millions a year. However, I don't see how you could legislate that certain cases must be done as outpa. tients and others as inpatients, or whether or not to use general anethesia, etc. All we can do here is preach and teach. Some doctors don't have facilities for minor office surgery and some are not confident enough to do anything outside of the hospital atmosphere. Some just weren't trained to do things simply. Again malpractice threats influence some unduly.

I think your committee would be interested in a third article published in Medical Economics Sept. 3, 1968, “The Case for Small Town Specialism”. Regional health planners are talking about sending more and more medical cases to big city centers or clinics and de-emphasizing community care. I refute that concept as being economically catastrophic and niedically undesirable. This article describes the problems and how a community hospital really can give excellent care for all but the rare or unusual cases.

I am sorry that I am not in a position to supply your committee with meaningful statistics. I suspect you have enough of them already. All I can supply is the philosophy of the practicing doctor on the front line of medicine. As I say, spokesmen for medicine are mostly from medical schools or big centers and their view lacks total perspective. My articles and my book may, I hope, give you a different slant.

Please feel free to contact me at any time. I am very concerned about the cost of medicine and would be glad to help your committee in any way I can. Sincerely yours,

G. B. MARKLE, M.D. [Enclosures]

EXHIBIT A: SHOULD HOSPITALS REQUIRE SO MANY TESTS?

[From Medical Economics, Sept. 30, 1968)
Definitely not, says this doctor, who contends that too many hos-
pitals are routinely ordering medically unnecessary tests and exami-
ations. By reducing the number of such unnecessary tests, he argues,
physicians can help to cut the cost of medical care.

(By George B. Markle IV, M.D.) Everyone is complaining about the sharp rise in health-care costs these days, but finding ways to reduce those costs is no easy matter. “Rising costs aren't our responsibility," physicians are likely to say. True, most higher costs are due to higher hospital bills, but we physicians do have a lot to say about those bills.

I'm not talking about reducing bills by cutting down on unnecessary admissions and shortening hospital stays. We're all aware of such important ways of saving the medical dollar, and we're probably doing about as much as we can in that direction. But I don't believe we're doing enough about doing away with medically unnecessary examinations and tests when we must admit our patients to hospitals.

My hospital's record committee, for example, has just returned some charts to me because physical examinations weren't complete. One chart was that of a young man who had suffered second-degree burns of his back and arms when a can of gasoline exploded. Although the burns were limited, I still hospitalized him for a couple of days to give him open-air-exposure treatment. He'd no other complaints, and he told me that he'd been in good health. In fact, he needed only a bit of nursing care and a bed where I could watch him. But the hospital insisted that he have a complete blood count, a urinalysis, a chest X-ray, and a V.D.R.L. These tests, like the complete physical that I'd omitted were strict hospital policy. Another patient had two toes crushed by a mine car. He needed bed rest, with elevation of his leg, frequent medication for pain, and observation for possible infection or gangrene. Though hospitalization was indicated, I saw no need for a complete examination, since he didn't require a general anesthetic. I didn't do a rectal exam, and I ordered no lab work. Of course, the work was done anywayand I was the recipient of a little billet-doux from the record committee.

In a third instance, a little boy fell off a horse and suffered a supracondylar fracture that I reduced under a general anethetic and immobilized in plaster. The boy's mother gave me a negative past history and a negative history for any of his current problems. So I checked his throat, heart, and lungs, and went to work. I admitted him to the hospital because of possible pain, possible ischemia of the arm, and to elevate the arm for a day or two under observation. Since I wrote no lengthy history, I got back the chart with snide remarks to the effect that it hadn't been completed. The lab work, to top things off, had been finished about an hour before the boy was discharged, and the lab report was sent to the record room for the greater glory of the record committee and the Joint Commission on Accreditation of Hospitals.

How often does this sort of thing occur in your hospital? Daily, I'd guess. Think of the unnecessary cost to the patient for tests that aren't likely to benefit him ! And what about the doctor's time? You can't do a thorough systemic review, past medical history, social history, followed up by a complete physical examination in much less than 30 or 40 minutes. Of course, I'm talking about only the isolated injury or the simple complaint. If the patient seems to have other ailments or if the diagnosis is obscure in any way, then the execution of a good history and physical is obviously indicated, and routine lab work plus the needed specific tests and X-rays becomes justified.

Granted, we did all these tests and physical exams as a matter of routine when we were attending medical school. But, as part of our training, they were designed to benefit us as much as the patient.

What about annual physical exams? I'm all for them. Suppose that, in the absence of any medical indications for a lot of work-up, the hospitalized patient asks for a complete examination and is willing to pay for it. The doctor in charge should certainly agree to it. He can do the examination either then or later in his office if that is more convenient. But what if-as sometimes happens—the patient expects his hospital insurance or Medicare to pay for the exam? Health insurers and Medicare don't ordinarily pay for routine annual physicals, yet in some cases they're unwittingly paying for this extra work when it isn't medically indicated—all in the name of the record committee, the tradition, and the holy accreditation commission.

Many doctors and hospital administrators, I expect, will charge me with advocating sloppy medicine. They'll use statistics showing that in some communities the routine V.D.R.L. or other serology tests do pick up an occasional unsuspected case of syphilis and that some hospitals do find a few cases of active tuberculosis by routine X-rays. A heart murmur in a child may be picked up, and sometimes this is a good thing to know, and sometimes not. During physical exams, I sometimes find an unsuspected hernia, though the patient would probably have found it himself soon enough.

Well, I'll concede that routine testing has some merit—but only for certain types of patients. For example, those with a history of promiscuity probably should have a V.D.R.L. whenever you can catch them. Others, particularly heavy cigarette smokers, should have chest X-rays often. Elderly people, since they're more prone to various ills, should be given regular physicals. Last month, for instance, I discovered breast cancer in an elderly woman who had been admitted to the hospital for phlebitis.

What it boils down to is that all medicine, at best, is a compromise between the ideal and the practical. Ideally, we could pick up more diseases by giving people physical exams throughout the year. But, practically, we can't advocate that kind of medicine. If we did an upper G.I. series on all adults annually, we could find an occasional stomach cancer. But we don't because the yield is too low to justify the cost of such exams. And how many doctors regularly have sig. moidoscopies done on themselves?

Some physicians are just as guilty as hospitals are in overtesting. Rather than aim for individual tests, the diagnostician often resorts to a shotgun approach in the hope that some diagnosis will fall in his lap. Testing has become a matter of blindly following routine. Yet any doctor should be able to determine when a patient needs a physical exam and specific tests. By using this more selective 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. Nolen, a general surgeon in Litchfield, Minn., would go a step further and eliminate routine lab work entirely. The physician and the patient, says Dr. Volen, 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. Nolen 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. Volen 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 article disagree with his recommendation to do away with routine hospital tests. Dr. Charles U. 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. Markle 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.”

Anotber 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 assume 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 thoro

ver for everyone who is 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)
Why not do minor operations in your office, instead of a hospital?
Use a local, rather than a general anesthetic when it's safe? Give
patients drugs from your sample drawer? The author does these
and other things to help his patients beat the high cost of medical

care.

(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.

1 Armpit.

The surgeon sent Jim a bill for $50—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 done 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 0.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.

2 Colles' fractures are the common type of wrist fractures of one or both bones.

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