Here is my response:
As a general internist concerned about not only the health care of my patients but of our nation, I like to think that I do my part to practice cost-effective medicine.
Jonathan Rockoff’s post about the Archives study listing the “Top 5” unnecessary health care expenditures bears some further analysis.
1. Brand name drugs. I always attempt to prescribe appropriate generic medication. I know it’s equally effective and costs everyone less. The problem is that a) direct-to-consumer marketing makes some patients insist on the brand name, b) some insurance company formularies often offer discounts on more expensive drugs (e.g. Lipitor vs. simvastatin) and c) mea culpa: we often are loath to change something’s that working, especially if a patient takes the medication and is able to get it for a reasonable price.
I will agree that not enough of us give consideration to what our patients can or will pay for medication. Some patients are certainly too shy to question us on this.
2. Bone density scans for women ages 40-64. No reason to order these except in special circumstances, like chronic steroid use or thyroid disease. In our culture of over-medicalization, women are requesting these tests all the time–the bisphosphonate manufacturers (Fosamax, Boniva, etc.) inundate our TV waves with fears about thinning bone, even in normal people. Sadly, it’s easier to placate a patient who wants something (under the guise of building rapport) than it is to spend the time talking them out of an unnecessary test. The stakes are pretty low for a BMD scan–it uses only low level radiation, so the potential harm is small. And in general, we like when our patients are engaged in their health and thinking about prevention.
3 & 4. MRI and CT scans for low back pain. Couldn’t agree more. A complete boondoggle. Try telling that, though, to your patient who can’t function because of their pain. I, for one, would be thrilled to have the Invisible Hand tell me I couldn’t order any more of these. They almost never show anything that’s ‘actionable.’ Even when there’s an abnormality, it’s never clear that what’s found is the source of the pain. People without back pain have abnormalities on lumbar MRIs a third of the time! My only surprise is that the authors calculated a savings of $175 million. I bet it’s closer to a billion on these items.
5. Antibiotics for viral sore throats. Fortunately, we’re making headway in this battle. Parents are learning slowly that antibiotics are not an unalloyed good. There’re side effects (C. diff, anyone?), and an increasing number of resistant bacteria due to our overuse of these medications. Still, like all of the above, when a parent is hell-bent on getting an antibiotic for their kid, if I do the hard work of telling them no, they can often run around the corner to the Minute Clinic and undermine me. And never come back since I’m too difficult.
No one said medicine is easy.