Healthcare spending dominates U.S. political and economic debate these days, for good reason. The rising cost of medical care isn’t simply a threat to our nation’s fiscal health. It is also, in the minds of a growing number of doctors, a sign that our society’s way of treating illness is out of whack, a dual threat to our health and pocketbooks. Two of those doctors—Joshua Kosowsky and Leana Wen—have written a compelling new book about a root cause of the problem: When Doctors Don’t Listen: How to Avoid Misdiagnoses and Unnecessary Tests. We spoke with both authors about what’s wrong with the doctor-patient relationship today and how it might be fixed.
How big of a problem are we talking about?
Wen: “In their landmark report, the Institute of Medicine found that 100,000 deaths occur due to medical error every year. The majority of these are due to misdiagnoses. And this represents only the fatal errors; it’s likely that millions of other patients are misdiagnosed every year.” Kosowsky: “Not to mention all those who suffer the consequences of delayed diagnosis, often going through months and even years of frustration and uncertainty—and yes, unnecessary tests. It is estimated that 30% of all tests and treatments in the U.S. are unnecessary. This is a tremendous waste and drain on our healthcare resources, and poses significant harm to patients.”
What’s the major reason for this? Why is so much of medicine off target, either in terms of missed diagnoses or wasteful testing?
Kosowsky: “Modern medicine has veered off course. Instead of trying to figuring out what patients have—what’s the diagnosis?— health care providers have become stuck on “work-ups” and “rule outs.” It’s become easier to practice a brand of medicine that’s all about checking things off a list, rather than working towards an actual diagnosis.That’s why so many unnecessary tests are ordered.” Wen: “And patients suffer the consequences: addition risks, additional complications, additional costs. Even worse, at the end of the day, many patients are left confused and without a real diagnosis.”
What is the biggest mistake patients make when it comes to their interactions with the medical establishment?
Wen: “They don’t ask about their diagnosis, even though diagnosis is absolutely key to everything that follows! If you don’t have at least a working diagnosis, how can you treat what’s going on? How can you know what to expect? We always tell patients: Make sure you’ve talked about your diagnosis—what your doctor thinks is likely wrong with you—before you leave your doctor’s office.”
What would you say is the biggest mistake companies, governments or other organizational “buyers” of medicine make when it comes to their interactions with the medical establishment?
Kosowsky: “Paying for tests and treatments, rather than for outcomes. There are so many perverse incentives that exist in our current system of reimbursement. Doctors and hospitals get paid more if they do more, so there are incentives for doctors to order more tests and to perform more procedures. Governments and insurance companies should, instead, reimburse for outcomes.” Wen: “We think that concepts like bundled payments and population management—paying a fixed amount for an episode of care or for certain conditions – are a step in the right direction. But some of these initiatives remain unproven, and will take a while for the effects of these programs to be felt at the individual patient-doctor level.”
You write about the move away from fee-for-service to more accountable reimbursement models. Can you explain that and discuss the financial and health implications, for organizations and individuals?
Wen: “Fee for service is one of the perverse incentives we mentioned above. These models reward the doctor for doing more, even if more tests and treatments may be wasteful or harmful. Accountable reimbursement, on the other hand, is a model that’s tied to quality of care. This makes sense to us. Doctors and hospitals become incentivized to be cost-effective and act in the best interest of patients. Of course, everything has unintended consequences, and we must make sure the right outcome measures are measured, and that cost-efficiency does not result in excessive rationing of care to the point of denying needed treatments to patients. But there are pilot programs testing all of this right now.” Kosowsky: “But patients can’t afford, physically or financially, to wait for the effects of healthcare reform to trickle down. That’s why the focus of our book is at the level of the individual patient-doctor relationship: Get to the right diagnosis and the rest can follow.”
What are the three biggest takeaways for patients from your approach, in terms of improving the diagnostic process from a cost and quality of care perspective?
Wen: “First, tell your story. About 80% of diagnoses can be made based on history alone. Doctors today are under pressure to listen less and less. You have to make sure that your doctor hears your story—and the way to do so is to become a better story-teller. Know what it is your doctor is will be listening for in your story. Write it down. Practice, practice, practice.” Kosowsky: “Second, partner with your doctor in deciding what tests, if any, you need. Let your doctor know that you want to be engaged in the diagnostic process. Help your doctor be a better doctor. Wen: “Third, Make sure your doctor’s visit doesn’t end without at least a working diagnosis or a clear plan to arrive at one.”
As patients become increasingly accountable for their healthcare costs, how can they help to lower that burden? And how will that affect the quality of their care, for the good or the bad?
Kosowsky: “Patients are the key to their own health, and we believe that patients can be their own best advocates. Americans tend to think that the best care means the most care, but that’s the not always the case: more tests don’t necessarily get you any closer to your diagnosis.
Wen: “Ask why each test is being done. If you’re not sure what you’re looking for, why do the test? If there are alternatives that are less costly, do the costs of the test outweigh the benefits? This simple concept can improve the quality of each individual’s care, and reduce the costs of healthcare nationwide.”
What can or should a patient do if they buy into your approach but encounter doctors or hospitals who don’t? How do you know if a cookbook approach is being taken?
Wen: “Here are some tell-tale signs of cookbook medicine. If you are being asked mostly yes/no question: Do you have chest pain? Do you have shortness breath? Do you have headache? Chances are that someone is using a checklist to try to diagnose you. Kosowsky: “Likewise, if you find yourself being put on a ‘diagnostic pathway’—like a ‘chest pain protocol’—beware. Ask for your own pathway, one customized to you. If your doctor doesn’t seem to ‘get’ your story, that’s the biggest danger sign.”
But what does a patient do if he or she has read your book but their doctor hasn’t? How do you recommend dealing with doctors who are resistant to being their patients’ partner or answering their questions?
Kosowsky: “All of us wish we can choose the ideal doctor who does listen to us, who does want to be our partner, and who does treat us like individuals. Our book illustrates how to help make your doctor into this ideal doctor.” Wen: “In fact, our book provides what we call eight pillars to better diagnosis. We spoke about Pillar No. 1, telling your whole story. Pillar No. 2 comes next. Assert yourself in the doctor’s thought process. You need to establish a partnership with your doctor as early on in your interaction as possible. Find out what your doctor is thinking as she is taking your history. Let her know that you want to be integrally involved in coming up with your diagnosis and in the next step or steps of your care. Literally, tell her this, using these words or words like them. It will lay the foundation for a true partnership between you and your doctor.”