A Model for Professional Action

A Model for Professional Action

Patients have a critical role to play in cutting costs in the health care system. Anxiety about outcomes or lack of trust in their providers or the system of care may lead patients into demanding postures that drive up the cost of their care without adding to the quality of outcomes. It also may give the physician an increased concern about being sued, which will lead to even more tests and procedures to defend against accusations that something was omitted from care. While there may be instances where the patient’s demand for a test or procedure leads to an improved outcome, that event is far outnumbered by a disastrous increase in costs and risks.

Take a patient in the office with a simple cold and cough. The lungs are clear, there is no fever and the patient is in no respiratory distress. When told that the condition is a cold, the patient questions the diagnosis. “I really can't afford to be sick right now. Can't you give me something to make this go away faster?” The patient wants an antibiotic and there is little reason for the doctor to say no, or is there? Though antibiotics don't help in the common cold, I have had patients leave my practice after I refused to prescribe an unnecessary antibiotic. Why fight it? This issue has become so important because of the development of dangerous resistant organisms that threaten everyone. It wasn't because of the cost of antibiotics, but the risk that drove doctors to get together to reduce abuse. What did they do?

Get Smart: Know When Antibiotics Work is a health education campaign of the National Center for Infectious Diseases of the Centers for Disease Control and Prevention. Over 200 health care professionals attended their last meeting in 2004 dedicated to promoting appropriate antibiotic use. The AMA, the American College of Physicians and the American Academy of Pediatrics are all part of the process. They had a variety of ideas presented at the conference aimed at decreasing inappropriate antibiotic use in people and animals. (The indiscriminate use of antibiotics in cattle and birds contributes to resistance of bacteria in humans. Recent experience with anti viral medications and the bird flu have demonstrated just how quickly resistance can develop. In 2005, the CDC declared that Amantadine and rimantadine, formerly effective treatments for Influenza A, were no longer effective in the majority of cases. They traced resistance directly back to the use of anti viral drugs by Asian chicken farmers trying to protect their birds from the “bird” flu.)

The CDC has provided physicians with guidelines for appropriate antibiotic use and a media campaign highlighting the dangers of inappropriate antibiotics has been directed to the public. I’ve seen newscasters on the evening news and morning TV shows giving the message. They’ve even developed a medical school curriculum about appropriate antibiotic use that is available to any school that wants to use it. It is an all out campaign.

Why is this so important? Inappropriate antibiotic use may contribute slightly to the overall cost of medical care, but not that much. Physicians and physician groups are intimately involved in the program because it has clinical relevance, addresses concerns about the quality of medical care and has been deemed to be important in the scientific media. Any cost savings here are purely coincidental, at best an example of how improving quality can reduce costs.

The campaign to reduce unnecessary antibiotic use, however, should be a model for a campaign to reduce any and all unnecessary expenses in the medical field. It is directly analogous to any future campaign to reduce health care expenses.

In either situation, physicians desperately need a reason to spend extra time and effort doing the right thing to achieve a common objective which is not solely determined by the need to treat the patient and which does not contribute to financial gain. Inappropriate antibiotic use has a small effect on each patient, but a large effect on the community as a whole. Excess spending on health care is the same. For each patient it may be a small expense. The aggregate is harmful to everyone and to society as a whole.

In order to succeed, organized medicine and all its various organizations had to make this focus on appropriate antibiotic use a legitimate area for discussion, research and practice. They had to make it clear to physicians and patients just why it was necessary to change behavior. They had to make it clear to the individual patients that they are not being denied their right to antibiotics, they are being given proper medical care according to the best scientific guidelines. They had to make the community aware that the failure to provide antibiotics to a patient with a suspected viral illness is not malpractice or breach of duty.

It will take just such an effort to change behavior concerning costs. As it stands today, physicians have no incentive to try to reduce costs. There is no institutional or organizational support for such efforts and some patients continue to expect and demand access to every treatment out there that might help. Failure to treat is a much more heinous crime than over treating, and a physician today is more likely to be sued for failure to diagnose and treat a real condition than for trying to diagnose or treat a condition that isn’t there.

This, then, is a call to action. There should be debates at scientific conventions about the value and ethics of considering cost as a factor in the care of patients. Payers should demand that these discussions take place among physicians. Government institutions such as the NIH should study the issue and convene expert panels to review the situation. The full power of organized medicine should develop a strategy to contain costs while providing quality medical care. This is the only strategy for medicine that will prevent a meltdown of the system and risky government decisions that may mean the end of the most creative and beneficial medical establishment on the planet. We need to get to work and we need to get to work now!