Healthcare Policy: What’s Defensive Medicine for Society Could Be Prudent Care for Individual?
by Alex Shteynshlyuger MD
It is certainly newsworthy when the President of the United States has to go to a hospital for medical care.
President Obama recently underwent evaluation with endoscopy for sore throat which revealed most likely findings that are typical of gastrointestinal reflux (GERD). While it is impossible to be certain about the exact clinical scenario, it appears that the findings were not unusual. Nonetheless the patient, President Obama, underwent a CT scan apparently to rule out other causes of similar symptoms, notably cancer. Now, no commercial insurance company or medicaid plan would ever approve or pay for CT scan in this clinical situation – FYI Mr. President.
With typical findings of GERD on endoscopy, the chances of associated cancer are fairly insignificant. Certainly, CT scan would not be the most likely next test. Endoscopic biopsy typically is more useful; whether one was performed is not clear.
From a medical perspective a CT scan is unnecessary for diagnosis of acid reflux disease. From societal perspective, CT scan performed to confirm a diagnosis of GERD or to be more precise, to exclude malignant mass is essentially unnecessary care. Such unnecessary care in the face of a very small chance of missing a diagnosis of malignancy is considered defensive medicine. Something that doctors get sued for, insurances don’t pay for; Presidents rally against it; and patients clamor for it.
Yet while from a societal perspective such care is considered defensive medicine, from an individual perspective of President Obama who can afford CT scan or at least can have CT scan paid for by someone else, even a 0.5% chance of early detection of a life-threatening cancer with high mortality rate is a worthwhile investment.
This is not to say that the CAT scan the president had done is necessarily defensive medicine, as we do not know the exact clinical situation that prompted the ordering physician to request a CAT scan. But based on most likely scenario, the best care for an individual in this case (getting CT scan) is not necessarily the best care from the societal perspective or at least not something a Society can afford to pay for.
The obvious question is as follows: What do we tell the patient? Will CAT scan cause harm? It’s possible that over-diagnosis can cause real harms. But missing a diagnosis can also be harmful. How do we make a decision? Society certainly does not want to pay for President Obama’s CT scan that has may be 1/300 chances of finding cancer.
Each person has a different tolerance for risk and values his or her life differently. Should a doctor use his or her risk tolerance to advise whether to get a certain study? Should society decide for what risks it is willing to pay and those with lower risk-tolerance would be left to pay for their level of risk tolerance and extra tests?
Should we simply tell patients a simple version that tests are not recommended without telling them the deeper narrative that cost considerations are involved in what is recommended and what’s not?
Food for thought….
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