After years of pondering the over-testing, over-imaging, over-diagnosis, and over-treatment that typify US medicine, I have concluded that, like everything else, it must be genetic: We have evolved a gene that controls (or rather, disinhibits) consumption in all its forms. Although the gene has yet to be identified, I think it should be designated as GETIT. The phenotype manifests as overconsumption of EVERYTHING: food, cars, housing, entertainment, appliances, energy drinks, dietary supplements. Of course, we no longer make most of these things; but we do massively produce health care: We’ve reached around 18% of the US gross domestic product (GDP) already and are projected to reach one fifth of GDP by 2021.1Â The gene may still be hidden, but clearly it has to be there.
This genetic driver has powerfully affected medicine. First, let’s pick on the patients, always a fun thing to do. Clearly, Americans LOVE consuming medical care. The statistics do not lie: Americans consume more health care per capita than any country in the world. Yet, the US leads the world in no other measure of health, suggesting that it is the act of consumption, rather than the medical benefit, that drives the process. Physicians every day face patients with viral upper respiratory infections demanding antibiotics, with headaches or back pain demanding magnetic resonance imaging (MRI) and narcotics, with upset stomachs demanding computed tomography … Of course, most physicians know that the overwhelming majority of these patients have self-limited diseases. But they also know that if their demands are not met, the patients will simply go to someone else. What’s a doc to do?
But a lot of us medical practitioners have the same mutation. Why should we be different? And if you want to consume, you gotta have the money, so medical bloat turns out to be a good thing. Of course, it’s a bit more complex than that—I don’t mean to say that all docs are money-grubbing evildoers. Defensive medicine concerns, discomfort with uncertainty, lack of understanding due to information overload, and a host of other causes beyond the GETIT mutation influence behaviors. But it is easy to see how the consumer mutation is driving the trend toward giant MBA-run corporate medical entities. The business folk have learned an awful truth: Medical overconsumption equals profits. And some physicians have taken the lesson to heart, shamelessly placing their own financial welfare above their patients. Those of us who don’t should view this move to corporatism in medicine with alarm: In your practice, how much are metrics about quality control (really, no one checks that) and how much about economic factors like Relative Value Units, referrals, utilization of imaging and testing, patient throughput, etc. And don’t even get me started on how billing is done. And how medical suppliers require hospitals to keep prices secret. And how the same MRI procedure can cost 20 times more in one place than another. And how drug companies can charge insanely more in the US than anywhere else … for drugs they make in the US.
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– Robert G. Stern, MD (Diagnostic Radiology, The American Journal of Medicine)
Tucson, Ariz
This article originally appeared in the June 2014 issue of The American Journal of Medicine.
