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Board of doctors says: Don't order that useless testFollow

#1 Apr 04 2012 at 8:25 AM Rating: Excellent
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A new round of guidelines to doctors recommends against futile treatments or tests that have been shown to have no little or no effect on patient survival.

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Nine medical societies, including the American Society of Clinical Oncology and the American College of Cardiology, representing nearly 375,000 physicians are challenging the widely held perception that more health care is better, releasing lists Wednesday of tests and treatments their members should no longer automatically order.

The 45 items listed include most repeat colonoscopies within 10 years of a first such test, early imaging for most back pain, brain scans for patients who fainted but didn't have seizures, and antibiotics for mild- to-moderate sinus distress.

Also on the list: heart imaging stress tests for patients without coronary symptoms. And a particularly sobering recommendation calls for cancer doctors to stop treating tumors in end-stage patients who have not responded to multiple therapies and are ineligible for experimental treatments.


Such voluntary rationing is expected to help eliminate waste within the system. The guidelines do get specific - when studies have shown certain treatments to be effective or have evidence that a test prevents or helps diagnose the illness further, the recommendation is to go forward still.

The problem apparently is an entitled attitude among Americans with insurance: I have insurance, therefore I deserve to have this test paid for, and it will help me sleep at night even if it doesn't show anything further wrong with me. And doctors have been complicit, which means giving antibiotics for viral sinus infections because patients insist on it, or ordering invasive biopsies for things that turn out to not be cancer at all. (I remember when my mother had a lumpectomy on a breast, and it tuned out to be a clogged pore. And any dermatologist would have known that, but because she went to an oncologist, they panicked.)
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#2 Apr 04 2012 at 8:31 AM Rating: Excellent
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One recommendation likely to stir controversy, and even revive charges of "death panels," is to not use chemotherapy and other treatments in patients with advanced solid-tumor cancers such as colorectal or lung who are in poor health and did not benefit from previous chemo.
So not using something that has already been used and was ineffective a second (or more) time is going to be associated with a Death Panel? Sounds like law enforcement: No matter what you do, you'll always be considered the bad guy.
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#3 Apr 04 2012 at 8:32 AM Rating: Excellent
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Chemo does terrible things to a body and if it hasn't worked the first or second time, maybe making someone go through that again for what will ultimately turn out not to work is rather cruel.
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I can't understand anyone who skips the cutscenes of a Final Fantasy game. That's like going to Texas and not getting barbecue.

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#4 Apr 04 2012 at 8:45 AM Rating: Good
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Yeah, it's a quality of life thing. If someone is dying of cancer, and the chemo is making them sicker and not made them any bit better (no shrinking of the tumor), then let them live out the end of their life without poison coursing through their veins.
#5 Apr 04 2012 at 9:00 AM Rating: Excellent
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I'm sick and tired of doctors coming between the insurance companies and myself in determining proper health care Smiley: mad
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#6 Apr 04 2012 at 9:12 AM Rating: Good
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I loved my doctor in Nebraska. While she was trying to figure out what was wrong with my digestive track she had me scheduled for various tests. The thing was though she went with the cheaper tests of results that it was more likely to be. I have yet to get a doctor here in Georgia but I don't think I am going to get lucky enough to find a doctor like I had back in Nebraska.
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#7 Apr 04 2012 at 9:33 AM Rating: Good
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Criminy wrote:
I loved my doctor in Nebraska. While she was trying to figure out what was wrong with my digestive track she had me scheduled for various tests. The thing was though she went with the cheaper tests of results that it was more likely to be. I have yet to get a doctor here in Georgia but I don't think I am going to get lucky enough to find a doctor like I had back in Nebraska.


We actually have some great doctors here in Athens - everyone knows that this town is famous for musicians, but the other thing its famous for is medicine, what with two major award winning hospitals always trying to one-up each other and hundreds of specialists all networked through one or both of them.

I'm sad that my old primary care physician Dr. Bell moved to Raleigh Durham on me, but my new doctor, Dr. Boran, is actually almost as funny so far. Smiley: lol
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Thayos wrote:
I can't understand anyone who skips the cutscenes of a Final Fantasy game. That's like going to Texas and not getting barbecue.

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#8 Apr 04 2012 at 10:05 AM Rating: Excellent
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Sadly I've found myself with little to say on this topic. I think I expended all of my healthcare energy in the other thread. Smiley: frown

I wouldn't want to be the doctor who has to tell people to give up on their loved one, because they were beyond hope. But I suppose that's why I'm not a doctor i nthe first place.

catwho wrote:
We actually have some great doctors here in Athens - everyone knows that this town is famous for musicians, but the other thing its famous for is medicine, what with two major award winning hospitals always trying to one-up each other and hundreds of specialists all networked through one or both of them.


This too. We have some very good clients from your neck of the woods. One of which I need to get data to while I'm thinking about it... Smiley: lol
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#9 Apr 04 2012 at 2:57 PM Rating: Decent
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Jophiel wrote:
I'm sick and tired of doctors coming between the insurance companies and myself in determining proper health care Smiley: mad


Except it's not "your doctor", it's a couple of societies of doctors setting guidelines. And while I agree with the logic behind them, the problem is that the insurance companies will use those guidelines to determine what they will pay for and what they wont. So it ends out being the insurance companies, following these guidelines, overruling the decision made between a patient and their doctor.

Not all cases will fall into the guidelines. While I absolutely agree that we over medicate and over test, I think a better approach is to limit liability to doctors. Most of those unnecessary treatments and tests are pure CYA. This is part of the tort reform which Republicans wanted to see in our health reform, but the Dems opposed. It's not that we disagree on the problem, but the solution. It's about what happens as a result of these guidelines that matters. If a doctor following the guidelines, and in full discussion with his patient, is protected from lawsuit in the rare case that something negative happens as a result we get the same cost reduction while still allowing doctors to identify those rare cases and act on them and still have the procedure covered.
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#10 Apr 04 2012 at 3:40 PM Rating: Excellent
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You know, Gbaji, I only know one person who ever went through with suing her doctor. It was a coworker's sister, about ten years ago. She went to her podiatrist for a routine bunion removal. A week later she noticed a strange smell coming from her big toe, and mentioned it to the doctor at her follow up visit. He said not to worry about it. A few days later the toe appeared to bruise, so she went back again, very concerned. He said not to worry about it. Yet another week later she came back in a panic because the toe had turned black. He said it was "normal" and she had been fine.

A few days later she was in the ER with gangrene and had to have it amputated.

They sued, and they won, because no **** practicing podiatrist should fail to recognize the symptoms of gangrene.

The settlement was $400K, which covered pretty much the costs of the medical bills and the prosthetic she had to get. The girl was only 19 years old.
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Thayos wrote:
I can't understand anyone who skips the cutscenes of a Final Fantasy game. That's like going to Texas and not getting barbecue.

FFXIV: Katarh Mest on Lamia - Member of The Swarm and leader of Grammarian Tea House chat LS
#11 Apr 04 2012 at 4:02 PM Rating: Good
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The number of suits, and the dollar amount of the settlements is only part of the picture though. The bigger part of it is the costs for extra tests "just in case". Again, the problem is that the doctor (or the health provider he works for) is the one on the hook if something bad happens and he gets sued. But, if it orders extra tests he can pass that on to the insurance company, who'll pass it on to the customer. Since the customer is already paying for that extra cost for everyone else who has a doctor who orders all sorts of "just in case" tests, there's no reason to say "let's save money and not do the tests".


In fact, there's no incentive at any level of the process to not do every test under the sun "just in case". And there's a lot of incentive to do those often unnecessary tests.

If, however, you were responsible for paying for those tests right out of your pocket, you will then engage in a conversation with your doctor and make a decision as to which tests you want done and which you don't want. The doctor has an incentive to keep costs low, and the patient does as well, and both of them balance that objective against the desire for a positive health outcome. This is the best way to ensure that we do only those tests which are actually needed, while retaining the freedom of the patient to get more if they want. If you're willing to pay an extra $100 for a test with a low percentage of being useful, you're free to do so. But you get to make that decision. Right now that decision is being made by a doctor who's primary concern is not getting sued (or he's being ordered to by his employer in most cases).

That's how lack of tort reform in our health care drives up prices as well.
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#12 Apr 04 2012 at 4:13 PM Rating: Good
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catwho wrote:
A few days later she was in the ER with gangrene and had to have it amputated.

They sued, and they won, because no @#%^ing practicing podiatrist should fail to recognize the symptoms of gangrene.

The settlement was $400K, which covered pretty much the costs of the medical bills and the prosthetic she had to get. The girl was only 19 years old.


Who the **** needs a prosthetic toe?
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You guys keep tossing facts out there like they mean something.


#13 Apr 04 2012 at 4:20 PM Rating: Good
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BrownDuck wrote:
catwho wrote:
A few days later she was in the ER with gangrene and had to have it amputated.

They sued, and they won, because no @#%^ing practicing podiatrist should fail to recognize the symptoms of gangrene.

The settlement was $400K, which covered pretty much the costs of the medical bills and the prosthetic she had to get. The girl was only 19 years old.


Who the **** needs a prosthetic toe?


Maybe she was a foot model?
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#14 Apr 04 2012 at 4:40 PM Rating: Excellent
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gbaji wrote:
Jophiel wrote:
I'm sick and tired of doctors coming between the insurance companies and myself in determining proper health care Smiley: mad
Except it's not "your doctor", it's a couple of societies of doctors setting guidelines
Wow. you not only wrote a couple paragraphs response to a one-line joke but you managed to miss the minimal point of the joke as well Smiley: laugh
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#15 Apr 04 2012 at 4:49 PM Rating: Good
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BrownDuck wrote:
catwho wrote:
A few days later she was in the ER with gangrene and had to have it amputated.

They sued, and they won, because no @#%^ing practicing podiatrist should fail to recognize the symptoms of gangrene.

The settlement was $400K, which covered pretty much the costs of the medical bills and the prosthetic she had to get. The girl was only 19 years old.


Who the **** needs a prosthetic toe?


Had this been a pinky toe I might have understood. I've heard that losing your pinky toe can lead to serious issues with balance. I would guess this is because a lot of people walk improperly and put undue stress on the outside of their feet (I know I do).

But with it being a big toe, this was my exact thought.
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#16 Apr 04 2012 at 4:53 PM Rating: Default
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without a big toe how are you going to pick sh*t up with your foot because you do not feel like/can't bend over. (Maybe thats something I do because I get bad back pain every so often, because I sleep on my face.)

Edited, Apr 4th 2012 6:54pm by rdmcandie
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#17 Apr 04 2012 at 5:14 PM Rating: Good
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Your big toe is important to balance, too. Walking around without a big toe is like walking around with half of your foot.
#18 Apr 04 2012 at 5:24 PM Rating: Good
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Guenny wrote:
Your big toe is important to balance, too. Walking around without a big toe is like walking around with half of your foot.


This was the issue - it was the big toe up to the first joint (the thing that caused the bunion in the first place.) If it was just the toe it might not have been such a big deal, but the emergency amputation took off the entire surgically worked area because it was gaseous gangrene, the most dangerous type caused by a bacterial infection and they didn't want to take any chances.

Walking without a prosthetic for balance would be difficult. Her sister said they did get a pretty nicely **** prosthetic, one that looked decent enough for her to not be afraid to wear sandals at the beach.

Edited, Apr 4th 2012 7:24pm by catwho
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I can't understand anyone who skips the cutscenes of a Final Fantasy game. That's like going to Texas and not getting barbecue.

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#19 Apr 04 2012 at 5:27 PM Rating: Decent
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Here's an analogy that explains why costs go up when you use insurance to pay for things instead of paying directly.

Imagine there's a group of 100 people and every week they go to the same restaurant for dinner. Imagine that the cost for dinner at this restaurant ranges from $20 to $40 depending on what you order. Initially each person orders his own meal and pays his own check. The members of the group order a range of meals that averages to $30 each, with some people ordering a $20 meal, and some ordering a $40 meal, and a whole range in between.

Over time, the group thinks that it's a pain in the **** to have 100 different people all paying with separate checks, so they decide to just pay collectively. They'll just allow everyone to order whatever they want and then split the check evenly among the whole group.

What do you think will happen to the average cost per person? What happens is that a "I'm going to get my money's worth" factor comes into play. All the people who were ordering meals between $20 and $30 will realize that they're going to pay $30 no matter what they order. So they may as well get their money's worth and order something at least $30. But this changes the average and makes the cost higher. So each week, as people realize this, they'll tend to order a more expensive meal to "get my money's worth", until the average price will end out just under $40 (cause there will always be a few who'll order something less than the maximum).

But that's only the first order effect. The restaurant owner knows that this group comes in each week and does this. He's no dummy, so he realizes that if he adds new and more expensive items to his menu, people in the group will start ordering them, and the price will keep going up and he'll make more money. Of course, he wont take the less expensive items off the menu, but it doesn't matter. The method of payment ensures that the group in question will over time gravitate to ordering mostly the most expensive items on the menu and he'll make more money.


Obviously, this isn't a perfect analogy. People don't have 100% choice about what health care they receive at any given time. No one's going to choose to break an arm just so they can get their money's worth out of their insurance. However, when we start pushing into the "preventative care" that choice factor does come in. If I'm already paying my share for insurance, I may as well get as many checkups a year as I can, and demand that the doctor perform as many tests as he can. In my opinion, since I'm paying as part of a collective into the pool of money we all share, I may as well "get my money's worth".


We could take the analogy even further btw and start talking about member of the group who can't afford the (now very high) cost of dinner. We could have the group leaders mandate that those who can afford it must pay more so that those who can't pay less (or none). And while that will help those who used to be able to afford to buy the $20 cost for dinner, but can't afford $40 (or more!), it does so by increasing the cost for the rest even more. Which means that more people wont be able to afford the cost. So we'll have to push that cost onto an even smaller portion of the group. Of course, if we get to a point where more than 50% of the group are getting free meals at the expense of the minority who can afford it (and we assume that decisions within this group are made by majority vote), why shouldn't they vote to add lunch to the deal as well? Or do this every day instead of just once a week? Or change venues to an even more expensive restaurant?


That's how you get out of control costs and frankly some horrible abuses of power.
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#20 Apr 04 2012 at 5:35 PM Rating: Excellent
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The analogy falls apart when you add in the factor that 90% of the people only go to the dinner once a year.
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Thayos wrote:
I can't understand anyone who skips the cutscenes of a Final Fantasy game. That's like going to Texas and not getting barbecue.

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#21 Apr 04 2012 at 5:38 PM Rating: Excellent
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When I had my incident, and I was coherent enough, I told the medics that if they removed my leg I wanted it to be replaced with a peg. With a **** knife.
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#22 Apr 04 2012 at 5:43 PM Rating: Excellent
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I'm a big boy so I don't throw a hissy fit when we split the bill. Also, I rate going out for dinner on a different plane than medical care.

Edited, Apr 4th 2012 6:44pm by Jophiel
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#23 Apr 04 2012 at 6:04 PM Rating: Good
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Not to mention, that the price of food is something people comprehend. They "want their money's worth" if they are ordering a $20 burger. For medicine, how are us normals supposed to know how much a blood draw is supposed to cost vs the price of a MRI? Or blood test A vs blood test B? Also, if I'm hungry and I can't afford a $20 burger, I go to McDonald's and order off the dollar menu.
#24 Apr 04 2012 at 6:09 PM Rating: Excellent
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When I had my incident, and I was coherent enough, I told the medics that if they removed my leg I wanted it to be replaced with a peg. With a **** knife.

I bet they were out of knives and were **** they had to work on your leg.
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#25 Apr 04 2012 at 7:02 PM Rating: Excellent
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I wouldn't want to be the doctor who has to tell people to give up on their loved one, because they were beyond hope. But I suppose that's why I'm not a doctor i nthe first place.


It's a kindness to be straightforward with a dying patient and his/her family.
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#26 Apr 04 2012 at 7:11 PM Rating: Good
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Not to mention the restaurant won't deny you food if you've had to go in and eat before.
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#27 Apr 05 2012 at 10:36 AM Rating: Good
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Not to mention the restaurant won't deny you food if you've had to go in and eat before.


Dunno, I've heard that 'eat all you want' Chinese buffets sometimes do that with fat folk.

Edited, Apr 5th 2012 12:36pm by Eske
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