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Less is Often More

Sunday, April 5, 2015 // Uncategorized

Why the Best Doctors Often Do Nothing

from the Wall Street Journal March 25,2015

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H. GILBERT WELCH: Doctors worry that if they don’t do something [pick one: start a medicine/order a test/refer to a specialist], patients will be dissatisfied and go elsewhere. Doing something is a quick way to make patients feel heard, even if it is a poor substitute for actually having the time to listen. But we also feel pushed to act because many patients have been taught to believe that the good doctors can reliably fix problems by trying medications, ordering tests, and referring to specialists.

That leads to knee-jerk medicine. If your blood sugar is a little high, prescribe a pill to lower it. If you have back pain, get a CT of the spine to see what’s causing it. If you have a headache, refer to a neurologist to evaluate it (let them get the CT of the head).

Knee-jerk medicine is not good for you. More medications, more testing and more referrals quickly add up to real money–money that is increasingly, as first-dollar insurance coverage disappears, coming out of your pocket.

But the harm can be more than financial. A blood-sugar pill can make your blood-sugar low–too low. That’s not good for your heart or your brain. The CT of the spine will almost certainly find something abnormal in your back, as it does even in people without back pain. The abnormality almost certainly has nothing to do with your back pain, but may nonetheless provide a rationale for back surgery (which can have the annoying side-effect of turning acute back pain into chronic back pain). And after finding nothing abnormal in the head CT, the neurologist may suggest a neck ultrasound. While he’s checking out the blood supply to the brain, the radiologist may stumble onto a small thyroid cancer.

Now you really have a headache on your hands. And now there will be real pressure to do something (even though many adults have small thyroid cancers if we look hard enough).

Doctors can fix some problems, others are better fixed by the patient. Some problems will resolve on their own, others are better left alone (particularly those “problems” that don’t bother you). The good doctor is not the one that always recommends doing something. It’s too easy for the physician–and it’s too easy for you to get somewhere you don’t want to be.

You don’t want a knee-jerk recommendation from your financial adviser that you always need to move money around. Or a knee-jerk recommendation from your insurance agent that you always need to increase coverage. Or from your lawyer that you always need to change the will. Or from your dentist that you always need X-rays. True professionals provide considered advice. And sometimes doing nothing is exactly the right thing to do.

The same is true of medicine. Recognize that the doctor who advises no action may be the one who really cares for you.

H. Gilbert Welch is a professor of medicine at the Dartmouth Institute for Health Policy and Clinical Practice and professor of business administration at the Tuck School of Business. He is the author of  “Less Medicine, More Health–7 Assumptions that Drive Too Much Medical Care.”

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