It’s no secret that the cost of healthcare in this country seems to be exponentially rising. We are one of the only well-developed western countries without an efficient healthcare system. Unfortunately, healthcare is still a business in the U.S. That means money.
Should it be? This seems to be at the heart of the debate these days. Should caring for someone’s life involve decisions that involve money? There are serious flaws in this type of system, as you can imagine.
First of all, doctors tend to be pretty clueless when it comes to money. We don’t know how to manage it. We don’t get trained on how to do this, and our head is stuck in a book for a minimum of 11 years post high school. By the time we start earning an income, we have no idea how to handle it or how to manage a business if we decide to pursue private practice.
We also don’t know how much anything truly costs in medicine. During my residency training, I particularly remember an uninsured friend who was picked up by an ambulance and transferred to the ER. I was absolutely floored to learn that the cost of the entire ordeal was over $25,000. Doctors are not well-trained to understand the cost of tests—this was the first time that I was exposed to the financial side of medicine. I was so focused on learning the art of medicine and how to problem-solve that I neglected this important component of our current U.S. system.
This can be good or bad. It’s good because you don’t want your doctor to think about the cost of anything they deem worthy of your health—you want them to practice medicine as it should be. Their decisions should be without those financial distractions. But it may be bad in another sense because it doesn’t reflect your reality—you may actually receive a bill, and perhaps an outrageous one at that, and you find it difficult to pay off for a long time to come. Especially if it’s a test that you really didn’t even need in the first place.
Most doctors are employees of large groups that aim to protect their reputation and jobs, just like any other business. Patients pay heftily for their health plans, understandably have high expectations for their care as a result, in a system where physicians are rated by patients online and employer surveys and not by the quality of medicine they deliver.
Most doctors are employees of large groups that aim to protect their reputation and jobs, just like any other business. Patients pay heftily for their health plans, and understandably have high expectations for their care as a result. And because physicians are rated by patients online or by employer surveys and not by the quality of medicine they deliver, an unhealthy cycle ensues where doctors may hesitate to deny patients their requests.
Where does this all lead?
To the cycle of over-testing, over-spending, and increased costs.
What also works against us docs is the ever-growing media monster that drives up costs of drugs, using skewed pharmaceutical advertisements that attempt to brainwash the masses in order to sell their drugs. "Low T" (referring to "testosterone"), anyone? How can I compete with that as a lowly physician in a clinic? And why am I placed in that position to do so in the first place, anyway?
It doesn’t look like our healthcare system is changing significantly any time soon. So us doctors need to fight back. We need to start saying no, and to educate the patient population as to why we are saying no. And patients can do their part by finding a doctor that they trust, and to try to learn the pros/cons of tests so that they understand why some tests are bogus and unnecessary.
Here are a few tests that many people think they need, but really don't.
1. Vitamin D Level
“Dr. Majd, can you also check my vitamin D level in my blood work?”
“Why are you concerned about your vitamin D level?”
“Because I’m tired all the time. And my sister tells me that Vitamin D can give me energy, and that I should get my level checked to see if I’m low.”
The hype is frustratingly widespread, and it’s truly a challenge to fight the vitamin D battle. The media has portrayed vitamin D as the miraculous answer to all things medical, from fatigue, to depression, to heart attacks, and even to cancer. But there’s not a lot of science to back up all these claims.
In fact, the vitamin industry is now quite a profitable one. If you recall a decade or two ago, the vitamin craze hadn’t hit yet. Everyone prefers something “natural” to treat their ailments nowadays. Hey, I’m with you on that. I wish there were a true “natural” option for everything. But as I’ve mentioned in my prior podcasts, not everything “natural” is safe. Or effective. But the vitamin industry doesn’t tell you that—that they remain unchecked and FDA unregulated.
The truth is that there is no good evidence that even checking vitamin D levels in most patients is beneficial. What population has been shown to possibly benefit from checking levels?
- Elderly patients at risk for falls
- The elderly in nursing homes or home-bound
- Those with intestinal disease such as Crohn's and Celiac
- Certain surgeries with removal of intestines or stomach
- Those with kidney or liver disease (that help metabolize vitamin D)
- Those with osteoporosis and parathyroid disorders
And get this: expert groups don’t even agree on what “normal” levels are. Some say 20 and some say 30. We don’t really know.
The cost for this one single test? Hundreds. And insurance often will deny coverage for anything that is not backed up by evidence. Unfortunately, the patients often ultimately carry the load and receive the bill.
2. A Shoulder or Knee MRI
As with everything else on my list, I am referring to most—most people with shoulder or knee pain don’t really need an MRI. Are you surprised to hear this? You're definitley not alone.
Let’s take this example: You are in your fifties or so and have been suffering from chronic knee pain for the last one to two years now. You finally discuss it with your doctor, who may order an X-ray. But it’s normal—now what? An X-ray doesn’t say much for the soft tissue, ligaments, and meniscus, right? So you request an MRI. What if you have a meniscal tear?
Meniscal knee surgery is the top knee surgery performed by orthopedic surgeons in the U.S. It costs an estimated $4 billion annually alone. Studies have recently shown that whether you have knee surgery for a degenerative meniscal repair or not, the end point is really the same. People do equally as well with conservative treatment (physical therapy, activity modification, anti-inflammatories, etc.) long term.
Now, an MRI is typically only useful if you are ready to surgically repair it. So let’s say you do have that knee MRI and it shows a ligament or meniscal tear? What will you do with that knowledge? Lots of people have a meniscal tear and live with it, and that is totally fine. There’s nothing “dangerous” about leaving it unrepaired for most people.
But we just spent thousands of dollars for a test that will not really change our outcome one way or another. What’s the point of doing it in the first place? Simply “to know”? In my humble opinion, it’s not worth contributing to the rising healthcare costs by performing unnecessary MRIs, one of the most commonly ordered high-cost tests in medicine.
3. Hormone Levels
“I am so moody these days, Doc. Can you check my hormone levels?”
By “hormone levels,” we are often referring to the female feed-good hormones estrogen, progesterone, and their precursors. Did you know that in a menstruating female, these hormone levels are all over the map? It can be low and seemingly in the menopausal range on one day, and then high enough to carry a pregnancy on another. In women who still have cycles, testing the levels are not very revealing because of this.
And the blood levels certainly cannot explain any moodiness. Here’s an article that explains what can cause moodiness, however.
The truth is, the symptoms of “perimenopause” can begin up to 5-10 years prior to menopause. Symptoms can plague us women during this entire time period. We don’t need a blood test to tell us that. Hormone levels are not even typically necessary to diagnose menopause, either, which occurs at an average age of 51 in U.S. women and is defined simply by a period of one year without menstrual bleeding. That’s it; no test needed.
Now, there are instances in which checking hormone levels may be useful. For example, it would be unusual for a 35-year-old young women to be in menopause. In this case, the blood levels may be useful if there are no cycles and I’m wondering if she’s had premature ovarian failure.
I don’t know my blood type either. The truth is, it’s not generally useful to us doctors.
Fertility clinics also may order estrogen levels to determine when to administer certain treatments.
4. Blood Type
I always get taken back when I receive the request to order a blood type on a patient. It’s not terribly often, but it does happen.
"I just would like to know, Doc. I’ve never known.”
Me neither. I don’t know my blood type. The truth is, it’s not generally useful to us doctors unless:
- You’re donating blood products.
- You’re receiving blood products.
- You’re pregnant.
Outside and nearby countries seem to routinely order blood types on patients. But as everything else in the U.S., unless there’s a scientifically-validated reason for ordering it, your insurance will send you a nice fat bill for this one, too.
So you have now taken part in some of the explanations that I hear myself reiterating repeatedly while in clinic. I would say that about 99% of patients are very understanding and are on the same page with me after learning the real scoop. But I must say, I do tend to attract a very kind patient population who trusts my expertise.
Today we’ve reviewed four of those conversations. Next week, let’s pick up where we’ve left off and review the next set of unnecessary yet costly tests that are commonly ordered in medicine.
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Please note that all content here is strictly for informational purposes only. This content does not substitute any medical advice, and does not replace any medical judgment or reasoning by your own personal health provider. Please always seek a licensed physician in your area regarding all health related questions and issues.
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