Shelf Life

Better medical diagnoses, lower costs

Kai Ryssdal Aug 24, 2009
Shelf Life

Better medical diagnoses, lower costs

Kai Ryssdal Aug 24, 2009


Kai Ryssdal: There’s no shortage nowadays of ideas for how to bring down the high cost of medical care. There’s mandatory universal coverage, or a government-backed insurance option, or changing the way doctors are paid. All of which are incredibly complicated problems.

Dr. Lisa Sanders says we ought to be looking more at the point where patients first enter the medical system — that initial diagnosis in the doctor’s office. Dr. Sanders writes the column “Diagnosis” in The New York Times Sunday Magazine. She’s an adviser to the Fox medical drama “House.” And she has a new book out. It’s called “Every Patient Tells a Story.”

Dr. Sanders, welcome to the program.

LISA SANDERS: Thanks for inviting me. It’s great to be here.

RYSSDAL: Do me a favor and place the art of diagnosis in the context of the current health-care debate.

SANDERS: Diagnosis is by far the most important step in figuring out what kind of resources are going to be expended on a single patient. You get the diagnosis right, right away, you’re thoughtful about it and don’t order tests like crazy, and then you only do one therapy. If you don’t get the diagnosis right, then every patient is a replay of House M.D., where you come up with a million, kabillion-dollar test, use a kabillion dollars worth of therapy, and maybe not get the right answer until 50 minutes into the show.

RYSSDAL: Yeah, I read some place that the most expensive piece of equipment in medicine is the doctor’s pen.

SANDERS: Absolutely. And yet the most effective piece of equipment is also the doctor’s pen. I mean it just depends on how it’s used.

RYSSDAL: So what’s the best way then to get the art of diagnosis more effective, and more well-performed.

SANDERS: Well, first of all I think that doctors need to have more time. Now, a doctor is free to make his schedule anyway he wants. He can schedule his … most of the time can schedule his appointments for as much time as it takes. And yet he has to see enough patients to pay for the building, to pay for the nurses and the medical assistants. You know, he’s a small business or sometimes part of a larger business, and they have their financial needs. And so the only way to give doctors more time is to pay them enough so they can see fewer patients. We pay doctors to do, we do not pay them to think. And yet thinking is what’s going to give us the best outcome and the most cost-effective outcome.

RYSSDAL: One of the points you make in this book is that a really good investment for us to make would be to beef up primary care, that that would help not only bring health-care costs overall down, which is what this whole debate is about, but also help patients enormously. Explain that, would you?

SANDERS: Certainly. The doctor who knows you best is obviously the one who is going to be best able to understand your symptoms, and the way you present your symptoms, and how it fits into the bigger picture of your health. So I think that there’s a strong case to be made that that’s the best way to be treated. But you don’t have to take my word for it. You can just look at every other industrial country on the planet. And you’ll see all the ones that are ahead of us in line, in terms of their outcomes and longevity, they all have a system that focuses on primary care.

RYSSDAL: The book you have written is a compilation in essence of diagnostic stories, of patient stories and the saga of figuring out what was wrong with that person. Is there one that’s illustrative of the point we’re trying to make here, that the importance of the art of diagnosis and primary care can really save you money in the long run?

SANDERS: Absolutely. There’s a patient of mine. I’ll call him Charlie. Who, 65 years old, spent most of his life outside the care of the medical system. Until one day he came in, and he felt really bad. Very ill. The nurse sent him to the emergency room when she found that his pulse was very, very slow. He had a huge work-up that was seen by four doctors, two specialists, cardiologists, was sent to the ICU. And when all was said and done, what had really happened was that his kidneys had shut down because he couldn’t pee. He couldn’t pee because of a very ordinary problem among men that age, his prostate had gotten too large and had cut off the urethra. But nobody really picked up on it, nobody elicited the history, and nobody did the physical exam.

RYSSDAL: And you multiply that by tens of thousands of similar cases across the country and pretty soon you’re talking real money.

SANDERS: Now it’s real money.

RYSSDAL: Lisa Sanders teaches at the Yale University School of Medicine. Her new book is called “Every Patient Tells a Story: Medical Mysteries and the Art of Diagnosis.” Dr. Sanders, thanks a lot for your time.

SANDERS: Thanks so much.

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