New research has found that patients make almost no unreasonable requests for medical treatment, undermining the tendency by doctors to blame higher healthcare costs on the demands of those they care for.
Only 1 percent of cancer patients ask for a clinically inappropriate medical intervention, according to a paper published Thursday in JAMA Oncology, part of the network of publications affiliated with the Journal of the American Medical Association. Suggestions were considered unreasonable when surveyed doctors ranked them between one and three on a 10-point scale in which the highest mark represented a request that was the most appropriate.
More than half of American physicians believe that patients have a “major responsibility” to help contain ballooning healthcare costs, according a 2013 survey, while only 36 percent of respondents said doctors do. In another survey, more than 90 percent of doctors said they ordered more tests and procedures than necessary because they fear malpractice suits.
Doctors tend to pin the rise in health costs on know-it-all consumers who insist on drugs and services they don’t need, according to Ezekiel Emanuel, the study’s senior author.
“Were my colleagues really right or wrong when they said patients are really driving it?” Emanuel, a professor at the University of Pennsylvania, asked in a phone interview. The answer is no, he said.
Still, dealing with patients who inform themselves about their conditions online has changed the usual medical relationship, according to Anthony Back, a cancer specialist at the Seattle Cancer Care Alliance.
“A lot doctors view this negatively as in, ‘If only those patients didn’t have this information my job would be simpler,'” Back, who wrote an editorial accompanying the new study, said in a phone interview. “We have to stop blaming patients about this. It’s not true from this data and it’s not helpful in terms of how do we move forward.”
For the study, between October 2013 and June 2014, 60 cancer clinicians were asked after their appointments, or in the middle of the day, if their patients had made any requests and, if so, to rank the appropriateness of the request. In more than 5,000 appointments, patients asked for interventions only about 9 percent of the time, and doctors thought 86 percent of the requests weren’t unreasonable.
“When a patient makes a request it’s somewhat of a vote of no confidence,” Emanuel said. “That makes them feel bad and I think that’s why docs perceive them as a lot more common than they really are.”
One patient asked unsuccessfully for proton-beam therapy, and there were also requests deemed inappropriate for chemotherapy agents and surgeries. Proton-beam therapy, which involves machines that can cost $100 million to $150 million to install, hasn’t been shown conclusively to be more effective than comparable treatments.
Doctors did comply with patient requests for two chemosensitivity analyses, two imaging studies, two blood tests and one hemodialysis that they thought were inappropriate. More than half of the requests deemed appropriate were for imaging tests.
Because the study only looked at cancer specialists, it might not apply equally to other areas of medicine.
In many cases, both doctors and patients are too resistant to considering cost, Marion Danis, a bioethicist at the National Institutes of Health, said in a phone interview.
“Both doctors and patients are not really as experienced as we might be in thinking about healthcare costs in a useful way,” Danis said.
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