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The Profligate Internist

February 20, 2021
by Mark David Siegel

Hi everyone,

When it comes to cost savings, we internists talk big. End waste! Order generics! Stop the mindless testing!

But look in the mirror- we’re the problem.

Consider Tom Smith, a 46-year-old man with fever, cough, chest pain, and shortness of breath. He’s been sick for a day and he’s coming in from home. He’s mildly hypoxemic and has crackles in the right upper lobe. His chest x-ray shows an infiltrate, right where you’d expect it. Tom has straightforward community-acquired pneumonia; he just needs targeted antibiotics and a little oxygen, right?

But that’s not what happens. Someone orders a CT to rule out PE. Troponins are checked to rule out MI. And then he’s placed in isolation because the infiltrate is in the right upper lobe and “TB can’t be ruled out”- never mind that Tom’s only been sick for a day and has no risk factors. Instead of ceftriaxone and doxycycline, he’s started on vancomycin and Zosyn “just in case.” Finally, he gets an echocardiogram because “everyone deserves an echocardiogram.”

Why do we over-test and over-treat? Are we afraid to be called careless or superficial? Are we reluctant to commit to obvious diagnoses? Were we taught to prioritize aggressive testing over aggressive thinking? Did someone claim broad spectrum antibiotics are harmless? Why do we obsess over impossible diagnoses? Is it group think? Social pressure? Habit? What?

I was thinking about these tendencies after last week’s Razor Case- the patient with polyarteritis nodosa. The goal of Razor is to promote diagnostic efficiency; the winner makes the diagnosis while spending the least amount of money. When we started doing Razors a few years ago, we hoped the exercise would lead to cost-conscious care. Sadly, that hasn’t happened. We’re still infatuated with million dollar workups and equally expensive treatments.

But we can do better. The best medicine is also the least expensive- careful, mindful, and judicious. The great Yale internist, Paul Beeson, said it beautifully:

We live…in an atmosphere of doubt and uncertainty, and make our decisions and take our actions on the basis of probabilities…So these are some precepts you must consider: Give each patient enough of your time. Sit down; listen; ask thoughtful questions; examine carefully…

As internists we must embrace uncertainty, use our brains and hands, and be deliberate with our treatments so we don’t cause harm. In doing so, we’ll also save a lot of money.

Are we ready to live up to these ideals? To pause before ordering useless tests? To be better stewards with our treatments? Can we commit to low cost, high value care- to the notion that less is more? Can we back up our words with our actions?

Some thoughts for today. Enjoy your sunny Sunday, everyone.


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Submitted by Mark David Siegel on February 21, 2021