Consider what goes on in our small area of the medical map. If one studies the cohort of patients referred to a rheumatologist, it is likely that a sizable number of them are being sent to us for the wrong reasons. Think about the patient with fatigue and normal lab tests except for a low titer antinuclear antibody (ANA), or the retiree with bilateral shoulder pain who has already undergone costly and unremarkable magnetic resonance imaging tests (MRI) ordered by someone searching for torn tendons, when the obvious cause of the abrupt onset of pain was polymyalgia rheumatica. In endemic areas, there is the ubiquitous Lyme disease conundrum, where a misunderstanding of Western blot antibody results may lead the physician and the patient down a perilous path of lengthy and unnecessary antibiotic therapy. Although we may not want to admit it, the consumption of low-value services can generate a steady flow of patients.
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Explore This IssueJuly 2017
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None of this pricing makes sense, particularly when one realizes that no major study has found an association linking the cost of services to quality of care. This lack of a correlation between cost & quality is stunningly consistent across a range of services & procedures.
Changing the behaviors of other doctors by educating them about our diseases would be the ideal way to correct this problem, but this is a highly impractical solution for several reasons. First, most doctors are not very interested in learning about our diseases—a sad fact, but true. Those who are intrigued often become rheumatologists, and there are currently only 6,000 of us, less than 1% of the 900,000 doctors practicing in the U.S.10
Second, there is the impact of the modern healthcare culture that insists that each minute of the day be productive. This has made it challenging to find the time for clinicians to halt their activities and attend a lecture or rounds.
Third, some deeply ingrained biases may contribute to the variations in care provided by doctors. In one large national study, the spending patterns of general internists and family physicians were tracked over the course of several years. Those who trained in residency programs that were based in high-spending regions of the country continued to spend more than their peers who trained in lower spending areas.11 So perhaps there is a psychological basis for ordering that questionable ANA or Lyme titer test or those costly MRI studies. Take notice fellow program directors: Once established in training, spending habits may be difficult to break.