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Recently I read an article in the New York Times by Elisabeth Rosenthal. She’s the same author of the enlightening article, “My doctor charged me $117,000 and all I got was this lousy hospital gown.” That may not have been the exact title of the article.
Following that article she wrote a follow-up about the long and difficult ordeal it was to obtain medical records for the original article, and how silly this seems in this modern technology age. Indeed, if Netflix can beam movies directly to your Google glass, why wouldn’t health care providers and facilities be able get them to you nearly as quickly.
She asks a profound and important question that requires a nuanced, intelligent, well researched answer. This she did not not provide. Instead she, in my opinion, callously and cynically took the low road in positing that physicians are money grubbing, greedy bastards who hoard the medical records of their patients in order to keep them coming back. Furthermore, she states, we do so while hiding behind a feigned wall of privacy concerns.
Ms. Rosenthal makes these bold statements on the basis that they must be factual because a Harvard Law professor told her so.
And who knows more about medicine than lawyers, right?
I can’t speak for all physicians, but I do know that in every profession there are bad, greedy people who do things for the wrong reasons. I also know that most of the physicians I know don’t wake up in the morning thinking about how they can make money by not giving people their test results. And while transparency is a good thing, simply giving results to patients without any context can be fraught with risk.
I have seen cases where patients have gotten their test results directly and lead to unnecessary tests. One individual had benign lymph node enlargements, which were confirmed by a biopsy. However, the person had a follow-up scan ordered by another physician, which was interpreted by a different radiologist who interpreted the follow-up scan as “malignancy can not be excluded.” They eventually went to another physician and demanded another biopsy that was unnecessary, and, of course, still benign.
Beyond the practical argument for not directly providing people with their medical test results there are financial reasons as well. And while some may refer to this as greed, remember that physicians are businesses, who expect fair or even less than fair payment for rendered services. While there are a few insurance companies who will pay a physician for their time in making phone calls to their patients, the vast majority (including Medicare) reimburse physicians on a “fee for service” basis. Thus, they will only pay for face to face services on insured patients. In effect, by relaying results over the phone, I would not only be providing a free service, I would, in fact, be coming out behind. This is because of the fact that in the time it takes me give out sage medical advice for free, I could have been seeing another patient.
If and when test results are to be provided to patients, it’s important that they be provided in the proper context. Test results should be discussed before they are ordered so that patients know what to expect. In my practice, simple blood test results can be viewed by patients through an electronic portal. If somebody wants their entire medical history at my practice, this can usually be provided to them within 1 to 2 business days.
While providing routine blood work tests don’t require much context, other test results are more complicated. How I handle biopsy and scan results is a different process that has evolved over time. Most people who have just been diagnosed with lung cancer, for example need to have a face to face conversation. Following the news of a new diagnosis of lung cancer there are tears, anger, and questions. What’s the next step? Chemo? Radiation? Surgery? Am I going to die? This takes the time and skill of a practitioner who knows and understands not just the science of the diagnosis, but an understanding of how to navigate the complicated medical maze that comes afterwards.
In her article, Ms. Rosenthal refers to the case of a man who had to return to their doctors office to get results of an MRI which turned out to be negative (apparently the good news that he did not need surgery did not offset the anger at having to pay for another office visit)
If I were to take this approach, I would then be calling all people with negative biopsies. It wouldn’t be long before people found out that no call from the doctor means that something really bad is happening. It is simply more expedient to say that any testing with potentially far-reaching implications (like surgery) should come in for a follow-up visit. This is one of the reasons why patients with certain medical tests are asked to come in for results, and this is what I try to explain to them when I ask the question of why tests simply can not be sent to them.
That’s not to say that people don’t try to circumvent the system. After explaining my policy to a patient who was undergoing a lung biopsy, her family called and demanded the results without an office visit. They finally called their primary physician’s office and found a sympathetic receptionist who agreed to forward a copy of a “lung biopsy” report. They were relieved to find that the biopsy report showed benign tissue.
She did not come in for her office follow up with me, which was concerning, because while one of her lung biopsy samples was negative, there were other parts of the procedure which the pathologist took longer to report.
I called the family and spoke with the daughter and family and explained how sorry I was that they had received results that were incomplete. Their mother did indeed have cancer. She yelled in disbelief “but I got the results, they were negative! How can you now tell me that she has cancer?” I explained that the pathologist wanted to perform additional stains and cell typing on other samples that we took. This meant that these results took longer to report than the initial tissue results that were negative. Her disbelief turned to sorrow and shock, as it often does when one learns of this diagnosis. She began to cry, as I heard other family members who were listening around the room on speaker do the same.
Transparency is good, and as both a purveyor of medical technology and as a preacher of the merits of social media, I look forward to the increasing openness of medical information. But there are lots of ways to save money, lots of things to cheap out on, and lots of middlemen that can be removed from medicine. Your doctor is not one of them.
Deep Ramachandran is a pulmonary and critical care physician, and social media co-editor, CHEST. He blogs at CaduceusBlog and ACCP Thought Leaders, and can be reached on Twitter @Caduceusblogger.