Does Less Medical Care Mean Better Care?

In the wake of mass cancellations and delays in elective healthcare due to the COVID pandemic, Sandeep Jauhar, MD, wrote in the New York Times , "Perhaps Americans don't require the volume of care that their doctors are used to providing."

There was plenty of support for the cardiologist's opinion, but the bullies crawled out en masse on social media. Interspersed between the re-tweets and "likes" on his feed were comments that his article was "trash, junk" and his opinion "humanitarian euthanasia." One frustrated patient wrote, "I have 2 surgeries on hold; describing this as 'fine' would be a definite overstatement." Yet another critic compared the Times to the National Enquirer for having published his article.

Nearly all the naysayers misunderstood his point.

Sandeep Jauhar, MD

Jauhar referred to patients with "stable chronic conditions." This does not include those with pressing needs for surgery or unstable/progressive symptoms, or those with a new or incompletely treated or inadequately assessed diagnosis. Jauhar acknowledged that postponing care had poor consequences for some patients, "such as those with newly diagnosed cancers that went untreated."

And he didn't come to this conclusion without some measure of data. He referenced a recent Kaiser Family Foundation poll of 1189 adults. Nearly half of the people surveyed admitted that they had skipped or delayed care, but only 11% described their condition as worsening and 86% said their health had stayed about the same.

So Much Unnecessary Care

With more than 27 years of full-time cardiology practice under my belt, I believe that most routine 3- and 6-month follow-ups don't improve longevity or well-being one whit. Even 1-year follow-ups in stable, asymptomatic, and adequately assessed patients often do nothing more than line the coffers. Additionally, cramming schedules with specialty and subspecialty well-patient visits leaves no room for nonemergency work-ins.

Routine specialty visits are especially unnecessary if the patients are regularly seeing a competent family physician. This may include the patient with previously "tough to manage" systemic arterial hypertension who now has excellent blood pressure control. I'll also include the patient with no angina a year after receiving a stent for single-vessel disease who is receiving optimal medical therapy and has good left ventricular function. Do these types of patient really need to see a cardiologist every 3, 6, or 12 months? Are we double-dipping the insurance company or Medicare when their family physician is also monitoring these conditions?

Overtreatment of patients happens in all specialties. One of the worst examples was a patient who bemoaned the "need to sit" in their family doctor's office every month waiting for a routine long-term prescription. "Are you sure you are going just for a prescription refill?" I asked. He produced the bottle. It was a thiazide diuretic. I was flabbergasted. Furthermore, this had been going on for years. Based on his long-standing trends of normal renal function and electrolyte levels, this patient could have easily been evaluated annually or whenever medically necessary.

Less Care, Little Harm

Jauhar conjectured why most patients seem to have fared surprisingly well despite delays in care: perhaps they had adopted healthful behaviors, such as smoking less and exercising more, or perhaps it was the benefit of spending more time with loved ones.

But perhaps they just don't need to be seen so often. He seemed to agree when I asked him what medicine should look like post-COVID. "We need to cut down on unnecessary care without skimping on beneficial care," he told me. "This means doctors avoiding prescribing treatments or diagnostic procedures at odds with specialty society recommendations. It also means patients talking with their doctors about what is really necessary. For example, if an elective surgery was put off, is it still needed?"

I agree with Jauhar, but we must add the disclaimer that the confidence level of many people surveyed by the Kaiser Family Foundation was likely boosted by their anticipation that healthcare treatments and assessments would occur within the next few weeks to months. With the ever-shifting COVID landscape of reshuttered businesses, some who were optimistic at 3 months might destabilize at 4, 5, or 6 months if their care is delayed yet again. Additionally, will the 13% of survey respondents who admitted to difficulty obtaining basic necessities like food and the 8% who were struggling to afford their medications manifest the consequences of poor nutrition and the lack of medications soon?

There is little doubt that the construct of our medical conglomerates drives the need for revenue from routine follow-ups. There may also be the misplaced concern that less tightly packed schedules will not produce enough revenue to cover the ever-increasing costs of healthcare for employees or office overhead. To most of these concerns, I say:

Build a schedule that allows for walk-ins and work-ins and they will come.
Mount an education campaign promoting office visits over emergency department visits for many illnesses
Do what it takes to unclog schedules of routine stable patients.
Pack schedules with patients who have real needs.
Make more time for meaningful preventive education (including nutrition and exercise) and surveillance.
Teach patients when to appropriately seek care and how to monitor symptoms and vital signs at home.

Perhaps the best response to Jauhar's article was posted by Bohdan A. Oryshkevich, MD, MPH, from Northern California. He wrote, "The question is whether we want to return to our past waste or whether we have the moral capacity and backbone to create a health care system that is sustainable, efficient, effective and equitable…. Deep down, every doctor and health administrator in America understands that."

Well, do we?

Melissa Walton-Shirley, MD, is a native Kentuckian who retired from full-time invasive cardiology. She enjoys locums work in Montana and is a champion of physician rights and patient safety. In addition to opinion writing, she enjoys spending time with her husband, daughters, and parents and sidelines as a backing vocalist for local rock bands.

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