Savvy Rx from a resident: Docs, know why and what you’re ordering, please

Well, just because.

That isn’t a great answer for cranky toddlers with too many questions. It’s also an unacceptable but real reason why too many hospitalized patients get woken up in the middle of the night and subjected 24/7 to expensive, invasive, and often unnecessary tests and procedures.

Abraar Karan (right), an internal medicine resident at the Brigham and Women’s Hospital/ Harvard Medical School, has blogged with welcome candor about doctors’ casual acceptance of medical routines that not only discomfit but also can harm patients. As he wrote online for BMJ (aka the British Medical Journal): “The reality of medicine is that there are many things we as doctors do for absolutely no reason. That is to say, there is no evidence (randomized controlled trial or otherwise) for doing them, other than ‘that’s the way we’ve always done it.’”

He was caught short when an angry patient described a sleepless night and how his hospitalization was exhausting him. Karan re-examined his patient’s chart, and saw that, as a matter of routine, nurses had been ordered to wire him up to uncomfortable monitors and to check his vitals every four hours, waking him to do so. The intensity of this care was unnecessary, Karan and other doctors decided after hearing the patient complaint. He notes that it was reflexive for caregivers to act and react as they always have rather than seeing and thinking through what an individual, specific patient needed. A big reason why?

I think much of this comes down to the fact that doctors are not the ones paying for the labs, are not the ones actually drawing them, and are not the ones being stuck by needles to have them taken. Consequently, doctors experience little to no cost associated with keeping daily monitoring going. This is true as well for overnight vitals, which the patient care assistant or nurse has to physically measure. If doctors had to actually act on many of the orders they place, I guarantee that most, if not all, of the unnecessary ones would quickly disappear.

In my practice, I see not only the harms that patients suffer while seeking medical services, but also their struggles to access and afford safe, efficient, and excellent medical care. This issue grows larger by the day as costs, complexities, and uncertainties skyrocket for prescription drugs and medical therapies. How can ordinary Americans, especially when they’re sick and hurt, navigate a maze of medical jargon and daunting options — much less needless routine care — when nurses and doctors, paying more attention to their regimens than patients, zip through hospital rooms? Hospital costs, by the way, are big ticket items in the total picture of U.S. medical spending, amounting to more than $1 trillion annually.

Over testing, over diagnoses, and over treatment, meantime, have become major problems, adding hundreds of billions of wasteful costs to the U.S. health system. They also fuel an epidemic of medical errors that claim the lives of roughly 685 Americans per day — more people than die of respiratory disease, accidents, stroke and Alzheimer’s. That estimate comes from a team of researchers led by a professor of surgery at Johns Hopkins. It means medical errors rank as the third leading cause of death in the U.S., behind only heart disease and cancer.

Karan wants his colleagues, including those far more senior, to be more aware of their practices. He says they should use electronic health records with care, un-checking auto-filled forms for patients to undergo rounds of duplicative, unneeded blood or other tests. They might draft “unnecessary checklists,” he says, to question tests and procedures. These would be akin to now widely accepted safety checklists that, research shows, have averted patient injuries and deaths. He urges all caregivers to learn more about the costs of tests and procedures, for their patients’ sake.

He points to a running, monthly feature in the Journal of Hospital Medicine: “Choosing Wisely, Things We Do for No Reason” for evidence-based reminders for doctors on wasteful medical practices that could be eliminated, not only could to benefit patients but also their finances, too. He closes with this sensible comment: “[D]oing things for no reason can unintentionally harm patients. I think we can all agree that there is no reason for that.”