April 15, 2011

The past few decades have been exciting for the practice of medicine. We have made many dramatic scientific advances and developed many tests, medications and therapies. In pediatrics, we have been blessed with breakthroughs such as vaccines that eliminate deadly infant diseases and vastly improved asthma and diabetes medications.

Doctors, always eager to take advantage of discoveries, are now often ordering expensive tests and therapies without considering how essential they might be for their patients. In the process, we are bankrupting our nation’s health system and depriving millions of people of any health care at all. Ironically, however, the United States has fallen behind in many categories of child health outcomes compared with other developed countries, including higher rates of infant mortality and teen pregnancy, more serious accidents, and more obesity and diabetes.

Every doctor I know in this country wants to provide the best medical services. We have embraced the new technologies, tests and medications, and we are encouraged by everyone to use them all: by our patients who want us to do everything possible; by hospitals that want us to use all their resources; by insurance companies that “cover” most of these interventions; by health administrators who develop detailed protocols; and by our legal system, which frightens us into practicing defensively. Incentives are everywhere; disincentives are few.

Medical students and residents are learning vast amounts of science, but they are given little time and opportunity to develop proficiency in the true cornerstones of medical practice: taking patient histories, physical examination, developing interpersonal skills and clinical judgment. They are rightly worried about this. Their models are doctors in practices, emergency departments and inpatient services who are spending less time examining and watching their patients and more time sitting at computers ordering tests, procedures and medications, monitoring results and documenting findings. Because doctors have such easy access to them, we order tests and therapies whose cost we do not know and whose safety and clinical value we do not fully understand.

Obviously, there are some patients who are very ill and need access to all that today’s advanced science and technologies have to offer. If we practice intelligently, there should always be the money, skills and specialists to help those in need. If we don’t, there won’t be.

Tests and medicines, like food, seem as if they should be good for you, but they aren’t always. Test results can be inaccurate or unclear, leading to incorrect diagnoses or the ordering of more tests. Medicines can be harmful. Our bodies are good at healing themselves, and a doctor’s challenge has always been to decide when, how and even if we should do anything to help this process. This is one of the major challenges of modern medicine.

By practicing expensive and unrestrained clinical care, we are over-spending precious resources on some patients while depriving others of care. There are not only ethical but deadly serious financial and public health reasons to provide some care to everyone. The health of each of us depends on the health of those around us. If someone gets a preventable infectious disease such as measles, whooping cough or flu, they put many people around them, especially infants and elders, at serious risk. Health disparities in this country are the prime reasons our health statistics are poorer than those in many other countries.

Few elements of the U.S. health-care system encourage doctors to practice in this sensible, thoughtful way. Doctors need to be given permission — in fact, a mandate — to practice more preventive medicine, not to test so much, to listen more and to watch our patients over time when they are ill. We need research on effectiveness and cost benefits to teach us which tests and treatments result in better outcomes.

How can we do this? All of us — doctors, parents, patients, health administrators, insurance companies and lawyers — must redefine our concepts of “reasonable care” and “reasonable outcome.”

As a pediatrician, I want to help parents fulfill their dreams for their children. The Affordable Care Act started this process, but it will never succeed in reducing health-care costs and providing health services to all children (and adults for that matter) unless we all change our practices and our understanding of appropriate medical care.

Doctors need patients’ and parents’ help, support and empowerment. Every time you see your doctor, ask for the best and simplest treatment. Ask all the questions that are most important to you; ask what you can do to prevent illness; and ask how you can help us practice as effectively, and frugally, as possible. We all need to play an active part in health-care reform.

The writer is a pediatrician at Boston Medical Center and a clinical professor of pediatrics and public health at Boston University School of Medicine.