Overtesting, Overtreatment, and Private Healthcare in a Public System

Dr. Zach

2018

 

The health care system in Canada is is great.  That is my opinion. No doubt I am biased as a Canadian doctor.  But everyone has access to high quality medical care, and that is how I think it should be.  It is not perfect of course. Waits are long for certain things, but in general the more urgent something is the shorter the wait.  In the ER the doctor gets paid the same whether you are an average Joe or a billionaire celebrity. That is how it should be.

 

There is private medical care available in Canada.  What is available varies depending on the province, but many places have clinics that are outside the public system.  They are for profit businesses and the people who go to them are those with the means or those whose company pays for this service as a benefit.

 

Private medical care offers several advantages — depending on the plan, you may have access to a doctor at any time, and the doctor may spend more time with you.  In general the waits are shorter. Testing is rapid. And often clients are provided with attractively printed and bound booklets with the results of their examination and testing.

 

But private medical care is not better care.  Sometimes it is more care, not better care. The goal in healthcare is to do everything that is necessary without doing anything unnecessary, including tests and treatments.  Wealthy, powerful people sometimes get more, different care without getting better care because doctors treat them differently. They should not, for their own good. Doctors need to be objective and not vary their practice based on patient status.

 

Choosing Wisely Canada is a campaign to help clinicians and patients engage in conversations about unnecessary tests and treatments, and make smart and effective care choices.  Choosing Wisely is now in over 20 countries. In January of 2018 The College of Family Physicians of Canada, in association with Choosing Wisely Canada, published a list of 13 things physicians and patients should question (https://choosingwiselycanada.org/family-medicine/).  Over 40 medical specialties have their own lists.

 

Examples from the list include:

-Don’t do annual screening blood tests unless directly indicated by the risk profile of the patient

-Don’t do annual physical exams on asymptomatic adults with no significant risk factors

-Don’t order thyroid function tests in asymptomatic patients

 

The above are things that many family doctors have done for years, both public and private.   You are more likely to have them done in a private clinic, in the interest of patient satisfaction.  Another test done in some private clinics that is unnecessary is an exercise stress test (seeing how the heart responds when it is made to work harder) in asymptomatic healthy young people.  This is not a screening test and in this case it is being done just to do another test. This makes money for the people doing the test and the truth is that some people feel they are getting more value if more tests are being done.

 

There are other important recommendations, such as not treating likely viral upper respiratory tract infections with antibiotics, and not doing imaging for low back pain unless red flags (such as history of cancer, fever, age over 50 years) are present.

 

Why would doctors do unnecessary testing?  The most cynical, and sometimes true, answer, is for money.  Someone gets paid when tests are done. Whenever profit is involved, one has to consider that as part of the motivation.  But that is not the only reason. Another reason is diagnostic uncertainty. Doctors are not supposed to miss things. The other day I saw a young man who had hit his head a few days earlier.  He was having a persistent headache. The question was whether to do a CT scan of his head. I did one and he had bleeding in his brain. Would it have been forgivable had I not requested the CT scan and had missed the bleed?  Would you accept that for yourself or your family member? Or would you make a complaint or sue the doctor who missed it?

 

That is one main reason why overtesting exists, because doctors don’t feel they can miss anything.  A doctor is much, much more likely to be complained about or sued for missing a diagnosis due to not doing a test than for doing an unnecessary test where the harms are not immediate or obvious (radiation exposure from CT scans can increase the risk of cancer).

 

Another reason why doctors may overtest or overtreat is that they are humans and can be biased or pressured.  It is very difficult (but necessary) to explain to a person who strongly believes that s/he needs a CT scan or antibiotics that they do not need it.  Patient satisfaction is important, and it takes a lot more effort and time to do the right thing, ie patiently explain to the patient why s/he doesn’t need the test or treatment.

 

But back to private healthcare in a public system.  People pay for access and for time with the doctor and for nicer spaces and nice, clear results.  People like to feel like they are special and that they are being treated better than others. But the beauty of the public system is that the care is just as good.