More Trouble

I remember going to see the movie \”Oliver\” in the theater when I was a kid.  Since this was my first movie in a theater, my mom made me a treat: a bag full of raisins and chocolate chips (Raisinets for Dutch people) and sent me there with my sister.  It was a fine film, with Oliver getting kicked out of the orphanage when he wanted more gruel, the dastardly Bill Sykes threatening Oliver and sweet Nancy, the funny and clever artful dodger and Fagan teaching Oliver about life on the street, and with (spoiler alert!) good overcoming evil in the end Oliver getting adopted by a rich dude so he can get all the gruel (or real Raisinets) that he wanted.  And though my memories of the movie are still vivid, my strongest memory was the look on my sister\’s face when I walked out of the theater covered with melted chocolate chip goo.  It went into family lore (and wouldn\’t have happened if they had sprung for Rasinets, I might add).  I think they still don\’t trust me with chocolate chips.


The key line in the film comes when Oliver loses a bet and goes up to the gruel-master and says: \”Please Sir, I want some more.\”  Which, as I am sure Oliver expected, causes the gruel-master to break into the song, \”Oliver! Oliver! Never before has a boy wanted more!\” and the whole dining hall to pull out musical instruments and singing harmony to the gruel-master\’s admonition.

I can see why Oliver was scared.  A whipping is welcome compared to his whole world breaking into song and dance.


Asking for \”more\” has caused trouble over the ages.  Adam and Eve wanted more food choices, the people of Pompeii wanted more mountain-side housing, Napoleon and Adolph Hitler wanted to spend more time in Russia, and America wanted more of the Kardashians. We can all see what destruction those desires reaped.

Americans have been viewing health care the same way, always wanting more: more antibiotics, more technology, more robots doing more surgery, more expensive treatments for more diseases.  The result: health care costs more in America than anywhere else.  Some folks think that our \”more\” approach makes our health care \”the best in the world,\” after all, where else can you get so many tests just by asking.  MRI\’s for back pain, x-rays for coughs, blood tests for anyone who dons the door of the ER.  \”Tests for everyone!\” shouts the bartender. \”Tests are on the house! \”

They aren\’t, of course, and we are paying the price for \”more.\”  This hunger for \”more\” is fueled by the media\’s fascination for the \”latest thing,\” the long disproved idea that technology will solve everything, and docs who aren\’t willing to take time to explain why it\’s actually better to do less.  It\’s hard to do, when we are paid more to spend less time with patients, and when the system is willing to pay for more and more.

There is a voice against this: the \”Choosing Wisely\” campaign, which argues against unnecessary treatments and tests.  This is a welcome voice of reason in the cacophony of cries for \”more.\”  Yet the battle goes against the irresistible tide of our payment system.  The root problem is this: there are a whole lot of people whose jobs depend on America\’s addiction to \”more.\”  The payment system has created an ecosystem that thrives off of waste (of which I once wrote an allegorical fantasy).  True health care reform will be catastrophic to many who work in health care, with many very nice and hard-working Americans losing their jobs at the ACO factory, at Meaningful Use Inc., and even at Stents-R-Us hospital here in my home town.

This is what you get when you make disease more profitable than health, when we treat problems instead of people.  The simple fact that our system would be destroyed if everyone got healthy should tell us something is terribly wrong.  Doctors want their offices full, not empty.  The goal of every patient – to be healthy and to stay away from the doctor – goes directly against the economics of \”more.\”

I have always tried to be a non-test orderer.  I was trained well by docs who believed it weak-minded and bad care to blithely order tests and prescribe medications without a well-defined reason.  This has always made it harder for me, as it\’s far more time-consuming to explain why a drug or test is not needed than to simply order it.  But in my new world, one in which an empty office is a good thing, I\’ve found my patients much more open to my aversion to \”more.\”  The main reason for this is that I am giving them more of me.  More of me means they can call if they don\’t get better, or if their symptoms develop.  They know I won\’t force them to take more of their time and spend more of their money to get my attention.

Ultimately, I want my patients to see as few doctors, be sick as infrequently, and be on as few drugs as possible.  I hope to wage an all-out assault on \”more.\”

Here are my rules to battle \”more\”

  1. Never order a test that doesn\’t help you decide something important.  Ordering tests \”just to know\” does much more harm than good.
  2. Use consultants only to do things you can\’t.  Orthopedists will aways give an NSAID and physical therapy for problems, so I don\’t send patients to them unless they\’ve failed those treatments (where appropriate).  I am just as good at ordering PT, and am more careful with NSAID prescriptions than they are.
  3. Don\’t give a patient a drug without explaining to them why they need it.  If I can\’t make a good case for a drug, I shouldn\’t be giving it.  This is not simply \”to lower your cholesterol,\” or \”to treat your blood pressure,\” but because doing so will raise your life-expectency.
  4. Remember the number that really matters: how many birthdays a person gets to celebrate in health. I don\’t care about blood pressure, LDL, or even A1c if treating it doesn\’t raise the birthday total.
  5. Don\’t forget about another number: how much money patients have in their wallets.  There\’s no point in ordering a drug they can\’t afford, or making them pay for a test they don\’t need (even when they ask for either).

I hope my new world of less overhead, less regulation, and less antacids for me continues on this trend toward less sick patients, less drugs, and less tests.  Perhaps I need to break into a song and dance number whenever my patients ask for \”more.\”

That would teach them.

10 thoughts on “More Trouble”

  1. glasshospital

    I love “Oliver.”
    Wait-are you saying ordering more tests and medicines are bad? How can having more tests and more information be bad? How can you be a good doctor and **not** order tests when your patients want them?

    Also, I have an app that lets me keep track of stuff. I need lots of data to fill it up. Isn’t that being an empowered patient?

  2. NPs Save Lives

    Glass hospital, I think that I can answer your question about ordering more and more testing. Sometimes, you just don’t need to know about EVERY nodule because it makes us have to order repeat testing, which exposes your body to often unnecessary radiation which increases your risk of developing cancer from looking too hard. (sorry about the run on sentence). If a person is a smoker, a yearly chest xray is usually enough to catch issues. Of course, if a patient presents with other systemic complaints such as unexplained fever, night sweats, weight loss etc. you need to go deeper. Too often patients will ask for the newest test because a friend had it or they saw it on TV. MRIs for the entire body (all too often by those wanting to be disabled) are a waste of time. We can usually tell that there is a soft tissue injury based on if it responds or not to physical therapy or chiropractic efforts.Rob, I agree so much with your efforts to practice medicine the way that you do. If I had the capital, I would open my own office with the same style. I am an “invisible provider” to the insurance companies anyway. I can write a patient a med that can stop their heart, but I am unable to sign a diabetic shoe order form or home health orders. It’s a stupid system. I am watching you closely from Columbia County, FL and am so envious. Kudos for doing it right!

  3. That’s John Schumann. He’s being a goof. I hope you get the chance to follow in my path. It is a whole lot better.

  4. Wound Care Nurse

    I love the concept of less testing, less expensive therapies, education and creativity in healthcare. I am a CWOCN in a nurse-driven wound care clinic where many of our clients have little to no money for healthcare and medications, forget expensive wound care therapies. We practice evidence-based wound care and are able to heal many of our patients without expensive grafting, medications and testing. We take the time with patients to assess their education level, failed therapies, home life and willingness to comply with therapy. We educate about basic hygiene, glucose control, elevation and compression. Our assessments cover reasons for immediate referral to vascular, podiatry, infectious disease, etc. But many wounds simply need basic wound care with some persistence and creativity to make the therapy fit the patient’s lifestyle. Patients are happy because we listen and create plans of care that address their specific needs. We are happy because patients heal and move on to, hopefully, less wounds in the future because of the education they received from us. There are certainly circumstances in which grafting, expensive vascular testing, referrals and medication are the necessary interventions. We just need to make educated and informed decisions about these rather than ordering them out of hand.

  5. As a French patient with chronic disease, I used to think French doctors overloaded us with medication. Then – Praise the Lord for Facebook – I met looooads of other people with my rare disease, alleluiah, most of them American. And there, wwwwow! Some of them talk about having to take 40 pills A DAY!!! Amazing. And, referring to my own experience with side effects and interactions, probably more harmful than anything else. Here in France, as you might know, the social security system pays for all or most part of treatments, so the government should – and pretend to, but not very convincingly – try going against this faze but it seems we get prescribed more and more stuff too, every winter we absolutely have to get vaccined against the new flu that’s the rage of the year or else we’re all going to die, if we have to lose weight we should not eat salad but take mediator, etc. – while it costs more and more and the deficit of social security is already huge. Doctors thinking like you are also a minority it seems – and they all seem to be blogger doctors too! (healthcare is probably broken everywhere).

  6. You are a wonderful writer and thinker, Rob! We posted this in our Facebook group, “Slow Medicine.” PLEASE come join us! And contact me personally through Facebook — Katy Butler or I have just finished a book about what happens when the hunger for “More” collides with old age and end of life.

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