NEW YORK DAILY NEWS
Sunday, March 29, 2015, 2:00 AM
THE SPECIALIST: Dr. Harry Cho
As the director of quality and safety for the division of hospital medicine at Mount Sinai Hospital, Dr. Harry Cho works to ensure that all inpatients receive the most appropriate treatments and to prevent adverse outcomes like hospital infections. He is also the Chair of the High Value Care Committee.
WHO’S AT RISK
If you’ve spent any time in a hospital recently, you know the dizzying array of tests that patients can be presented with. “The most recent studies are making clear how much excess medical care we use in this county — the cost of overuse, overtesting, and overtreatment is about $ 750 billion a year in this country,” says Cho. “Now what we’re finding is that overuse is leading to adverse outcomes for patients — which makes it all the more crucial that patients act as their own advocates and learn how to choose wisely what tests and treatments are actually appropriate for them.” It’s estimated that 30% of American health care spending funds overuse and waste.
What might medical overuse look like? “A classic scenario would be a 40 year-old patient who is out running, gets lightheaded, and takes a tumble that sends him to the emergency department,” says Cho. “In the ED, they might to a head scan and a lot of other tests to make sure that the patient is safe, even though it’s far more likely that the problem is dehydration; unfortunately, that head scan alone is causing a lot of radiation and costing a lot of money. In order to be sure that nothing horrible is happening to the patient, we’re actually doing a lot of unnecessary treatments that carry risks of their own.”
Hospitals are taking steps to do a better job of evaluating what steps are most appropriate for individual patients. “For instance, there’s strong research that shows that aspirin prevents stroke, but what we’ve come to realize is that only about half of patients are on the appropriate treatment they should be on — so as a hospital-wide initiative, we want to help all of our patients receive the appropriate treatment,” says Cho. “The other problem is that simply being admitted to any hospital carries risks, whether of hospital infections or daily blood work that might not be truly necessary.”
The risk of medical overtesting and overtreatment is universally shared by anyone who is admitted to the hospital, but some groups are especially vulnerable. “People who are not able to advocate for themselves and not able to ask a lot of questions are at particular risk of receiving unnecessary tests and procedures,” says Cho. “A lot of patients will feel that they do not know enough to ask questions, or that they inherently trust the doctor, but every patient should feel empowered to slow things down and ask the doctor to explain fully why they are recommending a particular test or course of treatment, and if there are alternatives.”
What are some possible red flags that you may be receiving excess care? “One thing to look out for is when a whole lot of doctors come by — in that case, the patient often doesn’t know what’s going on,” says Cho. “Another thing is when a lot of tests are being done, and you don’t why — and you don’t feel there are other options.”
Never hesitate to ask for a thorough explanation of any medical procedure. “When any test or intervention is being done, the health care provider should really talk to you and make sure you understand the cost benefit,” says Cho. “If you feel like your doctors are rushing through, be proactive about asking, ‘What are you thinking about, What are you looking for? What other possibilities are there for what I have?”
Doctors have a tendency to worry about the worst possible outcomes, which are generally rare occurrences. “Sometimes you have to say, ‘Doc, what do you think this really is?’” says Cho. “In general, you don’t have to worry about that long shot, 1% risk until some other symptoms develop.”
The tendency to prescribe unnecessary drugs or recommend unnecessary testing can happen at any level of medical care. “Another typical thing is that someone comes in to the doctor’s office for a runny nose or cough, and usually, it’s due to a virus that we don’t have a treatment for other than rest and fluids,” says Cho. “A lot of times we end up giving antibiotics even if they’re not really indicated, and that treatment actually does more harm than good.” Often patients expect that there should be a pill for everything, which may lead the doctor to prescribe something that isn’t actually beneficial.
Doctors, too, can be biased toward running a test rather than relying on taking a patient history. “It’s a busy world in the hospital or doctor’s office — there’s a lot of multitasking, so sometimes the doctor’s inclination might be to order a bunch of different tests,” says Cho. “That’s despite the fact that talking to the patient and listening, taking that time, is enough to diagnose the majority of what’s wrong.”
What we’re finding is that overuse is leading to adverse outcomes for patients — which makes it all the more crucial that patients act as their own advocates and learn how to choose wisely what tests and treatments are actually appropriate for them.
So what steps can you take to protect yourself against medical overuse? “Keep asking questions, and don’t feel bad about it,” says Cho. “Even though the doctor is busy, asking questions about what’s being done to your body is important. Do I really need this? Are there any downsides to this?”
Hospitals and doctors’ associations are collaborating to help reduce overuse. “Four years ago, the American Board of Internal Medicine (ABIM) came up with a set of recommendations called Choosing Wisely,” says Cho. “This initiative provides information to both doctors and patients to help them decide what tests and treatment are truly needed.”
Choosing Wisely is also generating a lot of rich data. “This awareness campaign is moving from the U.S. and Canada to Australia and around the world,” says Cho. “It’s a question not only of spreading awareness among patients, but also changing the education and awareness of doctors — and all of that takes time. The word is getting out, though.”
FOR YOUR DOCTOR
One of the most important questions you can ask if you’re being admitted to the hospital is, “Do I really need to be admitted?” “The admission process is a huge deal, and being hospitalized for an extra day brings extra risk,” says Cho. “We want to be sure that people get better and are safe to go home. Still, as careful as we are, things go wrong in hospitals.” If you’re being presented with a test, then ask, “Why do I need this test?” Follow up with, “What are you looking for?” “The more you’re involved in the decision, the more you have a discussion with the doctor about what’s going on, the better everything can turn out for you,” says Cho. “You want it to be a two-way conversation. It’s not enough to give treatment, the doctor needs to give the right treatment.”
THINGS YOU CAN DO:
The Choosing Wisely campaign partnered with Consumer Reports (consumerreports.org/cro/health/doctors-and-hospitals/choosing-wisely/index.htm) to help patients become informed health care consumers. For additional information, check Mount Sinai (mountsinai.org/patient-care/our-commitment-to-quality/patient-safety) .
SLOW THINGS DOWN.
Things can move really fast in the hospital — even if it’s not an emergency. Don’t hesitate to ask your doctor to slow things down to give you time to understand the situation and weigh your options.
ASK A LOT OF QUESTIONS.
The best thing you can do is be your own advocate. Ask questions until you understand what’s being done; this will also help give the doctor time so he or she isn’t rushing to judgment.