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Payers have made it so doctors cannot go with their instincts when caring for a patient and that's a shame.
Medicine is an art as well as a science. As physicians, we all strive to practice evidence-based medicine. There are clinical pathways that direct us how to diagnose diseases and start treatments. Yet, our training often shapes our instincts through real-world experiences to be on the alert to when something is off.
The world is full of stories of doctors missing diagnoses and not listening to patients. Patients often "know" there is something wrong with them, even when the tests indicate otherwise. Their gut instincts are often correct.
In the same way, doctors often have strong intuition there may be something wrong with their patent despite diagnostic tests showing otherwise. If you watch an episode of "House," doctors freely pursue a diagnosis with whatever is needed to find the answer. Reality is a far different story.
In the real world of medicine, doctors are not free to order tests that may be needed to uncover an elusive diagnosis. They are bound by insurance company determinations and all too often these days these services are routinely denied. The agents of these companies follow carefully developed clinical pathways and any deviation from these guidelines will not be covered.
It should be noted that these same guidelines are developed by the same companies that determine what services will be covered, not an outside source determining best outcomes and evidence-based guidelines. These guidelines are often outdated and use decades old data. Their chief aim is cost containment, not patient care. Surely, a conflict of interest exists, yet no one calls these companies to task for it.
So what happens when a patient doesn't fit onto that set clinical pathway? Unfortunately, there are no alternative paths to follow. To try to appeal a coverage determination requires hours of time and jumping through hoops, with no clear expectation other than to hope for good luck.
Doctors often rely on their sixth senses when evaluating patients. Often, reaching diagnoses is an easy task based on commonality. Yet, each human is unique with their own set of genes and disease predispositions. We must evaluate each human as the unique being that they are. And more people are realizing this as they advocate for precision medicine. Yet, those paying for healthcare services have yet to understand this. Instead, we are relegated to the path of least cost resistance.
The path we are expected to follow under third-party guidelines does not allow us to think outside the box, or pathway as the case may be. There is no checkbox for clinical intuition when trying to get approval for a diagnostic test. Doctors and other clinicians are the ones on the frontlines with the most medical experience. Just when I think I have seen it all, another unusual disease or presentation appears in my exam room. Yet that carefully honed experience is disallowed when it comes to making medical decisions. Rather, executives with no medical training and no real-world experience set the path my patients must follow. And appealing their decisions can be a journey to the outer reaches of the universe and back, often with little success.
In no way do I mean letting clinicians run amok ordering whatever seems to strike their fancy. We all need to be cost conscious as healthcare costs continue to soar. But, we need to allow instinct in. We need to recognize the art as well as the science of medicine. If it was all science based, there would be no such thing as good or bad doctors. I could just set my IBM Watson on auto-pilot and relax.
I now sit at my desk with a patient's labs sitting in front of me, as they have for the past two days. While these labs do not seem particularly alarming, I just know there is something wrong with my patient who I have been treating for more than a decade. The insurance company denied coverage for the CT scan I ordered and I do not have any of THEIR "red flags" to push it through. I suppose I could lie but I refuse to do that as then I would become part of the problem.
While this happens in exam rooms across the U.S., we should ask if we want doctors who trust their instincts based on years of experience or do we want those who just follow the guidelines without trusting their gut? In my mind, the answer could mean the difference between life and death.