"Harvesting" the Patient's Money

Townsend Letter for Doctors and Patients,  Jan, 2001  

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I recently consulted with a patient who has been looking for a way to treat a type of cancer for which conventional medicine has little to offer. Prior to seeing me, he had gone to a prominent "alternative" practitioner to discuss his options. What he remembers most from that visit was that the focus was on money. "How much can you spend?" he was asked, as if he were buying a diamond ring. For $5,000 per month, he could obtain a certain amount of care from the clinic; but some patients, he was told, have spent much more than that, more than $20,000 per month, and have received much more care. Implicit in the discussion was the idea that, the more money he would spend, the better his chances of surviving. The patient had already done a great deal of investigation on his own and had identified one treatment that appeared very promising. However, when he requested to be started on that treatment, the $5,000-minimum-permonth doctor replied that he does not like to be told how to treat his patients.

Assuming that alternative medicine will work at all for this patient's condition, it is not obvious that receiving a whole slew of treatments is preferable to receiving one or two of the most promising interventions. It is possible that some components of a "shotgun" treatment program would interfere with other components. More important, a patient's immune system may be damaged by the psychological stress of watching his life savings being slowly drained away. While it is not obvious that opting for Hope-diamond-style medical care would serve the patient's needs, such treatment would clearly be beneficial for the doctor. Consequently, the potentially powerful placebo effect that can play an important role in the healing process is rendered impotent when a patient is forced to question the motives of his "healer." And it didn't help that the patient's initial intake form asked for his credit-card number.

When I saw this patient, I agreed that his preferred treatment, combined with a few of my own suggestions (the sum of which were well within the patient's financial capabilities), represented a reasonable treatment approach. I do not know whether more would have been better, or whether our treatment will "work," but I do know it is one the patient can live with.

Another patient I saw this week had a chief complaint of intestinal bloating. She had come in primarily to ask my opinion about the results of a stool analysis, which a commercial "alternative" laboratory had allowed her to order on her own, for nearly $150. When she had asked the lab for an explanation of the results, she was told, "You clearly have something wrong with your gastrointestinal tract," and was advised to have further tests, at a cost of approximately $1,000, at a clinic with which the lab is affiliated.

Although the patient's stool analysis report identified several "abnormalities," the clinical significance of these findings was not clear. It appeared that the so-called "abnormal" results could be explained more by what the patient ate prior to submitting the sample than by any pathology of the gastrointestinal tract. Indeed, a stool analysis submitted previously by the same patient to the same lab had come back with completely different results. When I saw this patient, a brief history suggested that lactose intolerance was the likely cause of her bloating. She was therefore advised to do a therapeutic trial of a lactose-free diet. If avoiding milk does not control her symptoms, we certainly can order whatever additional tests are needed. However, it seems that leading off with a bunch of expensive lab tests is more for the benefit of the doctor's bottom line than the patient's well-being.

Most would agree that doctors deserve to make a good living. We invest many years and tens of thousands of dollars on our training; then, we work long hours and face one stressful situation after another. Such expertise and sacrifices should be rewarded. However, patients' interests are not served when they are pressured or frightened into purchasing various unnecessary tests, procedures, or treatments. There is no doubt that many of the interventions offered by alternative practitioners are worthwhile (and even dramatically beneficial) when used appropriately. However, when these tests, procedures, and treatments are viewed as the fodder that feeds a bloated medical conglomerate, the doctor begins to look more like a shark and the patients are at risk of becoming the bait.

Alan R. Gaby, MD

COPYRIGHT 2001 The Townsend Letter Group
COPYRIGHT 2008 Gale, Cengage Learning