What is “necessary” in health care?

Kishore VisvanathanIt must be a tough time to be an American astronaut.

Since the US Space Shuttle program shut down a year ago, their opportunities for spaceflight are limited to hitching a ride with the Russians.  It must be incredibly frustrating.  Consider the years of training, childhood dreams, and self-sacrifice – all for naught.  That is, unless they can convince the American government that space travel is a necessity, and a worthy recipient of public funding.

I imagine that US astronauts must be passionate advocates for funding space flights.  After all, their careers – and self-images – are at stake.

I don’t think the astronauts would behave any differently than any of us, should we suffer a similar change in fortune.  A recent on-line conversation has me thinking about how professional self-image (or perhaps self-interest) affects what we consider “necessary” in healthcare.  The discussion started with a post on Healthy Debate (see the comments), then Irfan Dhalla and Mark MacLeod stepped outside.   To Twitter.  The discussion was about fee-for-service and whether it leads to provision of “unnecessary” services:

It’s a generous offer from Dr. MacLeod, but I’d rather explore whether or not I’m providing unnecessary service in my own practice.  I took a look at this 2 years ago in this post.  I reviewed 57 new consultations over a 2 week period and tried to judge whether or not they were “appropriate”.  (To be fair, “appropriate” and “necessary” may be different classifications.  Read on.)  I judged that 8 (14%)  of the consultations weren’t necessary, that is, the condition referred for wasn’t serious, was for a false-positive test result, etc.

But, who should decide whether the consultation was necessary or not?  The various interested parties may have differing opinions.  I decided (according to a subjective review) that they weren’t necessary.  The referring physician felt they were necessary (by definition, I think, otherwise he wouldn’t have referred them…).  In most cases, the patient likely felt the referral was necessary but, for asymptomatic patients (in the case of the false-positive test result), the perception of necessity would have been influenced by the referring physician’s appraisal.  How did our provincial health insurance payment agency feel about it?  I don’t know, and I kind of hope they didn’t read my blog post about it.

The point is that it is easy to make a case that any health service is “necessary”, as long as someone wants it.  Patients may want the service to improve their health, relieve symptoms, or just give them reassurance that everything is normal.  Referring physicians may want the service because they have diagnosed a condition that is beyond their expertise to manage, or because they are uncertain of the diagnosis and/or treatment, or to satisfy a patient request to see a specialist.

That bring us to the medical specialists.  And the astronauts.

Both groups are highly-trained professionals who genuinely believe that their skills are necessary in society.  Naturally, either group would feel threatened if someone suggested that some of their services were not necessary.  Under those circumstances, a natural reaction is to be defensive and rationalize that one’s services are, in fact, essential in society.

The debate will just deteriorate from there, with the main point of contention being the definition of “necessary service”.

Perhaps we can avoid that divisive debate by rejecting the idea of necessity and instead considering value.  Let patients be the judges of how much value a given service is worth to them.  You might say that substituting “value” for “necessity” is just semantics.  After all, if something is necessary, it will be considered valuable, and vice versa.  Well, let’s go one level deeper to find out what patients are really seeking.

When a patient comes to see me with a kidney tumour, they may ask me to perform surgery to remove their kidney.  But, in truth, they don’t want surgery.  After all, surgery is painful, stressful and carries significant risks.  What they really want is to have the kidney tumour treated and trust my advice that surgery is the best treatment.  They then reluctantly submit to surgery.

But, do they really want the kidney tumour treated?  Popular health culture dictates that cancers must be treated.  But, one of the vagaries of kidney tumours is that not all of them – even though they may be cancerous – require treatment.  For elderly patients with small tumours, the risk of surgery may vastly outweigh any benefit, and we often recommend observing the tumour.  This is because the patient’s real goal is to preserve quality and quantity of life.  It’s not always correct to assume that a kidney tumour will affect either parameter.  Yet, without a full discussion about the patient’s desires (the patient is the expert here) and the medical facts (the doctor is the expert here), we can’t truly know what course will be most valuable for patients (AKA shared decision-making).

In our practice redesign work, we’ve tried to think about what value we’re providing for patients.  Back to that 2-year-old post.  Many men were being referred to us for “vasectomy reversal”.  We found that the men would come for their consultation, listen to us explain the reversal procedure, then tell us they didn’t want it done.   Some men were dissuaded by the fact that it is a non-insured procedure and they would have to pay for it.  Others were discouraged by the success rates.  Others were just interested to hear what the surgery involved.  In any case, many of them traveled up to 8 hours round-trip just for a 15-minute discussion.

The men, and their referring physicians, thought they “needed” a face-to-face urologic consultation.  But, when we dug deeper into it, we realized that the value was in the information, not in meeting the urologist.  We created an information pamphlet summarizing the vasectomy reversal information, and began sending men the pamphlet instead of booking a consultation.  We invited men to make an appointment for surgical consultation if they still wanted to go ahead after considering the information.  About 10% of men made those appointments.  They had their need addressed without having to travel.

I told you another (slightly discomfiting) story of poor patient value in this post.  An elderly man and his wife came to see me to get his CT scan results.  A medical student called me on the fact that they could have received the results in a different, more convenient fashion.  The system (my system!) had only provided them with one option – face-to-face with me.  It was a necessary service, but I could have given better value.

I suspect that most medical practices (perhaps even Dr. MacLeod’s) would yield similar examples if subjected to scrutiny.  But such attention to other’s work would be counterproductive as it would be perceived (correctly) as judgmental, and would lead to defensiveness.  I would rather encourage curiosity about how we can change our own practices to provide better value to our patients.  That also requires scrutiny, but we only need to open our practices completely to ourselves to achieve it.

American astronauts who see their mission solely to be to ride into space must be devastated.  But, those who see their mission to be to use their talent to serve society according to the public’s need and desire, and are capable of adapting to fit changing circumstance… they will land on their feet.

The comments section is closed.

  • Gerald I. Goldlist, MD says:

    Having patients come in for test results and the discussion around them is usually not efficient use of time. I recently had some investigation done and made an appointment for two weeks later to discuss the tests. The results were normal. As only discussion and followup arrangements were required, the whole thing could have been done on the phone.

    Personally I would have found this much more efficient to do this on the phone. I would have avoided a drive to the doctor’s office, paying for parking and, especially, cancelling half a day at my office and thus inconveniencing my staff and patients as well.

    This is no one’s fault but a flaw in the payment system. Currenly OHIP only pays for office visits and not phone visits. Personally, I would have been more than happy to pay for the phone visit but many people can’t or won’t.

    Because of their ease, if OHIP were to make phone visits an insured service then, because of their ease, they could be abused by patients and doctors. So who pays for these visits?” The government or the patient personally. There is no easy answer but we should be discussing this?

  • Justyna says:

    There’s a point to be made about booking visits simply for communication of test results to patients – I know some Family practices already do emailing/online test results but it would be phenomenal if it were more widespread generally. Having bloodwork and imaging results online where a patient can sign in and see their results for themselves goes a long way towards having informed patients that can give a good history when they show up in the ED for … Say weakness and vomitting secondary to hyponatremia — As opposed to “Oh I saw my doctor but they didn’t say anything about that on such and such a day.”


Kishore Visvanathan


Kishore Visvanathan is a urologist praciticing in Saskatoon, Saskatchewan and is a proponent of Clinical Practice Redesign.  He blogs at Adventures in Improving Access.

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