Tuesday, May 7, 2019

Where can I donate my pap smear?

I recently dropped some clothes off at a donation site after a doctor's appointment and found myself thinking - it's too bad I can't donate that unnecessary pap smear and lab work I just got instead.

I kept my thoughts to myself, though. The young man taking my donation looked a little awkward already, no need for me to make the interaction even more so.

Every few months it seems social media, or some other quasi news sites, has some uplifting report to share on how a restaurant or school cafeteria or grocery store found a new way to re-purpose its left over food for those in need. They partner with a food kitchen, or make extra lunches for kids to take home on weekends, or sell ugly looking fruit and veggies at 1/2 price but full flavor. We have thrift stores and antique shops for re-used clothing. You can buy almost anything used online, often for cheaper.

While these efforts don't in of themselves lift anyone out of poverty, change social determinants, or even help long term, they can provide some short term relief, a more reliable source of lower cost necessary goods, involve the community in caring for others, and help us recycle high pollutant items.

But do you know what I can't donate or share or give second hand? My healthcare.

It's easy to understand why. It is not as tangible, it's personalized, it involves so many systems and liabilities that it isn't a simple good to exchange. Even the payment for one office visit requires at least 3 different systems to adjust claims, payments, assessment of services, before the transaction is complete a few weeks later.

We don't exactly have "left over"health care. But we should, or could. What we do have is over used, or poorly used healthcare services which could have been spent more wisely, and I'll even say more justly.

Before moving 3 years ago I had a regular check up which included a pap smear. When I moved and got a new doctor and was newly pregnant, I got another one, just 1 year later. I didn't need one yet by evidence based standards, but they didn't have records from my prior doctor and wanted to have one on file. After I delivered my baby my OB doctor did another one post-partum- that was just their policy, how they've always done things, even though by evidence based guidelines I didn't need another one yet. Then this year, just 1 year later, I changed doctors and got another one. They didn't have records of my last one, despite the fact that I could see the my former doctor's office from the window of the new one.

That makes 4 pap smears in the span of 4 years, in which only 1 was needed based on evidence based guidelines that are agreed upon by all major medical societies. Every 5 years is the standard, as long as you ordered the test correctly, the results were all normal, and there were no other big obvious risk factors.

So that makes 3 pap smears that my doctors ordered out of convenience or habit, but not based on evidence. That makes 3 tests, that each cost about 50$, not including any other office associated fees or time spent, that were not needed. Now, imagine if there were about 1 million women (it is way more than that in reality, 1 million is just an easy number to use) whose doctors decided that they would stick with outdated guidelines and continue to provide once per year pap smears because, it is true, insurance will pay for it. In a year, that would be 50 million unnecessary dollars spent and paid for. In 3 years, 150 million. How many uninsured patients could receive coverage for basic health needs for 150 million? And so, I repeat - where can I donate my unnecessary pap smears?

I could use any other number of examples that demonstrate the waste of healthcare dollars, pap smears just happen to be on my mind - the same labs getting ordered by different doctors who don't share results, prescribing new brand name drugs without evidence that they are any more effective than the old ones, labs or tests ordered out of physician fear or to calm patient fears or out of habit. The list could go on.

I'm certainly not advocating to take away or refuse evidence based and necessary services. And I spend enough time arguing with insurance companies about what is evidence based and necessary to know that they are not the best first line decision makers on those questions. We don't always have perfect evidence, and sometimes it's frustrating when new evidence changes formerly tried and trued methods. But that is the journey that those in healthcare signed up for. To make the best decision today with the evidence published last night.

The very purpose of the field of medicine is to use evidence - ideally from well designed clinical trials, but sometimes just from years of collected experience - to improve the health of others based not on their insurance or race or disease state, but based on their humanity. When we stop using up to date evidence, the result is not neutral. The result is a violation of the very first oath taken as a physician: do no harm.

We typically think of this harm being done to the patient in front of us - an unnecessary lab test they got charged and poked for, radiation exposure from an unnecessary CT scan or complications from a procedure that didn't follow evidence based guidelines. But there is a responsibility to think as well about the millions of other patients that are not in the room at that moment. People whose insurance premiums go up when we over use the healthcare system, leading to a poorer and more under-insured population. People who needed that test or procedure but don't have access to it.

It is the patients who are not yet patients, because they don't have access to the healthcare system, who often are done the most harm when we overuse our healthcare system either as patients or as doctors. They are our patients just as much as anyone who walks into the waiting room with a newly minted insurance card.

We often think of living in excess to be defined by ones clothes or houses or cars or vacations. But if we are to argue that access to healthcare is a right, or that it is at the very least a matter of justice, then we have to accept that misuse of it is not our right and contributes to injustice. As with most matters of rights and justice, we have to look at our own misuses and inconsistencies rather than just demanding policy change and political action, though these are also generally necessary.

Like food, healthcare is not an infinite good springing from some magical well that will never run dry. We have a finite amount of healthcare dollars invested by the government, a finite number of doctors and places for care, and a finite amount of money individuals are able to spend. All those categories could be changed or increased to facilitate improved access, but the truth remains that it healthcare is finite. And just as access to food can nourish or starve, keep alive or kill, so can access to healthcare. Food pantries will not ultimately save the hungry and free clinics will not save the sick. Food can be given and shared and distributed more easily, but healthcare has a secret weapon: evidence. Evidence gives healthcare the power to provide high quality care equally, which is to do justice to the humanity medicine has sworn an oath to not harm, and whenever possible, to embolden with more life.

2 comments:

  1. seems smug and self referential

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  2. This is fascinating, Stefanie. Is there ANY incentive (financial or otherwise) for practitioners to use tests and prescriptions as efficiently as possible?

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