The doors to the clinic had been locked for over an hour, and the last light in the sky was quickly fading when two eyes appeared in Teresa Moore's office window, followed by a sharp knock and a glass-muffled plea to be let in: It was a patient.
Moore walked the halls of her closed practice and swung open the heavy front door to a woman in her 30s, who staggered forward muttering, "Sorry." The woman was a regular — someone with migraines — so even though it was after hours and Moore had two children waiting at home, she waved her in.
Moore's family practice is in Keysville Va., the same small community where she grew up. Her patients are people who attended her baptism and helped at her wedding. So in some ways, Moore has a true old-timey medical practice. But in one important way, her practice is completely different:
Moore cares for modern patients. They're the people who come in with specific requests for medications and procedures. And oftentimes they get what they ask for, whether they need it or not. This consumer-driven health care is part of what's driving up costs across the country.
The Modern Patient
The patients come in quoting commercials they've seen on TV, requesting pills or diagnostic tests, describing new treatments for diseases they're convinced they have.
"Five or six times a day, people come in saying, 'I looked this up on the Internet.' Or, 'I saw this and I wonder if I could have this?' " Moore says.
Sometimes her patients are right; more often they're wrong, she says. But Moore isn't judgmental about their self-diagnoses. She views it as a natural response to the ocean of health information that surrounds every modern person, and relates it to her own experience in medical school.
"There's a syndrome in medical school they teach us about called 'medical student syndrome,' " Moore says. When medical students learn about a disease for the first time, it's common for them to become convinced, at least temporarily, that they themselves are afflicted.
"Every time you start reading about this disease, you say, 'Oh my god, I have that!' Then you read about another disease and you say, 'Oh my god, I have that, too!' " Moore says. "So, the same thing that triggers medical students to worry that they have these diseases is part of what triggers people watching television or surfing the Internet to believe they have these conditions. Continued re-exposure to suggestions of symptoms makes people look for things."
The problem, says Moore, is that it can take a lot of work to convince her patients that their own diagnosis is wrong. More accurately, it takes a lot of work with her younger patients.
"In the older population, there is a tremendously different dynamic," Moore says. "There's a lot more belief and trust in doctors." But not in younger patients. "In patients between 25 and 50," she says, "there is a lot more push to get what they want."
What Transformed Patient Behavior
Moore isn't the only doctor to observe this generational divide. The fact is that the behavior of patients in our health system has changed dramatically over the past couple of decades. They've transformed from passive "patients" who almost blindly follow the doctor's orders — until the 1980s, patients regularly took pills without even knowing what they were for — into active and aggressive "consumers" of health services.
Dr. Joseph Zebley, 60, is a family practitioner in Baltimore who has been in practice since the 1970s and has witnessed firsthand the remarkable transformation of American patients. He says it began as a trickle in the early 1990s. People slowly started showing up with their own ideas and research.
"It was the sort of thing that would be a bit of a surprise, and it would be the occasional patient," says Zebley. "But by '95, it was an established pattern. There was a palpable change over about five years."
A kind of perfect storm of three major factors produced this change. The first was direct-to-consumer advertising of prescription medications, which started slowly in the mid-'80s. Those ads drove people to their doctors asking about specific medications, and in the process, taught patients that they could question their physician and play a role in their own health care.
Then came the Internet, which put an endless amount of medical information into the hands of anyone with interest and a computer.
Finally, in the 1990s, attempts to save money on health care encouraged Americans to get treatment through health maintenance organizations (HMOs). The idea was that primary care physicians would be put in charge of patients and given a fixed amount of money for all care. This would give the doctor an incentive to improve the overall health of the patient, because the healthier the patient, the more money the doctor could keep. The system, however, led to more denials of tests, medications and operations, which, says Zebley, was shocking to patients.
"They became angry and started researching why they should get things," he says. "Because oftentimes, physicians — hate to say it — but the physicians were looking out for their bottom line, and if they withheld services they could make more money." And so, says Zebley, patients started going online. "It was very rudimentary then, but people also looked things up in the library and photocopied things from the library. [Then they'd come in and] say, 'I think I have this, I think I need this.' "
How Modern Patients Affect Modern Doctors
There are some very real benefits to this new and improved American patient. Many doctors believe that a more active patient is more likely to adhere to the doctor's medical directions, and can also help doctors by drawing attention to things that the doctor might have overlooked.
But there are also problems. For a variety of reasons, it's really hard for doctors to say no to patient requests, even when those requests are unreasonable, wrongheaded and potentially harmful.
For example, Zebley says that several times a week a patient comes in asking for a test that he is 99.99 percent sure would be a complete waste of time. But Zebley will almost always give the patient the test they request, even though he knows it will cost money and time. The main reason: malpractice.
"I'm in a position of risk if I blow them off and say, 'No, forget it, you don't have it, I'm not doing the test.' "
Of course, physicians like Zebley could take the time to explain to their patients exactly why the test or treatment would not be beneficial and educate them out of their desire. But because of the way our health system is structured, that's often difficult, too.
Take Moore, the doctor from Keysville, Va. She works incredibly hard to spend time with her patients — in fact, she does spend much more time with them than family doctors typically spend with their patients. Still, Moore says, time is limited.
"There is a drive to get people in and out because insurance reimbursement is very difficult," she says. "So even though it is absolutely wonderful to say we could spend 30 minutes with each patient and explain these things fully, sometimes you just don't get to do that in real life."
So doctors will order you tests you don't need. And they will write you prescriptions for pills you probably shouldn't take — which is a huge problem with antibiotics, for example.
And, Zebley says, doctors even do operations, like back surgery, that they probably shouldn't do. They do it, he says, because you want it, have become convinced that you need it, and doctors fear that if they don't give it to you, they'll lose you.
"The orthopedic surgeon would be ill-advised to say, 'Well, I'm not going to do [it],' because the person will go next door to the next surgeon who maybe is a little less ethical who will do it," says Zebley. "Being a hard-ass and always saying, 'No, no, no,' people will go somewhere else. They have a free market."
Patient Behavior And Cost
It's unclear how high patient demands drive up costs in our health care system. Moore estimates that about 30 percent of the costs in her practice are driven by patient requests.
Moore is not necessarily proud of this number. For her, at least some portion of it is an indication of her own inability to communicate adequately with the patients that she cares so much about. But she says there's not much she can do. She is, she says, truly overwhelmed by the demands of insurance paperwork.
"Sometimes you have to request a form just to get the correct form — you do. You have to fill out a form stating the preauthorization form that you need."
Moore says she stays at her office late into the night, trying to complete paperwork so that she is able to spend enough time with her patients during the day — enough time to explain why this test is probably not necessary, why that pill wouldn't be a good idea. And her children, she says, pay the price.
If you ask Moore if she would rather have an old-fashioned, passive and pliant patient or a new, demanding and modern one, she really has to think about it.
"It depends on the phase of the moon," she says. "Passive is much easier to treat. But I do like an educated patient who's willing to read about their health issues. So I guess I'd like someone in the middle."
Zebley feels similarly. He'd rather have a modern patient. The idea that patients need to be "wise, intelligent, informed consumers," is great, Zebley says. But he also says he knows full well how our new conception of what it means to be a patient costs society. "It leads to a lot of overuse of services."