Can you ever tell the doctor “no?”

Have you ever tried to say “no” to your doctor? Have you ever even thought that might be a good idea?

To open The New York Times‘ new series on “how the economic incentives underlying the fragmented health care market in the United States have driven up costs,” Elisabeth Rosenthal makes a compelling case for transparent pricing for medical procedures by emphasizing the expensiveness of colonoscopies and their limited returns. I agree with her: we should know what procedures cost – and what we’re likely to receive at the end – before they begin. This is not because you should have to choose whether or not you want a life-saving procedure, it’s so we understand better whether or not it’s worth paying for non-emergency services.

But as one of Rosenthal’s subjects points out in the piece, “if a doctor says you need it, you don’t ask.” Fear of death is among the strongest we have, and that’s not terribly unreasonable. So even if we knew the prices of our procedures, how – and why – would we ever say “no” to our doctors?

Becoming a doctor is difficult, time-consuming work. MDs go through 4 years of college and at least 4 additional years of medical training.  We should respect doctors for the work they do.

But we should also acknowledge that doctors, like the rest of us, are human. They have agendas. A minimum of 8 years of education is very expensive, and not everyone who goes into the profession wanting to work on Medicaid’s rates has that option when they leave school. When reading that some doctors are able to charge “facility fees” for simple screening procedures, like colonoscopies, we should, logically, be able to file away that information and use it to buoy our skepticism the next time the doctor orders a test that we don’t understand.

But the reality is that most of us will never be skeptical of our doctors. If the doctor told you this procedure was $9,000, but you needed it, which of us would argue? How few of us would go to the next doctor and get another opinion? If the next doctor told you the procedure was $5,000, what then? Do you still do it? How do you justify not paying as much as you can for something that could save your life?

Transparency in healthcare costs is necessary and important, and I’m glad The New York Times is examining economic incentives behind rising costs. But transparency is not sufficient. What we actually need is patient empowerment; the ability to say “no” or “why?” when we’re looking in the eye an authority with 8 additional years of education and significantly more experience in saving lives.

There’s also a flip-side to this: there’s a reason we trust doctors, and for the most part, we should keep doing it. They know more than us. They have experience, they have education, and they speak to other doctors about what works and what does not. We pay a high price for that expertise, and on some level, we should, because it takes a long time to develop that.

But there has to be a better way to talk to patients about how to speak to our doctors. We all want the best possible care, but particularly on an individual level, that doesn’t always mean the most possible care, and it doesn’t always mean the most expensive care.

Until I can figure out how to ask the right questions, though, the NYT can do all the digging it wants: if the doctor says I need a procedure that’s $5,000, I have no way of knowing otherwise. And I’m not going to say no.


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