In the past few months I’ve seen enough stories comparing human health care to pet health care to declare it an official genre: the lessons we learn from the pets we treat. In many cases, the pets come out on top, like in this essay by Ken Farbstein, “My Dog Gets A Print Out From His Doctor, Why Don’t I?” and this piece, “How A Veterinarian’s Experience Influenced Her View On Assisted Suicide.”
The latest pet vs. man piece, published in the Journal of the American Medical Association makes a somewhat different — but equally important — point: it suggests that whether you’re a vomiting cat or a woman with reflux, figuring out the best course of treatment can be infuriatingly difficult, even for the most savvy patient.
In the JAMA piece, Nancy Kressin, PhD, director of the Healthcare Disparities Research Unit and associate professor at Boston University School of Medicine compares her own experience with gastroesophageal reflux disease to her cat’s vomiting and weight loss. She notes that while the diagnostic path for each case varied substantially — in cost, risk and time — ultimately the two treatments were similar, involving a fairly cheap, readily accessible medication to ease symptoms. So, Kressin writes, “why was it so hard for this patient/client to negotiate her way to obtaining enough, but not too much, information to address these symptoms?
“Patients are increasingly being encouraged to take an active role in understanding their physician’s thinking about diagnostic testing, to express their own preferences, and potentially decline or postpone tests with limited value or excessive risks or costs. Yet it remains exceedingly difficult for even the most informed patient to do so….”
The piece gets into the tangle of diagnostic decisions both cat and woman face. On the cat’s care Kressin notes:
Results from a $,3000 intestinal biopsy for my cat wouldn’t provide information that would change the course of therapy, said my friend (J.M.A.), since there were two possible causes — inflammatory bowel disease or cancer — and he knew I wouldn’t be inclined to seek chemotherapy for my cat if the diagnosis was cancer. When I countered with this perspective to the veterinarian caring for my cat at the tertiary care veterinary hospital, she agreed, although the biopsy had sounded much more crucial when she had originally mentioned it. What if I hadn’t had a veterinarian friend to call? How many others would have unquestioningly paid the money to learn more—without changing the treatment on the other end, while needlessly inflicting additional suffering on the animal?
In the end, Kressin concludes that her decision-making process regarding the cat’s health care proved to be more rational:
The cost difference between the two paths was thousands of dollars –the price of the cat’s steroid <$10) vs the out-of-pocket cost to me for an endoscopy ($394), $3,566 to my insurer, plus the loss of a day’s work for me, half a day for my husband to accompany me, and the risks I incurred in undergoing endoscopy. The informational difference — at least to me, in hindsight — was not worth this cash or time outlay.
Why was I unable to negotiate a more conservative and less costly path for my own care? How could I, as a patient, have combated the forces driving the rush to diagnosis, or garnered more support for an empirical trial of medication to alleviate my symptoms and potentially illuminate their cause? Although I am a health services researcher and medical school faculty member and am aware of the issue of over-diagnosis — enough to question whether I really needed en- doscopy immediately, or whether a few more days of watchful waiting with the changed medication dosing might suffice — I deferred to the clinician’s knowledge and experience, and scheduled the test, knowing my insurance would “cover it.” Had I realized in that moment that even with this coverage, several hundred dollars of out-of-pocket expenditures were in the offing, I may have protested further, but I didn’t have that information until after I underwent the procedure and received the insurance company’s “explanation of benefits.” There had been no discussion of the cost of the procedure with the clinician.
But with my cat, buoyed by coaching from my veterinarian friend and the up-front knowledge of a several thousand dollar cash outlay, I not only explored the value of the diagnostic tests with the veterinarian, but ultimately found that she agreed that having a diagnosis wouldn’t change the therapy, in the end.