Needs, wants, resources, responsibility

     Trolling the blogosphere I came upon a blog that had me thinking for several days, trying to sort through my initial reactions and to form some understanding of both my gut and of reasoned approaches that might help this blogger.  Her story raises questions about need vs want, how we understand need, the ways need can be met, and an ethical dilemma for the doctor. How do we both respect patient autonomy and voice in managing their lives and at the same time be stewards of health care resources, using them wisely when they are known to improve the health related result for the patient and not using them when they do not meet this mandate?

     Imagine you are a young woman who had a pregnancy loss at 23 weeks. tests on the fetus did not show any chromosomal or structural abnormalities.  There were neither knots in the umbilical cord nor anything abnormal about the placenta.  Now you are pregnant and nervous.  In fact you have so much anxiety that you want to have a Doppler machine (the little machine that lets you hear heart tones) so you can hear the heart tones whenever you feel anxious, to calm your fears.  A prescription was not given to you because it was not felt to be medically necessary.  This has been upsetting you and your anxiety increases.

     You call your doctor and ask for a same day appointment with an in-office ultrasound to reassure you.  You are told the ultrasound is not necessary and given an appointment later in the week.  Since you had been promised immediate access if there were problems with the pregnancy, you are angry and even more worried.  Why are they treating you this way?  Why can’t they understand that you deserve care that gives you what you need?

     You leave your next visit reassured that you are still pregnant and with the prescription for the Doppler. What is it that you need, really?  A Doppler to take home?  An ultrasound that day? How often will you used the Doppler?  How often do you think you need a view through ultrasound?  No one commenting on this blog was asking these questions.  There was an outpouring of empathy around the prior fetal death and the current nervousness.  And virtually all shared her anger about not getting what she “needs.”  No one questioned her being nervous.  (I don’t either).

     Everyone accepted at face value what she said would help. That I do question. And on that subject, what role do we each play in the high cost of medical care in the US?  Just looking at medical tests and whether they are necessary or not, current estimates suggest that we have about $6.8 billion spent annually in unnecessary medical tests.What’s necessary?  Whose responsibility is it to be stewards of smart choices?  We know new technology woos doctors, often long before there is any evidence that using the technology has any impact on the health of individuals or of communities. We know tests are often done because a physician is nervous of being sued if something is missed or has delay in diagnosis.  And a family asking for tests or treatments sways doctors as well.

     What the patient in the above example needs to navigate this pregnancy is a lot of support and understanding about her loss and her anxiety about this pregnancy. Certainly she would be helped with quick access to her providers when she has either worrisome symptoms or a rise in her anxiety.  She also would benefit from evidence based strategies to manage her anxiety. There is evidence that suggests that regular ultrasounds (and that would include frequent at home Doppler following of fetal heart rate) does not improve the likelihood of a healthy baby born at term.

      It would be great if those tests calm her.  And if they do not?  Then what?  Whether she got the Doppler or the ultrasound, she still can take well proven steps to be less anxious. These include exercise, good diet, and training thoughts to have a more balanced and accurate view of the situation.  Mindfulness also has and excellent track record for managing anxiety. Many cities have Mindfulness Based Stress Reduction (MBSR) sessions based on the work by Jon Kabat-Zinn. In the case of this pregnant and legitimately worried woman, what she thinks she needs may not be what actually helps her.  What is the responsibility of her doctors?  Give her what she wants? Or give her what they think she needs?

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