Does this scenario sound familiar? You bring your car into the dealership for routine servicing. The service representative (patch on his shirt says his name is “Bob”) checks your car history. He tells you they will do the routine service check, but he also recommends the “manifold inspection,” a “carburetor cleaning,” and a “transmission flush.” Now you have no idea what the hell a manifold is or does, but you don’t want Bob to think you are an automobile maintenance moron. So, you give a pseudo-knowing nod as you sheepishly agree to the “new and improved” service plan. Dear fellow health care colleagues: You have just been suckered into what Bob and his ilk call “The Upsell.” I myself know nothing about carburetors, transmissions, or manifolds. But one of my patients, who happens to be a service manager in this business, has confessed to me that all these things, in most instances, are totally unnecessary. But it is a “win … win … win” situation for everybody. The dealership makes more money. Bob makes a bigger commission. The customer thinks he is getting his car in extra tip-top shape. And all this got me thinking. In our health care business, are we not guilty of the medical brand of The Upsell? How many unnecessary MRIs, CT scans, lab tests, etc., do we order? More importantly, why do we order them? And what are the consequences of ordering those unnecessary tests? Think about it. Let me confess to you, I too, have succumbed to practicing the medical version of The Upsell. I, too, have sometimes become the physician equivalent of Service Rep Bob. As I reflect on this, let me share with you some of the reasons: Fear: Medical-legal issues. CYA. Training: Medical school and residency trained me that I must consider every possibility, and I must do every possible test to check out those possibilities. Caution: I might miss some zebra diagnosis. Hubris: Exotic and obscure tests that I order will reveal my medical brilliance. Paranoia: If I don’t order tests, other physicians may criticize my lack of “adequate” workup. Obsessive personality: I must find the answer to everything and find it now! Patient service scores: If I don’t order the tests that my patients request or demand, my patient service scores will suffer, or worse, my chief may get a patient complaint letter. Mount Everest syndrome: Why’d you climb it? “Because it was there!” Why’d you order serum porcelain? “Ditto.” Think about the downsides of ordering these unnecessary tests to us physicians: The time it takes to put in the orders. The time it takes to explain incidental findings (like a bulging disc on lumbar MRI). The clutter of our inboxes with superfluous lab and X-ray results. The unnecessary referrals they may engender, thus affecting specialist access. The extra work for other physicians, like radiologists, who must triage our requests. And perhaps worst of all, the gut punch to our integrity as we find ourselves ordering tests that we don’t believe in. And what about the risks of all this to our patients? (Not to mention the financial burden to the health care system.) Such as, among other things: The copays working folks spend for these various X-rays and other tests. The time a patient must spend away from family and work for these tests. The worry and anxiety these tests put on patients and their families. The risk of radiation. The risk of the incidentaloma that leads to a harmful invasive procedure. And of course, when we explain why we are ordering a “serum porcelain” level to our patients, they may be just as in the dark as when Service Rep Bob suggests we need a manifold inspection. Yet our patients, too, may give the pseudo-knowing nod, sheepishly assenting to their doctor’s “new and improved” service plan. But for our patients, unlike with Service Rep Bob, The Upsell is not about ginning up the maintenance of an automobile. For our patients, The Upsell could put at risk their very lives. What I’m saying is simply this: Next time we are about to order that “who-woulda-thunk-it” test, let’s think about Service Rep Bob. Let’s think about why we are ordering the medical equivalent of that “transmission flush.” And let’s think about the potential consequences to our patients. Nowadays, upon the advice of my service manager patient (who wishes to remain anonymous), my wife now hands Service Rep Bob a note whenever she brings our car in for the routine service checkup. In big letters, the note says: “No upsell.” Perhaps when our “customers” come to our medical clinics for their routine service checkups, they should bring us a note that demands the same. Source
