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RENEE MONTAGNE, host:

This is MORNING EDITION from NPR News. Good morning. I'm Renee Montagne.

STEVE INSKEEP, host:

And I'm Steve Inskeep. It is Monday morning, which is when we look at Your Health. And this morning, we'll look at our role as medical consumers. Compared with other nations, we spend an unusually large percentage of our income on health care. There are plenty of reasons for this, and we're about to focus one: That reason is us. We behave differently as consumers at the doctor's office than we did 20 years ago. We're being trained to demand more treatment.

NPR's Alix Spiegel begins her story in rural Virginia.

(Soundbite of door opening)

Dr. TERESA MOORE (Family Practitioner): Allie, where are you sweetie?

ALEX SPIEGEL: The doors to the clinic had been locked for over an hour, and the light in the sky was quickly fading when Dr. Teresa Moore was disrupted by a knock on her office window and looked up to see a patient. She walked through her empty office, swung open the front door and called out into the parking lot.

Dr. MOORE: Allie?

SPIEGEL: After a second, a woman rounded the corner. She was a regular, someone with migraines. And even though it was after hours and Dr. Moore had three children waiting at home, she waved her in.

Dr. MOORE: Go on back there, sweetie, and sit in the - you know where to go…

ALLIE: Oh. I'm sorry.

Dr. MOORE: …and I'll be there in a minute, right?

SPIEGEL: Teresa Moore has a family practice is in Keysville, Virginia, the same small community where she grew up. Her patients are people who attended her baptism, helped at her wedding. So in some ways, Teresa Moore has a true, old-timey medical practice. But in one important way, her practice is completely different: Teresa Moore cares for modern patients, consumers who know exactly what they have and what they want.

Dr. MOORE: I'd probably say 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.

SPIEGEL: They come in quoting commercials they've seen on TV, requesting pills and diagnostic tests, or treatments for diseases they are convinced that they have.

Dr. Moore says that sometimes they're right. More often, they're wrong. But she's not judgmental about their self-diagnosis. 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 as a medical student.

Dr. MOORE: There is a syndrome in medical school they teach us about called medical student syndrome. And what that is is the first few times you learn about certain diseases, you think you have it. So, the same thing that triggers medical students to worry that they have these diseases is part of what's triggering people watching television or surfing the Internet to believe they have these conditions, is that the continued re-exposure to suggestions of symptoms starts making people look for things.

SPIEGEL: The problem, says Moore, is that it can take a lot of work to convince her patients that their own diagnoses are wrong - or anyway, her younger patients.

Dr. MOORE: In the older population, there is a tremendously different dynamic between doctors and patients. There is a lot more belief and trust in the doctors in general. In patients who are typically between about 25 and 50, there is a lot more push to get what they want.

SPIEGEL: The behavior of patients in our health care system has changed dramatically over the last couple of decades. We've been transformed from passive patients into active and aggressive consumers of health services.

Dr. Joseph Zebley is a 60-year-old family physician in Baltimore, Maryland, and he dates the beginning of this transformation to the early '90s. He says people slowly started showing up with their own research.

Dr. JOSEPH ZEBLEY (Family Practitioner): It was the sort of thing that would be a bit of a surprise, and it would be the occasional patient. By '95, it was an established pattern, became a palpable change over the period of about five years.

SPIEGEL: What produced this change was a kind of perfect storm of events. The first was direct-to-consumer advertising of prescription medications, which started on TV in the mid-'80s. Those ads drove people to their doctor asking about particular drugs, and in the process, taught patients that they could play more of a role in their own health care.

Then, obviously, there was the Internet. And finally, there was the attempt in the 1990s to save money on health care by pushing people into HMOs. The original idea was that primary care physicians would be put in charge of patients and given a fixed amount of money for all care, which 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 and operations, which Zebley says was shocking to patients.

Dr. ZEBLEY: And they became angry and they started researching why they should get things, because oftentimes the physicians - I hate to say it, but the physicians were looking after their bottom line. And if they withheld services, they could make more money. So a person went online - it was very rudimentary then - or looked things up in the library. And people photocopied things from the library and say, I think I have this. I think I need this.

SPIEGEL: Now, there are real benefits to this new American patient, but also some problems. For one: We cost a lot of money. You see, under the current system, it's just really hard for doctors to say no to our requests, even when they're wrongheaded.

For example, Zebley tells me that several times a week, a patient comes in asking for a test that he, as a doctor, is 99 percent sure would be a complete waste of time. But does he give it? Absolutely, because of malpractice.

Dr. ZEBLEY: 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.

SPIEGEL: Of course, Zebley could take the time to argue his patients out of it, explain exactly why the test or treatment is a bad idea. But because of the way our health system is structured, that's often difficult, too.

Take Dr. Teresa Moore. She works incredibly hard to spend enough time with her patients. But since time is always limited…

Dr. MOORE: There is a drive to get people in and out because insurance reimbursement is very difficult. And 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.

SPIEGEL: And so doctors will order you tests that you don't need, give you pills you probably shouldn't take. That's a huge problem with antibiotics. Zebley says doctors even do operations, stuff like back surgery, they probably shouldn't do. They do it, he says, partly because you want it, have become convinced that you need it, and they fear that if they don't give it to you, they'll lose you.

Dr. ZEBLEY: 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 other surgeon who maybe a little less ethical who will do it. And being a hard-ass and always saying, no, no, no, people will go somewhere else.

SPIEGEL: Experts estimate that anywhere from 10 to 20 percent of the health care costs are driven by patients in this way. Teresa Moore says it feels more like 30 percent of her own practice, but she's not happy with that number. For her, at least some portion of it is an indication of her own inability to adequately communicate with the patients she cares so much about. It's just, she says, that she's truly overwhelmed by insurance paperwork.

Dr. MOORE: Sometimes you have to request a form to get the correct form. You do. You have to fill out a form stating the preauthorization form that you need.

SPIEGEL: As Dr. Moore talked about this, she actually gets emotional.

Dr. MOORE: I just really want to do right by every one of my patients, and I want to be able to spend the time it takes to educate them.

SPIEGEL: Do you feel like you're not able to, really?

Dr. MOORE: I feel like my children suffer because I spend so much time with my patients. I stay here a lot of times until 10 and 11 o'clock at night trying to catch up on the paperwork so I'm able to spend the time with the patients at the office.

SPIEGEL: Still, if you ask Teresa Moore if she'd rather have the old, passive patient or the new demanding one, she really has to think about it.

Dr. MOORE: It depends on the phase of the moon.

(Soundbite of laughter)

Dr. MOORE: No. Passive is much easier to treat. I do think I like a more educated patient who's willing to read about their health issues and who wants to learn about them.

SPIEGEL: Dr. Joseph Zebley says the same, though he knows full well how our new conception of what it means to be a patient costs society.

Dr. ZEBLEY: You know, you must demand of your doctor this. You must ask them all these questions. You must be a wise, intelligent, informed consumer - which is all true. It's all good, but it leads to a lot of overuse of services. We have an infinity of need.

SPIEGEL: An infinity of need that grows more infinite all the time.

Alix Spiegel, NPR News, Washington.

(Soundbite of music)

INSKEEP: And that's Your Health for this Monday morning on MORNING EDITION from NPR News.

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