If both patients and doctors don’t accept the changes required of their behavior, no amount of comparative effectiveness studies will cut health care spending.
Two prominent medical journalists write as much in their respective blogs.
First, the NY Times’ Tara Parker-Pope notes that patients have to realize that, yes, they should demand the best care possible. However, that means, “we will have to accept that ‘best’ doesn’t always mean the newest drug or the latest treatment. The looming question is whether patients are ready to embrace the realities of reform.”
Publicizing the findings of comparative effectiveness research can help, but not always, as evidenced by the $130 million ALLHAT trial. Despite finding that cheaper diuretics worked as well as more expensive drugs, the study didn’t really change anti-hypertensive prescribing patterns much. (I have my own reasons on what the ALLHAT findings were ignored.)
Next, Newsweek’s Sharon Begley comments on how patients can refuse to adhere to the findings of comparative effectiveness research by suing doctors who try to do so. As she points out, “What are [doctors] supposed to do when a patient demands antibiotics for a cold? for a child’s ear infection? when a patient demands an MRI for back pain or knee pain? If they refuse, several doctors told me, they can expect a call from the patient’s lawyer that afternoon.”
Duncan Cross takes the patient perspective, and like most progressive health reformers, blames doctors: “By all means, let’s nobody examine the role the medical profession has played in creating and sustaining dysfunction in our health care system. Let’s all ignore the effect of physician licensure rules, prescription drug laws, and training that inculcates physicians to believe they are their patients’ superiors; let’s ignore all the myriad ways medicine disempowers and diminishes patients, and gives them over to alienation and disaffection with the medical profession.”
Yes, physicians are the ones ultimately responsible for ordering unnecessary antibiotics or MRIs. But, the threat of malpractice is indeed a cloud that hangs over every decision a doctor makes. Just because Mr. Cross disagrees with that doesn’t make it any less true, or any less of a factor.
(As an aside, Duncan Cross, along with having the best written patient blog on the web, demonstrates a level of patient empowerment that, unfortunately, is representative of a minority of patients. If every patient shared his attitude questioning whether every test a doctor orders is really needed, it will make my job much easier.)
Throwing billions of dollars at comparative effectiveness research is all well and good, but if both doctors and patients refuse to abide by the findings, you might as well flush that money down the toilet.
Related posts:
- Do patients trust doctors to bring about health reform?
- When will doctors find it acceptable to deny medical services?
- What doctors can learn from patients in the health care reform debate
- Multimorbidity, and why it’s difficult to care for complex medical patients
- We need comparative effectiveness research, or, I agree with Paul Krugman for the first time ever
- Health Care Reform: Putting Patients First, medical bloggers at Washington, DC
- Patients still trust their doctors, and how that can influence health reform
{ 11 comments }
Kevin – thanks for the nice words. Just to be clear, I was responding – perhaps intemperately, but quite specifically – to a Dr. Mintz post that put the burden of reform on patients. It’s too much to say I “blame doctors” for what’s wrong with health care; I agree that both doctors and patients are going to have to accept changes if we are to build a functioning health care system. Regarding the patient’s role, I have since posted some thoughts on what patients can do to help fix health care.
Duncan Cross takes the “patient advocacy” thing to a militant degree. I still can’t get over that post about telling patients how to advocate for time alone for sex in a double room in a hospital.
The best patient advocates encourage the patient to exercise, eat non-crappy foods (ie lead healthy lifestyles to begin with), listen, write stuff down, ask the doctor/nurse questions about things they don’t understand or a rationale for a treatment, tell the doctor if they can’t afford something or if there is a more affordable option (when the alternative is no treatment), and follow up as recommended.
People who have their lawyer call the doctor’s office for not being prescribed antibiotics for a cough or virus probably have a personality disorder, and I’m not kidding on that. Most REASONABLE patients will accept a physician’s opinion if he or she explains his thought process on simple things like this.
” But, the threat of malpractice is indeed a cloud that hangs over every decision a doctor makes. Just because Mr. Cross disagrees with that doesn’t make it any less true, or any less of a factor”
Simply because Kevin agrees with that doesn’t make it true, or any more of a factor. In fact, when you think about the millions of patients seen every day all over the country, and you look at the actual number of claims made, it’s difficult to make the case that it does hang over every decision, or many at all.
Let’s not forget that doctors have been prescribing unnecessary tests and procedures long before malpractice lawsuits were so prevalent. Doctors receive a fee for service, they often perform unneeded “services” because they get paid more to do so. Health care professionals must admit they have seen their colleagues do this again and again and again, and have turned a blind eye to the practice. It is also easier to write down a drug on a piece of paper and scoot the patient out the door, than deal with a bunch of pesky questions. Patients do shoulder some responsibility for their own health, but Duncan Cross’s suggestions are a bit naive in the real world. Same can be said for Nurse K’s suggestion of the best health advocate should teach healthy lifestyles to patients. Give me a break. The drug addicted pregnant mom is not going to yoga class on my suggestion. It is up to the health care professionals to teach and converse with their patients, not talk at them. We have lost the art of communicating, and we need to get it back fast.
Kevin, as you well know, eleven years ago, as I was finishing up a federal service obligation in my “under-served” hometown, I was fired by a “non-profit” hospital . . . two weeks after intervening in a “bad baby” case being badly mismanged by someone else. By all accounts I saved the child’s life.
Two days before that incident (not the first time I had cleaned up a mess) I got a “warning” letter from the practice manager telling me essentially to “shut up or else” about quality-of-care problems and/or bad physician behavior at the hospital.
The warning was based on a complaint made by one of my parents – a local dentist – who was livid because I would not over-ride a decision made by the local health department (and give a vaccine to her child that was not deemed necessary). She was an important businesswoman in town, and as the lowly employed peon, I was supposed to immediately drop everything I was doing (like ministering to a woman who had just left her abusive husband with nothing but her kids and the clothes on their backs) and do her bidding by phone (without ever seeing her child). Multiple phone calls ensued. The woman could not be placated or reasoned with. It gave entitlement a whole new meaning.
When I would not cave, she wrote a vicious letter to the hospital CEO (accusing me of “malpractice”) and that set the ball rolling to boot me out the door – on the trumped up charge of being “disruptive”.
Very long, ongoing story short, for doing the right thing in both instances, I’ve been through HELL.
And my God, do not get me started on lawyers.
Contemplating my next step, I’ve been going through legal files lately and it gave me an idea. I have started a “series” of sorts on my own blog: http://drjshousecalls.blogspot.com/2009/03/in-face-of-crippling-shortages-voices.html
In future posts over the next few weeks, I am going to detail everything that happened in the weeks that led up to my termination – posting the text of letters – demonstrating how a good doctor fell through every crack of fair play or oversight.
It’s time more doctors-done-wrong fought back against this kind of crap – especially since the Obama administration seems determined to ram socialized medicine down our throats.
I’ve got news for you people, the government could not manage its way out of a wet paper bag! Things are NOT going to be better – FOR ANYONE – if the government takes it all over – and continues to pose doctors as the enemy – or “obstacles” to be crushed – in some kind of warped battle for dominance.
Here’s the other thing: I’ve been in the blogosphere for four years beggging the MSM to cast some attention on my case – so that I might finally extract some small measure of justice from North Carolina’s beyond corrupt system of medicolegal oversight.
Nobody but nobody gives a damn. I’m a “rich” doctor, and I’m supposed to just suck it up and get over it. And I’m a wack-job if I don’t.
You’ll forgive me if I now have a very low tolerance for “progressive” patient advocates (like Duncan Cross) who want to blame all of medicine’s woes on doctors.
Some of us have bled and bled and bled taking the hits and fighting the good fight FOR YOU.
WHERE HAVE YOU BEEN WHEN WE NEEDED YOU!?!?!?
Well, if I had a drug-addicted pregnant patient, she’d need a social worker who specialized in that who could help her get treatment/sober housing and that sort of stuff and make sure she doesn’t ‘fall through the cracks’. In my area, there are programs specifically designed for this. Obviously, eat-your-vegetables would not be an overly appropriate use of one’s time for her in the short-term. I’m not an idiot.
The vast majority of patients would do well SHOWING UP, listening to /following their doctor’s suggestions, taking notes, getting off their butts, staying away excessive amounts of McDonald’s, and asking questions when appropriate.
I always love how reform is depicted as rampant rationing and what our insurance companies are doing to us now isn’t. Who are these people with awesome insurance that apparently never denies anything and never leaves them with a big balance bill to cover?
I see the advocates of “Evidence based medicine” as somewhat two-faced, or at least, not entirely honest about the assumptions inherent in their approach. I have no problem with science, and I say, where good science exists on a topic, get the word out. But realize also that there are limitations with this approach due to three main issues.
(1) Evidence based medicine assumes a group-level approach to costs. In other words, if you have 100 patients with condition x, and treated them with medication y versus z, what are the proportion of good outcomes, versus costs. This assumes cost is a group phenomenon (which, in our current third-party dominated medical world, it is). But, in the outpatient world, it needn’t be. If our system was more rational, there would not be this huge third-party to contend with. If I am a patient who is paying for the majority of what I am getting, as an outpatient, then I should be treated as an individual, and should be informed of the differential in terms of costs and efficacy. This doesn’t make the doctor’s job easier, but very different and more patient focused. This doesn’t mean I treat a cold with an antibiotic, if I am convinced it will do no good, but I may offer Zofran over Phenergan – if the patient wants to pay the higher cost, for a better chance at efficacy.
(2) Evidenced based medicine often does not take into account individual differences. Quick – what’s the ‘best’ stroke preventative for a patient with an embolic appearing stroke with no discovered source of embolus? There is no obvious answer to this question. We can do a study of 100 such patients and try to see what sort of outcomes occurred, but in many cases, the facts of each case are so different that it is very hard to compare. As with many, many cases for which evidenced-based medicine is meant to apply, you must individualize to the specific pt. you are treating. I’m not against trying. I am always looking for relevant data, but it does not always abound. Sometimes you have to THINK about the case and come to conclusions based on presumed mechanisms of disease.
(3) People often disagree. Even scientists. In fact, it turns out that scientists disagree a lot, and because of that, science is allowed to progress. There are different ways to view and interpret data. Certainly large organizations including, gulp, God Forbide, *the government*, can get it wrong. So it isn’t possible to adhere to some monolithic set of recommendations called “evidence based medicine” and check your brain at the door. You must always examine the underlying data, the assumptions, and even the underlying motivations (such as cost containment) that may be ‘informing’ the end result.
It is my body, my life, and my health. The government has the right to say what it will and will not pay for, but it does not have the right to tell me what treatment I will or will not get.
That is none of it’s business.
Besides, I haven’t noticed that all the supersmart superhonest government regulators who were supposed to regulating banking were smart enough or honest enough to prevent catastrophe. The winners right now are the untrusting paranoids who, in the face of scorn and derision, put in under their mattress.
Why should I have any more faith in medical central committee’s? Experience? Like that with the shills who were secretly on the take from the drug companies while using their position as “top doctors” to spread the crapola that everybody with an emotional fart was bipolar?
I would rather make my own mistakes and live or die by them than be forced to accept the mistakes of that unprincipled untrustworthy bunch of courtiers in Washington.
The patient’s lawyer will call that afternoon and… what? Threaten the doctor for complying with a Federally-approved de facto standard of care?
Put simply, CER will cut both ways. A doctor who does not utilize a CER-approved treatment will have a lot of explaining to do down the road if that treatment would have helped. Conversely, a plaintiff alleging a doctor should have used a CER-disapproved treatment will have a hard time convincing a jury that the doctor should have overridden the billion-dollar research.
From a liability / malpractice standpoint, doctors who abide by the standard of care should welcome the CER with open arms, as it will give them a powerful tool to wield when a plaintiff’s lawyer later asks “why didn’t you do _____?” They can quite honestly answer “because the CER says it’s not effective.”
Max:
A guideline does not define standard of care. Coming from an overfunded federal council will make that no more true than it is now. Such a council would define the standard of care only if the medical profession collectively decided that it did and generally provided testimony to that in court.
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