Unlike mechanics, doctors have been denied the basic logic of futility

So a guy has his car towed to the mechanic. All four tires are slashed. He has a simple request.

Please replace the tires.

But this is one of those comprehensive care mechanics. He not only examines the tires, he does a full once over. He pops the hood and immediately knows that the engine is shot. It’s fried. The cost of fixing the engine is more than the value of the car. It’s a zero sum game. The owner shouldn’t replace the tires, he shouldn’t work on the engine, this car belongs in the scrap heap. He saunters out to the waiting room, and delivers the bad news to his eager customer. The mechanic is utterly stunned by what he hears next.

Please replace the tires.

The mechanic, being a kind and gentle sort, assumes that he has been misunderstood. He sits down quietly next to his fellow human being. He again explains, more slowly this time, how the cars value is minimal. He draws a diagram to demonstrate why the engine won’t function. He reiterates the futility of changing the tires on such a car. It is not only a waste of money, it is a waste of precious time.

The customer turns his back to the mechanic, pulls out his mobile phone, and dials furtively. He hands the mechanic the phone. It’s the customers insurance agent.

Please replace the tires. We will cover it.

The office is full, the cars are piling up in the lot, and yet the mechanic patiently tries to explain the situation again. Again he tells how the engine is nonfunctional. Again he outlines the price of possible fixes and how they are completely cost prohibitive. The tires are just the icing on the cake. They are not the problem, and fixing them will solve nothing.

The customer snatches the mobile out of his hand and dials yet another number. He pushes the phone back without saying a word. This time it is a lawyer. He demands that the mechanic fix the tires unless he wants to face a lawsuit.

So the mechanic bills the insurance company. He replaces all four tires. He drops the car in the lot and gives the customer the keys. The customer thanks him, walks out to the car, gets in, and puts the keys in the ignition. Nothing happens. He gives it another try. Nothing happens. He walks back into the shop and approaches the mechanic with one more question.

How much will you charge me to tow this thing to the junk yard?

In reality, no mechanic would have been expected to fix the tires. No insurance company would have paid the bill. And no lawyer would have taken a case they so clearly couldn’t win.

Yet doctors are expected to put dying patients on dialysis, give fourth line chemotherapy when the first three lines (which actually have some clinical benefit) fail, and refuse to turn off the battery of defibrillators in bed bound, obtunded, dementia patients.

We don’t do this because we want to.

Unlike the mechanic, we have been denied the basic logic of futility.

Jordan Grumet is an internal medicine physician and founder, CrisisMD.  He blogs at In My Humble Opinion.

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  • Shirie Leng, MD

    Nice. Especially the comment about the insurance company. Car insurance is generally for catastrophic “car care” right? Little things and routine maintenance are the responsibility of the owner. Medical insurance is no longer “insurance”. It’s the total method of payment for all care. Makes it hard to refuse not only futile treatment but unnecessary care in general.

  • http://omnimedicalmarketing.com/ Patrick Chavoustie

    Excellent! Thanks for posting this.

  • Rob Burnside

    Yes, but… There’s one element missing–the replacement vehicle. We need Part Two, Dr. Grumet: “To Clone or Not To Clone.” Then maybe Part Three: “What Happens to the Old Me After I’m Replicated?” And perhaps a Part Four: “Maintenance Intervals for the New Self.” Finally, Part Five: “My Clone and I Bowl Every Thursday.” Lastly, forgive my feeble effort to make light of a serious topic. Like you, I think we’re a little wacky when it comes to death and automobiles. Throw in politics, too. Thanks for a nifty piece!

    • SarahJ89

      Stop, please!!! I’m laughing out loud here. I figure the last thing this planet needs is more of me.

      • Rob Burnside

        Goodonya, Sarah. We need more laughter–desperately. Moves you right to the top of the clone list! Do you bowl?

        • SarahJ89

          Badly, very badly. Plus I live in New England, home of “the little balls”–candlepin bowling, which I’ll bet is held in low regard amongst ten pinners.

          • Rob Burnside

            Thank you for sharing! It won’t change your position on the list. I live in PA, where the balls are too heavy, and I once had 11 gutter strikes in a row! Is this TMI??? Probably.

  • SarahJ89

    Great analogy, to be sure. But the gap is that the mechanic is employing left-brain solutions to a right-brain problem. You may as well be speaking Swahili to someone who is speaking French. And all the blame and logic in the world won’t help.

    No, sadly, I do not know the solution. But the problem of total missed communication is pretty clear.

  • SarahJ89

    I think what bothered me in this otherwise on-target analogy was the consistent emphasis on the fact the car wasn’t “worth it.” I really think this is not accidental, though it’s obviously not conscious.

    Analogies are never perfect, of course, but this one is good. The repeated references to the car’s value, however, leave me wondering if it’s simply an example of a not-quite-fitting analogy or an expression of our society’s very real view of the value (or lack thereof) of the elderly. It’s an important point because if it’s the latter it *will* be communicated and it *will* cause a reaction the very opposite of what the “mechanic” wishes.

    I’ve actually had mechanics plead with me to get a new car. I hate
    car shopping, plus I tend to develop irrational attachments to the ones I
    drive–always for over a decade. What gets through to me–after a
    while, I admit–is when the mechanic admits he simply cannot fix the
    vehicle any more. The cost-benefit logic is lost because I’m in an
    emotional place, not a logical place.

  • curmudgeon

    So, we need death panels and a high functioning proactive IPAB?
    I was an intern in the very early ’70s when dialysis machines were sparse
    and before medicare coverage for CKD/dialysis existed. New renal failure
    patients were extensively evaluated for positive lifestyle factors favorable to dialysis. At one meeting of the committee that decided who got dialysis and who didn’t I can recall the final summation after the SW report: “John
    is not a good man…” And that was it, no dialysis. Things changed rapidly over the next 3 years as the automatic medicare coverage was set
    up and that committee no longer had to meet.

    • PoliticallyIncorrectMD

      Congratulations! Now severely anoxic artificially fed and watered bedridden 95-year-old on life support can get dialysis, and Medicare will pay for it too.

    • SarahJ89

      I worked in a hospital with a dialysis unit in those days. I always think of that when I hear people express horror about the “possibility” of rationing medical care. They have no idea…

    • John C. Key MD

      I remember those days too–we observed those panels as medical students. You also had to get past a panel to get into methadone treatment and those panels were pretty stingy too. Thus I shake my head when people say “there can be no such thing as a death panel….”

  • drjoekosterich

    Very insightful piece. The healthcare system has become a logic free zone.

    • SarahJ89

      Alas, I think it shares that space with the rest of humanity’s world.

  • Skeptical Scalpel

    Great post. I just became aware of it today. It is particularly relevant because of the sad case of the 13 year old girl in California who is brain dead after obstructive sleep apnea surgery.

  • drrob8091

    Must have been a recent grad. None of my partners would have attempted to dissuade you with that presentation. I am not one to stand in God’s way, especially in futile cases.

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