To fix health care, ask patients to change their understanding of how a health care system should work


On a recent flight, I sat next to a woman of about 30 who was originally from France but has lived in London for a number of years for work. After exchanging the usual pleasantries, she found out I am a family physician and it became clear she wanted to give me her opinion of the British health care system. I didn’t dissuade her.

For a little background, both the U.K. and French health care systems consistently rank as some of the best in the world. The U.K. commonly is ranked at or near the top as the system that delivers the best care at the lowest cost. The French system costs a little more, but it tends to be ranked at or near the top for scores of overall effectiveness of the system. Apparently, this woman was not aware of the rankings.

She found the U.K. system to be almost primitive. By inference, she was a healthy young woman who accessed the health care system mostly for contraception and cervical cancer screening (Pap smears). Her experience in London was that she was told to lie back on a regular exam table, put her feet by her bottom and lift her pelvis up enough to make room for a speculum. After the sampling was finished, that was it. The doctor or nurse (I’m not sure which) told her the exam was over and the visit was over.

She was mortified about two things. First, the fact she was made to do some minor gymnastics on a plain exam table. The surgery did not have a table with stirrups like she was used to in France. Second, her gynecologist in France always checked her labs each year “to be sure I’m well.” This did not happen in London.

I could tell from the righteous indignity in her voice that it would have been pointless for me to explain the wasteful practice of the French gynecologists that I just learned about and that the British had it right.

I think the take-home message of this story is that even in 2 very high-functioning health care systems, common problems are managed differently. Each country has its own quirks of what it prioritizes. The British planners in effect decided that their resources should be used for purposes other than exam tables with stirrups. The second message is that it is extremely hard to change health care systems because the most numerous units in the system (“agents” in complexity theory) are the patients. If they have fixed beliefs about what a proper health care delivery system should look like that does not match what the system people think, change ain’t going to happen. At least, it will be extremely hard to move the system needle, and even if it moves a little, it will likely snap back to its original state when the external pressure is removed.

This phenomenon is one of the fundamental reasons health care reform in the U.S. has been so ineffective. This is why programs like accountable care organizations, shared savings programs, primary care payment reform programs, patient-centered medical homes, and so on couldn’t show much for their efforts. They never asked the patients to change their understanding of how a health care system should work in the first place. On the national stage, the politicians and system people never ask U.S. patients to change their habits.

And because of this, we remain stuck with the same inefficient exorbitantly expensive health care system that now consumes 18 percent of our economy and will only get worse.

Richard Young is a family physician who blogs at American Health Scare.

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