I tweeted yesterday that the US healthcare delivery system remains broken. With only 140 characters, there was little means to expand. Let me tell you a story and then you be the judge.
The patient was elderly and had multiple chronic medical problems, including the chief complaint of debilitating orthopedic issues. I was asked to perform a procedure that specifically addressed one of the many problems–a heart arrhythmia. The procedure is one of the simplest that I do. It takes about 30 minutes, causes little pain, and I am well-compensated for doing it. When done in selected patients, this procedure can provide incredible benefit. And there is science to back it up.
The patient was ready, and all I had to do was do the damn procedure. It would have been so easy. On paper, it was justifiable.
But I didn’t feel right about it. The effects of the procedure would be permanent. The risks of making things worse were real. There was a possibility of benefit, but it in my mind, the likelihood was modest. It was a pure judgement call. No right answer. I just didn’t like what I was about to do. (I fear making the elderly worse; they are a fragile lot.)
I tried not to show it, but my brain was flailing with the decision to express doubt. The patient’s doctors are excellent; they thought the procedure (that I do) would help. They knew the patient well, but we had just met minutes ago. My internal estimate of the correctness of my decision was 90%/10%. (I always assess my level of certainty with decisions. You do too, right?)
It would be disingenuous to omit this thought: “Oh boy, Mandrola, you might get in trouble for over-thinking and not doing the procedure.”
So I tried to explain my doubts. Picture the scenario: The patient was hard of hearing; the family member had a notebook and was trying to transcribe my every word–to explain why I didn’t feel so cheery about doing a procedure that I was expert in, and that other doctors had recommended.
It took more than an hour to get through this. It wasn’t just the time spent, I had to get it all down on paper. And then there was the matter of communicating with the other doctors.
Here is the broken part: I burned a tremendous amount of time and emotional energy walking this thin line. A note chronicling that time earns less than a quarter of what the procedure would have paid. Not only that, if I don’t include, in the e-note, pages of irrelevant medical nonsense, I could be held liable for fraud. That’s tragically ironic, because I just saved the patient and medical system from a potentially harmful and expensive procedure. (Don’t forget, there was a 10% chance I was wrong.)
As a procedural clinician, not giving in means everything to me. But I notice the temptation, and conversations like these make running on time a fantasy. Fortunately, it is easier for me than most doctors. I am a veteran here in the local healthcare system. I have capital, and the energy and risk-aversion to burn it. Many–likely most–doctors aren’t in the same position. They want to do the right thing, but the pressure to do more, not less, is too great to overcome. Plus, our healthcare behemoth has been defaulting to delivering more care for so long, it is reasonable to think that most doctors and patients have come to expect it as normal. Like a flat earth and the benefits of non-statin cholesterol-lowering drugs.
Right-minded people point to the problem of misplaced financial incentives. The US model favors doing. That’s a big part of the problem for sure. But it’s way more than just dollars. And one has to be careful with incentives: it’s possible to induce too little care–remember the HMO experiments.
Real (I won’t say meaningful) improvement in the over-treatment crisis will come only when patients and doctors wholly accept the merits of discussing the option of no treatment or conservative treatment. This is the key. We are all believers in doing more.
It’s pointless to write about problems without offering a possible solution. I have a simple one that might appeal to policy makers and medical educators alike.
May I suggest that doctors avoid the word ‘need’ in the exam room. If we stopped saying patients needed stuff, we might be able to open our minds to the benefits and harms of the disease versus our treatments. If patients were never told they needed something, they too, might be allowed to consider their options.
I once wrote about the most overused word in cardiology. I believe it more than ever.
Changing the need culture might be safer than messing with dollar incentives.