Successful US healthcare reform must consider human nature

Reform of healthcare in the United States is infinitely complex. Millions of words have been written. The noise drowns out the signal. It’s rare therefore that one paragraph could sum up the problem so concisely.

It came from Edward Davies, an editor at the British Medical Journal. He was quoting journalist Owen Dwyer who was writing on the challenge of doing less.

“How many of us would voluntarily take steps that slash our income, and that of our employees, while simultaneously alienating our customers? That is what US physicians are being asked to do. Only a physician of rare moral courage could push back alone against these relentless pressures, which is why physicians are now being asked to try collectively.”

As many of you know, I am a vocal advocate for both the Choosing Wisely campaign from the American Board of Internal Medicine Foundation and the Less is More movement from Dr. Rita Redberg at JAMA-Internal Medicine. These ideas, which urge doctors to practice less disruptively, fly in the face of human nature. No headwind is tougher to pedal against than human nature.

Consider the roofer anecdote: How many times has a roofer looked at your roof (which you cannot see) and told you: “No sir, your roof is fine; you don’t need any of my highly profitable services.”

I often kid around with patients and proclaim that I am the only doctor in this city trying to make less money. Hyperbole? Yes, surely.

But the point is that when I practice less disruptively; when I teach patients to help themselves; when I give time a chance to cure, and when I do fewer procedures, there are certainties:

• I practice the best medicine possible;
• I come home mentally and emotionally fatigued;
• I hurt my productivity;
• I endanger my referral base;
• I might just expose myself to liability risk.

These are the problems that ObamaCare does nothing to address. These are the hard problems.

Read that quoted paragraph again. Then put yourself in the shoes of a young doctor who does not have a stable referral base, adequate savings or paid off student loans. Consider what the good young doctor does have: a compliance officer breathing down her neck to prescribe guideline-mandated ‘quality’ care, twenty other patients to see before she picks up her kids at day care and maybe even the false idea that more care is better care. Does the good young doctor know that said guidelines are born from medical societies with financial ties to industry? Does she realize that today’s quality care might be tomorrow’s medical reversal?

It’s a mess.

The complexity of it all always leads me back to the same basic and obvious things.

To patients: I say take care of yourself. Make good choices and stack them together. Such is not a guarantee, but it improves your chances of avoiding this imperfect business.

To doctors: I say go slowly and think. Aim for less disruption. The human body can do a lot if we let it.

To medical educators: You have one shot with these young people. Teach them well. (Not everyone gets the benefit of Hoosier wisdom, but you can get close.)

And to policy makers: Please pay more attention to the contact points of healthcare–that is, where human doctors meet human patients. Human nature is a stiff headwind to go against. Ask real doctors to help you, even cardiologists.

JMM

See also this Storify Twitter thread published by my colleague Jay Schloss (@ejsmd).