As a practitioner of modern medicine, I am privileged to have an in depth understanding of the human body and the institutions that have been made to maintain it. I am highly trained to treat disease. You may not believe it, or you may consider this arrogance, but it is quite true. You probably won’t agree with it at the end of this post, but I still believe it to be true.
My day is spent primarily in my clinic seeing patients. My productive quotient is quite high. What I mean is that I see many patients. And it needs to be. I only make my salary when patients come into the office.
However, my quality quotient may be low. What I mean by a quality quotient is the percentage of encounters in which an intervention is required, and the correct intervention was chosen. The individual in which I am required by a disease state to intervene upon each day is low, even though I see many per day. In fact, it is so low that I would estimate that necessary intervention is required in 10-20% of encounters. However, the number that are actually intervened upon is much higher. The necessity of that intervention is questionable. Hence, a low-quality quotient.
Most patients have ample access to me. Some can be seen within 24 hours. Almost all can be seen within a week. Many encounters I have are not due to a disease, but more symptoms that are irritating. The expectation is to be evaluated for a disease and to have it treated. Since there are symptoms, there must be a disease, but this is unlikely the case. Most symptoms have no explanation, and require no intervention. Most of my day should be sent saying there is nothing to do. However, being told that I should leave you alone leaves you unsatisfied, and sometimes angry (I've tried). It certainly doesn’t benefit me.
Some have called our health system terrible. One of the worst in the modern world. This is not true. It is the best. Without question. We have the best technology, the highest degree of access, the highest number of specialists and sub-specialists per capita (comparably) and more usage of the system than anywhere else in the world. All of these metrics suggest we are the best. But that could be the problem. We use it too much.
I get paid by seeing you in the office. I make more money if I prescribe you a medication, or if I order tests to investigate your complaint. It doesn’t bother you because you are there for action, not inaction. Your psyche favors action over inaction. This is known as action bias, and it is very dangerous. You feel better because you are getting a medicine, and something is being done about your complaint. But this is a mistake.
There are many times in which the complaint is unlikely to be anything serious, your prognosis is excellent, and you would be better off to heal on your own than to have engaged with the system.
Everyone is happy and incentivized with action. Very few are happy, and no one is incentivized for inaction (doing nothing). I should be protecting you from Me, and Yourself, by telling you to go home and be merry.
So, what is a negative balance sheet when it comes to our healthcare system? Does the improvement in quality of life we provide outweigh the costs and burdens in an attempt to achieve it? Are we scoring more runs than striking out?
I would like to tell a short story about a patient of mine that I managed very poorly. The details are changed to protect privacy.
She is an elderly woman that came to see me for incontinence. This was mostly dribbling and urgency. She had to wear a pad which she found irritating. I explained that her that the incontinence was mainly anatomical and she could try to improve it with Kegel exercises. I recommended to continue wearing the pad. There is no risk to the pad, other than annoyance. There is risk to taking medication for incontinence and I did not think they would help her very much.
She was not happy with this explanation and wanted to try a medication. She informed me it was embarrassing and she did not want to live like this (even though she could). So, I caved and prescribed a medicine for her to try.
(For some quick perspective…These office visits happen very quickly. The time allotted is twenty minutes. Half of that is spent checking you in. We have to work very fast or we quickly get buried by our schedule.)
A couple weeks later she presented to the office complaining of constipation. I had completely forgotten about the prior visit’s intervention (this is a common side effect of her new medicine). Her constipation was mild, she requested something to help. I recommended over the counter MiraLax. She started this medication which relieved her constipation.
She returned two months later complaining of dizziness. It was described as the room spinning multiple times a day. It had been going on for about a week. Her exam was normal and I diagnosed her with benign vertigo and prescribed meclizine for her.
At this time, we are in a routine. And it’s bad. These interventions are leading to more interventions, which will lead to a mistake. Unbeknownst to me she had continued the MiraLAX every day and was having 2-3 stools. She was also on a diuretic chronically for leg swelling, which further dehydrated her. This was likely the source of her dizziness. This is a miss.
She continued to have dizziness and continued taking the meclizine. I refilled this a couple of times. Two more months go by and her daughter brings her in for fatigue (a common side effect of dehydration and meclizine). She has had several blood tests and work-up for her other complaints so I diagnose her with depression and started an anti-depressant. Now she has crossed a threshold into being overmedicated.
Since the start of her complaint she is taking 4 new medications with an innumerable amount of side effects. Three of them act on her central nervous system.
Two weeks later I see that she was in the emergency room after a fall. She had fractured her femur. I look back through her chart to review our visits. Now, from a bird’s eye, I see my errors. She had surgery. She spends the next 2 months in a rehab facility. She uses a walker now. She’s lost most of her independence. I’ve stopped all of her medicines. She doesn’t mind the pad, because now she has trouble making it to the bathroom.
You would think this is a rare case. This is not rare. It happens every day. It happens to many patients. She (and I) would’ve been better off if I told her to just go home and use a pad, but I didn’t have the courage to do so. I did not protect her. Mainly because I was afraid to lose her as a patient. If I don’t treat it, she can easily find someone that will. She didn’t complain one time to me about her care. In fact, she is a very loyal and pleasant patient. If she recognized the pattern, she’d probably be very upset, and ask for her money back.
She has a negative balance sheet. Her costs and burden outweigh any potential payoff.
For all the cost that was incurred, what was the potential payoff? The payoff was to get rid of the incontinence pad. The payoff of action is easy to understand. The potential costs are hidden and difficult to detect. They occur haphazardly. Compared to “payoffs from action,” the costs are spread over longer time horizons. The payoff of inaction is the same, it is hard to see, because what could’ve been, doesn’t exist. All you know is you are the same, which isn’t necessarily bad. It may be good, even great, compared to the alternative.
Optionality in the form of new and competing technologies, vast healthcare networks, and competitive business models exacerbate this phenomenon by prompting us to swing at many pitches even though they are in the dirt, or way over our heads. This leads to plenty of strike outs. We’re often better off waiting for a good pitch rather than swinging at whatever the pitcher throws at us. Swinging at good pitches keeps you alive, and limits your effort (costs and burden). The most important thing is surviving and thriving.
Quality of life / (Burdens + Costs)
To be continued…