Friday, March 08, 2013

Is medical practice moving from "What can I do for you" to "What can't I do for you"?

In a society in which individuals are more or less free to interact with one another and seek each other's services and goods the following phrase is routine; "What can I do for you?" or "how can I help you?"
I have said that  said many times to a patient at the beginning of an office visit.

It seems to me that that phrase captures  an important aspect of the mind set of the clinician as she relates to her patients. What can I do for you, how can I help you, what are you concerned about all speak to the role of the physician in her fiduciary duty to the patient.

Why is it that clinicians seems to be concerned with what they can do for patients and so often health policy wonks emphasize  how we as physicians  can limit what patients receive? To talk of the need  to limit resource use is to assume that a vaguely defined or undefined  too much is being done for patients which translates further to a third party ( either a third party payer or a third party self appointed expert) deciding that the individual decisions of doctors and patients about clinical management issues results in "overuse" of resources.There is a body of thought that maintains physicians are not only obligated to serve the best interests of their individual patient but somehow they are ethically obligated to be the stewards of  resources that somehow in other than a metaphorical sense are owned by society.

 Overuse seems to lie in the eye of the third party payer. Could it be that many in the health policy arena and many of the self appointed thought leaders of major medical professional organizations  believe that patient treatment is too important to leave to the myopic lens of doctor and patient and that their selfish interests are no basis for appropriate medical decisions and that the experts' enduring wisdom should over ride the archaic physician patient dyad.Perhaps first advice and "education" would be enough to disabuse the practicing physician and her relentlessly self centered patient from doing too much. However if discussions about cost savings did not prevail more carrots and sticks might be required.

Of course "what can I do for you" is not an boundless,open ended agreement to do all and everything a patient may request. If a patient concerned about difficulty with word finding and misplacing his car keys possibly indicating early dementia you might reasonably refuse to comply with his request for a referral for a brain biopsy.  The physician can give informed and reasoned advice about how to proceed taking into account the views and wishes and concerns of the individual patient.

The new initiative lead by the ABIM Foundation (does anyone else wonder why a organization ostensibly tasked to test the competence of internists needs a foundation ) labelled Choosing Wisely appears to be a list of  "thou shall not s"- sort of a hundred commandments. OK, they are currently phrased not as absolutes but are presented as the much softer and gentler opportunities to have a discussion with your patient not as rules not to be broken.Suggestions first, guidelines later and then perhaps extra payment for compliant socially conscious stewards of society's resources namely the physicians (make that health care professionals) and reduced payment for the recalcitrant and selfish.

Of course some tests and treatments are ordered and carried out in instances in which no patient benefit is obtained and in some cases harm may  done  but for numerous medical professional organizations to proclaim that  numerous tests and procedures should  not be done ( however gently this is currently presented) seems to me to be efforts to change to mind set from the traditional what can I do for you to what I can not allow you to have.

I have seen few comments ( see here for one) in anyway critical of the specific recommendation of the Choosing Wisely campaign but there should be thoughtful analysis of each of them before there is any widespread acceptance.Remember evidence based medicine. What is the evidence behind for example no pap tests before age 21.Are there randomized clinical trials ? Is it based on expert opinion? Are we told about potential conflicts of   interests of the authors of the recommendations? Are there published systematic reviews or cost effectiveness analysis for each of the recommendations or for any?

Any of the numerous ( current count is 130 but stay tuned) recommendations  made by various medical professional organization may well pass the tests of coherence and correspondence with valid evidence but you have to be skeptical  of some many recommendations appearing seemingly so quickly and their manner of presentation appears more authority based or expert based than evidence based.

No one is in favor of tests and procedures that are of no benefit and/or are harmful.No one is against Mom and apple pie or in favor of the nation going broke from run away medical costs, but to rush to publish 100 plus prohibitions under the banner  of preventing  harm or waste may end up itself doing much more harm than good and even costing more if each specific recommendation is not based on sound evidence based analysis.  Making recommendations that might affect the health and lives of thousands of people is serious and heady business and time after time we have seen well meaning medical recommendations turn out to be very bad advice ( remember HRT for just about all post menopausal women and then for none and then again for some). Doctor,were you wrong then or are you wrong now?

 American Board of Internal Medicine President Christine Cassel, MD, said such rules of thumb  (those suggested by various medical professional organizations regarding certain tests and procedures) seek to change the mindset of physicians and patients alike that "more is better," which can lead to wasteful spending and sometimes harm to the patient.

"What you're talking about is a culture change," Dr. Cassel told Medscape Medical News in a recent published interview. Let's hope the hoped for  cultural change does not include discarding the fiduciary role.Yet I believe it is significant that neither the New Medical Professionalism nor the New medical ethics of the ACP talks about the fiduciary responsibility of the  physician to the patient.I believe that de-
 emphasizing the fiduciary role of the physician and claiming a role of resource steward for physicians is
conceptually dangerous and to the extent it is incorporated into day to day medical thinking destructive to the traditional physician patient relationship doling damage to both physicians and patients.


For each of the recommendations published by the Choosing Wisely campaign  physicians and their patients need to know what is the nature of the evidence? For some probably the evidence is strong and convincing for others maybe not so much.Let's not replace "more is better" with" less is better" because neither is a universal all encompassing decision rule and clinical decisions should not be based on  empty catch phrases such as "less is more" and the vacuous  "the right treatment for the right patient at the right time".


3 comments:

Anonymous said...

I am surprised that you have not brought out the "follow the money" principle.Are not the third party payers the recipients of benefits from a change in culture that leads to less money spent on health care?

james gaulte said...

Sure.It couldn't be better if they planned it.Maybe...


James

Ruth James said...

I completely agree with this article. It seems as though medical practices are getting out of the habit of actually treating patients. And now they are telling patients what they don't have symptoms for. I don't really understand the purpose of this. I am never given enough information. It seems like the nurse just skims over what is going on. I love being spoken to like I am an adult and knowing what is going to happen. This was so informative.
Ruth James | http://www.mednet-tech.com/services/internet-marketing