Physician, Heal Thyself (or at least do it more cheaply)
There’s a real lack of understanding in this country of the extent of the problem of medical waste and what I guess you’d have to call doctors’ incompetence. Uwe Reinhardt has a great post laying much of this out including the striking fact that “on average, American patients receive the recommended treatment for their condition only slightly more than 50 percent of the time.”
The structure of Medicare allows us to do pretty solid apples-to-apples comparisons of what different hospitals are spending on treatment, and the evidence is clear that the hospital-to-hospital variance is costs is large, and in quality is also pretty big, but the differences seem uncorrelated:
According to the Dartmouth researchers, if physicians with relatively higher cost preferred practice styles could be induced to embrace the preferred practice styles of their equally effective but lower-cost colleagues, overall per-capita Medicare spending probably could be reduced by at least 30 percent without harming patients, and similarly for commercially insured younger Americans. How can a nation that routinely wails over its high cost of health care ignore such important research?
I’ve been watching a lot of House re-runs lately, and they’re a striking encapsulation of part of what’s wrong with the way Americans think about medicine. Dr House is unfailingly portrayed as a bad person but a fantastic doctor and the medical ideal is seen to be that of the brilliant explorer-hero who does what it takes to solve the most difficult cases. An alternative model would see the doctor as a kind of custodian of public health. A general practitioner who develops an effective method of nudging people toward quitting smoking or exercising more during his brief post-checkup chats would save many more lives at dramatically lower cost than would all of Dr House’s heroics.
And of course most doctors in the real world aren’t like genius television characters — unleash them from concerns about cost-efficacy and imbue them with a heroic self-conception and they don’t even give you costly-but-effective medicine. Almost half the time they don’t even do the right treatment.
58 Responses to “Physician, Heal Thyself (or at least do it more cheaply)”
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December 28th, 2008 at 3:10 pm
House is a good show, though.
December 28th, 2008 at 3:16 pm
” Almost half the time they don’t even do the right treatment.” Really Dr. Yglesias? Do tell.
December 28th, 2008 at 3:21 pm
I too enjoy House and I was very glad that the surprise coupling this season was NOT House and Cutty (and I was very glad that the surprise coupling was Forman and 13).
Another aspect of the medical care on House that always elevates me to snorts of laughter is the “we do everything” approach — all the doctors doing their own lab work, doing their own surgery, doing their own imaging, etc. And why is it never vasculitis?
An side reference to House — during his recent online interview at the W Post, Neil Patrick Harris was asked whatever happened to Doogie Howser anyway? Harris replied that he became addicted to pain medication and now walked with a cane. Funny interview, by the way, if you can track it down.
December 28th, 2008 at 3:29 pm
Dr House is unfailingly portrayed as a bad person but a fantastic doctor and the medical ideal is seen to be that of the brilliant explorer-hero who does what it takes to solve the most difficult cases.
House is Sherlock Holmes: you wouldn’t want a police force (or even a detective squad) consisting of Sherlocks.
And sam? You could always read the fucking study. There’s a valid criticism that the recommended treatment model doesn’t adapt well to real-world situations (in particular, screening and other preventative care over extended periods) but it backs up the anecdotal sense that the “Best Healthcare In The World” kicks in late when conditions are more severe and thus more expensive to treat with worse prognoses.
December 28th, 2008 at 3:40 pm
House practices medicine like most techs I know “troubleshoot”; and mechanics too; just keep replacing parts until the symptom goes away. Marcus Welby was smoother.
December 28th, 2008 at 3:51 pm
I hope it’s not true that House is supposed to represent our ideal of what a doctor should do. It’s a TV show, so naturally it is exciting, to the point of making the doctors a kind of adventurer-hero, and people enjoy watching that. But at the same time, I really can’t imagine people wanting their doctors’ jobs to be very exciting, despite what they want to see on TV. I can think of nothing worse for me than my doctor’s life being exciting, full of jeopardy and difficult decisions. I want his life and, in particular, his job, to be especially easy, because that’s good for me.
There’s enough material in House that suggests his behaviour is exceptional, and there’s little behaviour in House that I can read as advocating for there to be more doctors like House, so just maybe public misunderstandings about health care are more technical and less fundamental than this.
December 28th, 2008 at 3:54 pm
An alternative model would see the doctor as a kind of custodian of public health. A general practitioner who develops an effective method of nudging people toward quitting smoking or exercising more during his brief post-checkup chats would save many more lives at dramatically lower cost than would all of Dr House’s heroics.
But who would watch such a boring show?
December 28th, 2008 at 3:58 pm
Oh, slap my forehead! I’m supposed to tell people to stop smoking! Jeepers, I’m glad you straightened me out on that point!
December 28th, 2008 at 4:02 pm
Has anyone ever been to a doctor who didn’t tell them to quit smoking, eat better, and generally have a less enjoyable life? It’s the one constant with every doctor I’ve ever seen, and I don’t even have that many unhealthy habits.
December 28th, 2008 at 4:05 pm
J Bean and too many steves, the important word in Matt’s sentence is “effective”.
December 28th, 2008 at 4:30 pm
“Physician, heal thyself” presents me with the opportunity to ask how much post-punk our author listens to, and hopefully drum up a conversation about Mark E. Smith and The Fall. Rowsche! Rumble!
December 28th, 2008 at 4:31 pm
This strikes me as similar to teaching. We are obsessed with the idea of the “superstar teacher” who suddenly gets the hardship kids to learn who couldn’t be reached before. What’s more effective, overall, would be a bunch of “custodians of public education” running through scripted/structured teaching plans. But, as many of the teachers on these comment threads make clear, few would want such a job and few see themselves that way.
December 28th, 2008 at 5:05 pm
too many steves:
No, I have never been lectured by my doctor. My dentist does nag me to come in more often and it works on me.
I have a ruptured disk and the doctor jumped from the MRI to recommending surgery, skipping the step where you try a cortisone shot into the disk area to cut the inflammation.
Thank God he retired. The next doctor followed recommended practice, surgery was averted.
December 28th, 2008 at 5:47 pm
House would not be a great doctor for most people. That’s why they don’t give him most cases. (I’m setting aside for a moment the fact that he’s a TV character.) They give him patients who HAVE SEEN EVERYONE ELSE ALREADY and aren’t getting better. There are very few doctors who don’t simply tell their patients to stop smoking and exercise. In fact, I’ve found the opposite problem to be a treatment barrier. For patients who are overweight and obese, doctors often dismiss symptoms as caused by the weight, without even considering other possibilities. It’s like they think fat people don’t get illnesses unrelated to fat.
December 28th, 2008 at 6:33 pm
Lila: …which was in an episode of House. (Maybe more than one, it seems like the sort of twist the writers would like.) Super-morbidly obese guy turns out to have lung cancer even though he doesn’t smoke.
December 28th, 2008 at 8:14 pm
I’m sorry, but House is a terrible doctor. He’s constantly giving patients medications they don’t need because he’s blindly guessing at what’s wrong with them. Often, he makes the situation worse.
Saying House is a great doctor is like saying the A-Team is a great example of a military unit. The entire show is as wildly unrealistic as the fact that 10,000 rounds of ammo are fired on every episode of the A-Team and no one ever gets hit.
Also, it’s a ridiculous waste of resources and inferior care to have doctors pulling blood for tests, transporting patients, running tests, etc. The person you want taking your blood is the phlebotomist who spends 8 hours a day JUST taking blood. That’s the person who will do it fast, and do it right, and do it with less pain, all at 1/8 the cost of the doctor.
December 28th, 2008 at 8:33 pm
Yglesias, why don’t you go through 4 years of medical school and another 4 years of residency before discussing doctor “imcompetence”. Medicine is the hardest material known to man to master.
December 28th, 2008 at 8:53 pm
So what exactly are you saying, brad? That the Dartmouth researcher are wrong? That only doctors should be allowed to criticize the medical profession?
Last time I checked it was doctors and the AMA that are in large part responsible for the fsckup that is American medicine.
It was the AMA that consistently opposed any sort of government role in health care.
It is the AMA that deliberately throttles the number on entrants into med school so as to limit the supply of doctors and keep their salaries high.
It is the AMA that insists on retaining the barbaric practice of keeping residents working for 24hrs straight without sleep, in spite of the fact that plenty of other countries that don’t do this seem to produce perfectly adequate doctors.
It is the AMA that continues to fight, kicking and screaming every step of the way, against evidence-based medicine (presumably they would prefer medicine of the “I know what my guy tells me” variety).
It is the AMA that seems to have absolutely no problem with the increasing purchase of doctors, hospitals, universities and medical research by big pharma, with all the obvious attendant ills (research that is never published, doctors who reach for the expensive drug rather than the cheaper one, etc etc).
The AMA today is no different from the doctors guilds of the past that refused to listen to people like Lister and Semmelweis — god forbid that anyone claim to know better than them how to do things.
How about we make a deal? I and MY will stop commenting on the medical profession when the medical profession stop behaving like douchebags and start behaving like responsible professionals who actually care more about the society they are part of than about their paychecks?
December 28th, 2008 at 8:56 pm
Well, I had to diagnose my own thoracic outlet syndrome, using the internet, because every doctor I saw missed it (til, I finally went to a neurologist and said, very slowly and clearly, “I think I have thoracic outlet syndrome”).
Now I’ve found out that surgery scars can cause trigger points, which hardly any MDs know about, even though there’s a huge book about them that was written by JFK’s official doctor, with the latest edition published in ‘99.
I’m completely and utterly disgusted with doctors. In my experience they’re basically expensive human vending machines for pills.
December 28th, 2008 at 9:15 pm
There are dozens of med schools opening up in the US within the next few years. In addition many med schools have been increasing their enrollments. There are also plenty of well trained physicians coming from the Caribbean schools, Eastern euro schools and India.
December 28th, 2008 at 9:57 pm
I think what MY does not address is the fact that “doctor incompetence” is unfortunately only one rather minor (in my opinion) cause of not following recommended treatments. The most common divergences are due to the patient such as when with antibiotics the patient will demand them and if you don’t give them the prescription, they will throw a scene about it. Before becoming a physician, I admit I did this as well like many other people one knows…
Other common examples of not following recommended treatments include with allergic reactions (patients will again refuse things like beta blockers post myocardial infarction on those grounds), comorbid conditions limiting the use of the recommended treatments, patient specific differences, etc.
Unfortunately, the Dartmouth researchers make a big deal out of their findings without necessarily proving that these divergences are either actually harmful or always due to the physician…
December 28th, 2008 at 10:03 pm
Again, this is ignoring the fact that one’s incentives, due to liability concerns, in the current system (or indeed with any national health system) are for the doctor to always order more tests and tend towards overtreatment or referral to specialists. Without addressing that issue, it is highly unlikely that any doctor in any medical system would focus on eliminating medical waste as a priority. The disincentives, independent of competence, are too strong…
December 28th, 2008 at 11:17 pm
Medicine is the hardest material known to man to master.
Based on what? It seems to me that a lot of what doctors do could be replaced by good software. Mastering lists of symptoms, diseases and drug interactions all jobs for search engines.
December 29th, 2008 at 1:37 am
“like many other people one knows…”
And of of course, this kind of arrogant shit is typical. Have I mentioned I was correct about the TOS?
December 29th, 2008 at 2:01 am
The structure of Medicare allows us to do pretty solid apples-to-apples comparisons of what different hospitals are spending on treatment, and the evidence is clear that the hospital-to-hospital variance is costs is large, and in quality is also pretty big, but the differences seem uncorrelated
these are only “apples to apples” comparisons if we also know that the treatment style (which drives costs) is unrelated to unobservable factors about the health of the patients (which drives outcomes). Every health wonk in DC has been quoting that Dartmouth study in every speech they give for like three years now, but I’m not convinced it’s really so conclusive.
December 29th, 2008 at 2:44 am
Seems a tad moronic to mention House and medical policy / costs in the same post. Reminds me why I don’t read this blog often.
December 29th, 2008 at 6:17 am
I studied to be a doctor by watching episodes of Full House. I have a great bedside manner but all my patients die.
December 29th, 2008 at 9:16 am
Nonsense. It is a very efficient use of resources. If a phlebotomist were taking the blood they’d need to pay another actor and pay the writers to develop that character.
December 29th, 2008 at 9:29 am
I hate to say this, but having taught hundreds of premeds for the MCAT, I have a dread secret to share, which is that most doctors aren’t actually all that bright.
December 29th, 2008 at 9:51 am
The answer to our health care crisis is…non of the above. Our medical system is great for emergencies and marginal for applying band aids to symptoms, but not for ensuring a healthy population. As stated by Michael Pollan, we need a Secretary of Food not Agriculture, because our health is dependent upon what we eat. Our current eating habits are like building a house out of paper mache and expecting it to withstand a hurricane.
December 29th, 2008 at 9:52 am
These effects should not vary significantly from one hospital to the next. There should not be locallized extremes of allergies or comorbidities in some hospitals.
I would say that even the competence of individual doctors is not the problem. If competence is predictable, it will tend to align with pay, and costs. If it is not predictable, it will be random, and therefore tend to spread across hospitals evenly.
Significant variance in efficiency from one hospital to the next would stem from policy decisions higher up in the power structures of each hospital. Only then would a random distribution of competence produce the starkly varied disparities. An individual bad doctor is insignificant, statistically. A bad department head can hire many sub-par doctors, or instruct good doctors to use inefficient practices.
December 29th, 2008 at 11:35 am
Good example of the mental deterioration caused by TV. I don’t mean that House encourages acceptance of poor medical practice, which would be a hard link to test. I mean that Matt starts off with a short, workmanlike post simply pointing us to another blogger, an economist with a very fine post. And then, after the TV review, he comes to a conclusion that has zilch to do with the point. If he hadn’t summarized and quoted Reinhardt, one would wonder if he’d read him.
The problem isn’t that physicians are practicing medicine rather than giving advice. They do give advice, and patients don’t need their doctor anyway to tell them the obvious advice they’re already hearing elsewhere. The problem is with the medicine they practice. And it’s also not even really about internists, who refer you elsewhere for almost anything beyond advice to quit smoking. Geez. What happened to literacy?
December 29th, 2008 at 1:26 pm
So what do you have to say to the good folks at Dartmouth Medical School, which has one of the top teaching hospitals in the NE as their primary affiliation? I suspect they know a little about medicine. Just a bit.
December 29th, 2008 at 6:30 pm
Ha ha, for 30 years doctors diagnosed my asthma flares as pneumonia and prescribed antibiotics. When I finally (by blind chance) got an older doc who knew what he was doing, he stepped in the exam room, heard me trying to breathe, and said “You have the worst bronchial asthma I’ve ever heard”.
If you have a problem caused by lifestyle, most of what a doctor can do to help you is to suggest you change your lifestyle. Strange to say, studies show that doctors don’t consistently do that, but it makes a difference when they do. That shouldn’t make any sense, alcoholics should know that drinking is a problem to them, but a study in Seattle showed that when doctors consistently pointed that out, more people got into treatment and stopped drinking. Go figure.
As for the people who couldn’t follow Matt’s train of thought, try thinking about what he was saying.
December 29th, 2008 at 7:20 pm
DOCTAH’S NEED PRESCRIPTIONS, THE WIVES NEED THE PILLS SO ROWCHE RUMBLE!
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