George Bernard Shaw wrote The Doctor's Dilemma, Preface on Doctors in 1909. It is fun to read some excerpts:

It is not the fault of our doctors that the medical service of the community, as at present provided for, is a murderous absurdity. That any sane nation, having observed that you could provide for the supply of bread by giving bakers a pecuniary interest in baking for you, should go on to give a surgeon a pecuniary interest in cutting off your leg, is enough to make one despair of political humanity. But that is precisely what we have done. And the more appalling the mutilation, the more the mutilator is paid. He who corrects the ingrowing toe-nail receives a few shillings: he who cuts your inside out receives hundreds of guineas, except when he does it to a poor person for practice.

Scandalized voices murmur that these operations are necessary. They may be. It may also be necessary to hang a man or pull down a house. But we take good care not to make the hangman and the housebreaker the judges of that. If we did, no man's neck would be safe and no man's house stable. But we do make the doctor the judge… I cannot knock my shins severely without forcing on some surgeon the difficult question, "Could I not make a better use of a pocketful of guineas than this man is making of his leg? Could he not write as well—or even better—on one leg than on two?"

Why doctors do not differ

The truth is, there would never be any public agreement among doctors if they did not agree to agree on the main point of the doctor being always in the right. Yet the two guinea man never thinks that the five shilling man is right: if he did, he would be understood as confessing to an overcharge of one pound seventeen shillings; and on the same ground the five shilling man cannot encourage the notion that the owner of the sixpenny surgery round the corner is quite up to his mark. Thus even the layman has to be taught that infallibility is not quite infallible, because there are two qualities of it to be had at two prices.

But there is no agreement even in the same rank at the same price. During the first great epidemic of influenza towards the end of the nineteenth century a London evening paper sent round a journalist-patient to all the great consultants of that day, and published their advice and prescriptions; a proceeding passionately denounced by the medical papers as a breach of confidence of these eminent physicians. The case was the same; but the prescriptions were different, and so was the advice.

Now a doctor cannot think his own treatment right and at the same time think his colleague right in prescribing a different treatment when the patient is the same. Anyone who has ever known doctors well enough to hear medical shop talked without reserve knows that they are full of stories about each other's blunders and errors, and that the theory of their omniscience and omnipotence no more holds good among themselves than it did with Moliere and Napoleon.

But for this very reason no doctor dare accuse another of malpractice. He is not sure enough of his own opinion to ruin another man by it. He knows that if such conduct were tolerated in his profession no doctor's livelihood or reputation would be worth a year's purchase. I do not blame him: I would do the same myself.

But the effect of this state of things is to make the medical profession a conspiracy to hide its own shortcomings. No doubt the same may be said of all professions. They are all conspiracies against the laity; and I do not suggest that the medical conspiracy is either better or worse than the military conspiracy, the legal conspiracy, the sacerdotal conspiracy, the pedagogic conspiracy, the royal and aristocratic conspiracy, the literary and artistic conspiracy, and the innumerable industrial, commercial, and financial conspiracies, from the trade unions to the great exchanges, which make up the huge conflict which we call society. But it is less suspected.

Statistical Illusions

Public ignorance of the laws of evidence and of statistics can hardly be exaggerated. There may be a doctor here and there who in dealing with the statistics of disease has taken at least the first step towards sanity by grasping the fact that as an attack of even the commonest disease is an exceptional event, apparently over-whelming statistical evidence in favor of any prophylactic can be produced by persuading the public that everybody caught the disease formerly.

Thus if a disease is one which normally attacks fifteen per cent of the population, and if the effect of a prophylactic is actually to increase the proportion to twenty per cent, the publication of this figure of twenty per cent will convince the public that the prophylactic has reduced the percentage by eighty per cent instead of increasing it by five, because the public, left to itself and to the old gentlemen who are always ready to remember, on every possible subject, that things used to be much worse than they are now … will assume that the former percentage was about 100.

Paul Levy is the former President and CEO of Beth Israel Deconess Medical Center in Boston. For the past three years he blogged about his experiences in an online journal, Running a Hospital. He now writes as an advocate for patient-centered care, eliminating preventable harm, transparency of clinical outcomes, and front-line driven process improvement at Not Running a Hospital.

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23 Responses for “Shaw Got It Right”

  1. Jonathan says:

    Great find. It’s a bit exaggerated in parts to sharpen the point, but Shaw as a satirist can be easily forgiven. I wonder how much further back the understanding of perverse incentives actually goes.

  2. Back to the Future
    Paul – Did you know that Dr. Malcolm T. MacEachern, Director of Hospital Activities for the American College of Surgeons once presciently observed:
    … “Our hospitals are now involved in the worst financial crisis they have ever experienced. It is absolutely necessary to all of us to put our heads together and try to find some solution. If we are to have effective results we must have concerted and coordinated immediate action. Repeated adjustments of expenses to income have been made. Never before has there been such a careful analysis of a hospital accounting and study of financial policies. It is entirely possible for us to inaugurate improvements in business methods which will lead to greater ways and means of financing hospitals in the future. It is true that all hospitals have already trimmed their sales to better meet the financial conditions of their respective communities. This has been chiefly through economies of administration. There has been more or less universal reduction in personnel and salaries; many economies have been affected. Everything possible has been done to reduce expenditures but this has not been sufficient to bring about immediate relief in the majority of instances The continuance of the present economic conditions will force hospitals generally to further action. The time has come when this problem must be given even greater thought, both from its community and from its national aspect” ….
    No doubt many CEOs, CFOs, physicians, comptrollers, healthcare organization administrators and policy-makers would agree that Dr. MacEachern accurately described today’s healthcare environment … back in 1932!.
    Dr. David Edward Marcinko MBA
    http://www.HealthcareFinancials.com
    [Editor-in-Chief]

  3. Paul, Thanks for giving a sampling of this relevant piece by Shaw, about which I’d forgotten. Now I want to read the whole thing -

  4. Gary Levin says:

    Without seeming overly critical of this post, I’d like to offer several observations. This critique of physician motivation absents many features of why physicians start their own venture outside the hospital environment. As a CEO and hospital administrator you fail to mention that inherent bias, without mentioning the ‘hospital conspiracy’ Hospitals are subject to similar external forces to maintain profitabilityand ensure ‘survival’ in an increasingly hostile environ,environment. Not mentioned is the historical poor efficiency of hospitals in providing outpatient services, both financially and operationally. In the 1980s and early 1990s physicians required efficient operations in terms of cost, and the mechanics of seeing a higher volume of cases, not so much to make more money, but to offset decreases in environment. As a developer in a joint venture of an ASC our hospital was at a loss as to how to implement those changes, and the physician group was allocated the design and operation of such a facility. By actual comparison our ASC was able to perform surgeries on the average at twice the rate of the hospital for several reasons. Turnover time was drastically reduced, Rescheduling of routine cases virtually disappeared without the need for inseting emergency cases in the schedule. The presence of one or more dedicated anesthesiologist prevented cancelling or rescheduling cases.
    I know from experience, that I and my fellow physicians were trained in a different era, however all the things you mention regarding ‘the conspiracy’ were dealt with in my training, we all took the Hippocratic Oath, which is very meaningful to all of us. Our proudest moment is at the time when we graduate, stand on the stage and all take the oath in unison. There were few who did not feel the chill that went down our spines.
    Each time a surgeon (which you seem to focus upon) lifts his scalpel he knows the risks, to the patient, and his own responsibility to determine a safe uncomplicated outcome.
    Each surgery takes a toll on the surgeon, mentally, emotionally and physically. We may love our work, but we are also taught “primum no nocere”. Physicians are supposed to detach financial gain from their objectivity and decisions in their daily patient care. Not only is the work on patients part of being a physician, but the administrative, paperwork burden, dictation part of the load, so too is the malpractice liability, and the real threat of financial survival by health reform.
    I agree that statistic are an illusion. One can prove almost anything statistically, or conclude a result such as you describe. The delivery of the results are not the ‘conspiracy of physicians who do have solid grounding in basic statistics, but the inane descriptions and delivery of them by statisticiants the writers of the papers, and the lack of use of simple English. That is why and how patients ( the public) are misinformed.
    Hospitals and physicians do not (as you well know) operate in tandem or unison.
    I did enjoy your blog post, it was stimulating, although I disagree with most of your conclusions.

  5. Someone once told me that there are only two types of a doctor: the ones that care and that ones that don’t. It always pains me to encounter those doctors who do not even pretend to show some compassion and have the face to bill their patients too much. It’s so inhumane.

  6. Marilyn says:

    Money is what talks in this world. With so-called lost revenue for the Urologists, Gastroenterologists, and Dermatologists, they are now setting up their own laboratories within their group and hiring a Pathologist to do the Anatomic Work so these Subspecialty Groups can make up for lost income. Then, some Pathologists cry foul because they lose their income. Reading the debate for In-Office Pathology Labs is mind-boggling. Hospitals and Commercial Laboratories are in it for the business, too. Nurses and Ancillary Services are trying to survive. And what is the difference between a For-Profit Hospital and a Non-Profit Hospital? I can only shake my head at the whole wide world and just do the best I can to help people in my own little world.

  7. Paul Levy says:

    Gary and Shiela,
    This was satire. Written over 100 years ago. It was meant to be humorous then, and I think it still is.
    BTW, Gary, I am not a hospital administrator (any more.) Also, I did not reach any conclusions other than in the title, which was also meant to be humorous.

  8. DeterminedMD says:

    Perhaps satire, but, your comment “But for this very reason no doctor dare accuse another of malpractice. He is not sure enough of his own opinion to ruin another man by it. He knows that if such conduct were tolerated in his profession no doctor’s livelihood or reputation would be worth a year’s purchase. I do not blame him: I would do the same myself” hit home for me. Having once had to take a colleague to task after basically letting a patient take one’s life and then later totally disrupting the treatment interventions of another patient’s care I had intiated that led to the patient being horrendously back in serious symptoms following said doctor’s care plan, guess how it ended?
    The state invested my complaints, took 4 years to finish the review and then, only after I commented at a newspaper letters to the editor about the dearth of action by the state board of physician quality review on complaints about doctors to this board by physicians and patients, did they find against this doctor and admonish him just with a letter of poor care behaviors.
    Me, on the other hand, was ostracized by the community I tried to protect, attacked by colleagues for intiating the complaint, and realized first hand that legitimate whistleblowing is not only a waste of time, but can ruin the career of the concerned party(s).
    So, hope your satire effort was humorous for you and the readers who gleemed the comedic input. Not for me!

  9. Kim says:

    I like the Shaw piece…I used the same one to summarize the key issue in my blog entry “Prescribing Profits” back in November (http://mcolblog.squarespace.com/kcblog/2010/11/10/prescribing-profits.html)
    I’m sure many others have also cited Shaw’s piece…amazing how applicable it still is.

  10. Jonathan says:

    DMD, a couple of very basic points: Those weren’t Paul Levy’s words you quoted; they were George Bernard Shaw’s. Also, the point of satire is to laugh at something or someone in a critical fashion. Yes, it is meant to amuse but also to inform and criticize. Shaw is not describing this behavior with approval. In fact, the point for Shaw was to motivate reform. Easily verified by Google or Wikipedia.

  11. Asif Zardari says:

    having 4 Doctors in my family and i don’t like it ):

  12. Peter says:

    Satire works because it has an element of truth. Would you docs who dislike Shaw’s “Doctor’s Dilemma” agree with his comments on religion?
    http://www.positiveatheism.org/hist/quotes/gbs.htm

  13. imdoc says:

    Satire, cynicism, and criticism are easy. Leadership is more difficult. Suffice it to say there will never be a system which is not constructed with incentives. The challenge is to balance the forces so the desired outcome serves the patient population. Taking Shaw’s simple example of leg amputation, perhaps the best system is one in which the surgeon is paid the same for operating or for treating the case medically.

  14. rbar says:

    I am not sure how much still applies.
    “But for this very reason no doctor dare accuse another of malpractice. He is not sure enough of his own opinion to ruin another man by it. He knows that if such conduct were tolerated in his profession no doctor’s livelihood or reputation would be worth a year’s purchase. I do not blame him: I would do the same myself.”
    That physicians stick together and cover for each other is, for the US, largely an obsolete observation. Sure, there may be inactive state- and specialty boards (as DMD experienced), and local doctors may occasionally obstruct fact finding (but even that may be limited because in today’s environment, the 1st reflex to stay out of trouble yourself and shift responsibility). However, it is no trouble to find a medical expert to testify anything … outsiders for the crackpot stuff and academics for partisan exploration of fact.
    And the fact that procedures are highly incentivized: could be fixed by just adjusting fee schedules. Unfortunately, public awareness/pressure is lacking.

  15. Andy says:

    This Dilemma is present in many different industries. My auto mechanic doesn’t make any money telling me my car is in tip top shape, and that darn air filter is always dirty and in need of replacement.

  16. MD as HELL says:

    Shaw quite clearly illustrates the short-comings of patients, both seperately and collectively.
    Try telling a patient their are anxious when they are certain something is wrong. There is never a positive test, yet no amount of normals will reassure the anxious patient.
    I see them over and over.
    Give me tort protection and I will save you millions of dollars. Leave me out in the breeze and you will pay more and more and more.
    But I expect to be paid a risk premium. All the savings will not be yours when all the risk is mine.

  17. Frank says:

    I love George Bernhard Shaw. The Doctor´s Dilemma was unknown to me until today. But your post made me curious to read more. I love satires and I really appreciate the numerous interesting comments that are made to this blog post. It proves that Shaw´s thoughts are still vital today.

  18. nurs6022 says:

    I am a student in the advanced practice nursing program. In reading Shaw’s Satire it is not all difficult to draw parallels to today’s efforts at reform. Systems, policy, politics and social injustice really have not changed. The question I see is what or how do we successfully integrate change and still provide adequate care. I currently am employed as an RN, one of my clients can not afford health care even though they are insured. The insurance costs them over $700/mo and they have a $10,000. deductible. Catastrophic protection, yes, but for a self-employed family of 5, they can not afford basic health care, well child visits, vision and dental care. Their only choice is free clinics and the minimal care provided at these clinics. They are the working poor.
    Marilyn commented that money talks, but so do people. Our voices need to be heard.

  19. DeterminedMD says:

    You can always count on Peter and Jonathan to twist any possible dagger offered in a post or thread.

  20. nate says:

    nurs6002 are you complaining about the cost of insurance or health care? In their sitution wouldn’t they be further ahead using that $700 to buy healthcare instead of insurance?
    Do you think people should be able to get catostrophic insurance and basic healthcare for 5 people for $700 per month?

  21. imdoc says:

    Nate you are absolutely right. This is the problem which actually is the core of the problem in my opinion. Patients need price transparency and the ability to find affordable care for discreet services, particularly outpatient ambulatory type care. Current high deductible plans are a step in the right direction, but even those do not promote aggressive consumer behavior because the fee schedule is implanted. Best way out: Medicare needs to stop price fixing.

  22. nurs6022 says:

    I would like to believe that a payment of $700/month would provide more than catastrophic protection. However, one hospitalization, and they would probably meet that deductible. But they still have to pay that first $10,000. They can not afford to have a saving account at less than .25% interest, to put away $10,000 in the event someone becomes ill or injured. They will have to borrow money at a high interest rate if they qualify for a loan.
    To answer your question, Nate, I am commenting on both. I live in a rural area. Our small clinic is now charging $125.00 for a ten minute office visit. How can the uninsured or the under-insured afford the cost of basic health care, annual check-ups, and recommended screening tests when they cannot afford to walk through the door?
    My husband has moderate to severe reflux. He developed a cough and laryngitis. After about a month, he saw the local doc who said it is a bad cold take Robitussin, after three bottles of cough syrup he was referred to an ENT. The ENT said go for a barium swallow test, it showed an esophageal pocket. He was referred to a GI doc who recommended another test, the initial diagnosis was precancerous. When the lab report arrived, it revealed normal tissue. The note from the doc said I do not need to see you again. He still has the cough that sent him on the Merry-Go-Round in the first place! Where is the competency? I feel very much like Shaw’s comment on the influenza patient. We have insurance, but have still paid out of pocket a godly sum of money. The family I spoke of could not have stepped on the Merry-Go-Round. Of course they would not have an answer and neither do we.

  23. nate says:

    insurance cost is a direct reflection of health care cost. With current hospital expenses catostrophic insurance cost $700 for 5 people to cover catostropgic health care expenses.
    Insurance is illrelevent, as long as healthcare cost is unrestrained there is nothing we can do about premium. We can artifically maniputlate it by robbing our grandkids but sooner then later those bills will come due. The problem is politicians have taken the easy way and attacked the insurance companies which only exaspereted the healthcare cost issue.

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