I don’t know why, but even as a young person I never could make sense of the saying, “seeing is believing”. Seeing, vision, is nothing more than a data collection instrument, not an arbiter of insight. I saw my wife frown at me the other day, for example, after I claimed to have washed the dishes so thoroughly that no spot of grease could be left behind. I have made this claim before and been incorrect, so the frown, the data, triggered an anticipation of being rebuffed. However, nothing of that sort followed. I asked, Why the frown?” She responded, “I just cut my finger”. The frown was obvious, the cause unclear. I believed I was about to be reprimanded and missed the chance to notice her accident. This story suggests that a truer aphorism might be, instead, then, that “believing is seeing”.
These comments about bias in interpretation of data are not new. Consider the condition of “hindsight bias”; once we know, we change our minds to show how correct we now can be. How about, “confirmation bias”; since we believe we know the diagnosis we find information to justify that diagnosis, eschewing contrary data. Counselors tell us all that if you change your mind, you change your life.
But changing our minds is not that easy, and, in medical care, it is extremely difficult because of deeply held beliefs that shape the ideas, which shape the actions, which produce the consequences of costly, wasteful care. So, let’s examine some beliefs:
If we believe that the young and well must pay through the nose to assure care for the sick, we will continue to design profitable margins into plans, and make sure inequality in those plans fulfill our beliefs. Right (sarcasm), my son and daughters should pay to make sure my 82 year old relative gets 2 CT scans, 2 MRIs, 1 PET scan, and 3 months of chemotherapy for an metastatic non treatable cancer; the treatment that finally contributes to her end from an infection during a nadir in counts.
If we believe that economics and profit matter in medicine and that medical care is a good employment system, we will continue to let economists and governments intrude in medical care. We will keep adding people to the mix of delivering wasteful care. Specialists will proliferate, physicians and nurses will proliferate, and integrative medicine groups will proliferate to bill the unsuspecting.
If we believe we can determine what is best for patients with averaged out, small-randomized trials conducted with patients who we have no idea where they came from, we will continue to produce inferior trials and not advance the science of letting individuals have information to make informed choices.
If we believe in population health we will continue to disparage the lives of individuals who are not at the mean. We will continue to aggregate into groups rather than take full advantage of the singular, cottage industry needed to provide time and space for a doc and patient to become informed about care.
If we believe that physicians know best about decisions we will continue to let physicians drive costly care to even newer highs. (See my aunts care above, and then multiply by thousands of daily decisions).
If we believe that malpractice insurance somehow protects more than harms, we will see decisions promulgated by physicians in specious attempts to protect themselves.
If we believe we need “guidelines” to bulldoze care decisions over unsuspecting physicians and patients, we will unduly continue to underwrite the economic interests of suppliers of medicines, tests, and procedures.
If we believe that money matters, as much or more than best care for people who are ill, we will see TV and radio adds targeted to unsuspecting people proliferate.
If we believe only physicians can judge the veracity of medical information we will continue to see cults of organ based physicians continue to grow. Biomedical journals will sprout to produce the weakest of seeds, as good and bad information will carry the same fermentation weights. Since patients cannot presently sift the wheat from the chaff, contrary data will destroy confidence and trust.
If we believe physicians are more important than patients, we will see the development of guilds and gilded unions to advocate for physicians and the system rather than patients.
The title of this piece is based on a well-known saying. I did not put the title in quotes, as we really don’t know who wrote it, but, who we think wrote it, did not say it this way (Blaise Pascal, according to a superficial, non-expertise based search for the quote). Its value, in my view, is that it embodies a contrary notion; we expect the end of the sentence to be 180 degrees opposite. This sort of twist is used in comedy, sarcasm and irony. But, it also suggests that sometimes what we believe is just the opposite of what is true.
This is why what we believe is paramount and penultimate to forward thinking. What we believe spawns our ideas; I think it is time for medical care to change what it believes”