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Shaw Got It Right

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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natenurs6022FrankMD as HELLAndy Recent comment authors
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nate
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nate

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.

nurs6022
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nurs6022

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… Read more »

imdoc
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imdoc

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.

nate
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nate

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?

DeterminedMD
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DeterminedMD

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

nurs6022
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nurs6022

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… Read more »

Frank
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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.

MD as HELL
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MD as HELL

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.

Andy
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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.

rbar
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rbar

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… Read more »

imdoc
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imdoc

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.

Peter
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Peter

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

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

Jonathan
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Jonathan

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.

Kim
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Kim

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.