Our comments regarding this interesting blog, and the comments to the blog, may seem tangential to the author’s points.
The blog and comments point, we think, to a confusing set of principles being considered, perhaps, out of context?
Those comments range from: ACOs will lead to better figuring out what is best (impossible) – to mismatched information regarding a specific clinical case (reasonable). What is striking is that we have medical students worrying about costs of care.
Instead, shouldn’t we be teaching them to understand the value of information for decision-making? Shouldn’t we be teaching them the concepts of co-dependent testing leading to all tests being less useful than we think?
Shouldn’t we be teaching students the concepts of decision-analysis, and thresholds, and patient’s being involved in the decisions? Shouldn’t we be teaching that it is better to know than to think we know? Shouldn’t we be doing studies rather than scratching at the “tragedy of the commons” (so many physicians feasting on the grassy fields of a sick patient)?
Shouldn’t the student be worrying about the consequences of the false positive and false negative tests when a valve is being repaired that carries mortality from a low of about 1% with non-invasive methods rather than invasive that may portend mortality rates up to 10%?
Are we really confused about low and high risk when a heart is about to be assaulted?
Our suggestion to this wonderful, bright and well-meaning student is that it is time to think for yourself and not listen to a medical business that seems to focus on the system and the systems winners and losers in the medical mine fields.
Focus on knowing and making sure patients know as much as you do.
Robert McNutt, MD has been an associate editor at the Journal of the American Medical Association for 12 years and before associate editor at the Journal of General Internal Medicine. He is a professor of Medicine at the University of Wisconsin and Rush University Medical Center.
Nortin M. Hadler, MD is a graduate of Yale College and Harvard Medical School. He joined the faculty of the University of North Carolina in 1973 and has been a professor of medicine and microbioogy/immunology since 1985. His assaults on medicalization and overtreatment appear in many editorials and commentaries and 5 recent monographs: The Last Well Person (MQUP 2004) and UNC Press’ Worried Sick (2008), Stabbed in the Back(2009), Rethinking Aging (2011) and most recently, Citizen Patient (2013).
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creates a false choice. I see no reason students can’t be concerned about both the costs of care and the way we arrive at sound medical decisions.
“Focus on knowing and making sure patients know as much as you do.” – This. What’s wrong with students nowadays is that they’re more into the business side of medicine and thinking about the welfare of the patients have been set aside. This should change and this should change now.
Dr. McNutt and Dr. Hadler, many thanks for your thought-provoking response to my post. My read (itself perhaps somewhat tangential) is that rather than thinking about costs of care and iatrogenic harm — the two drivers of my piece — we ought to be learning about the decision-making dynamics that lead to high-cost care and potentially iatrogenic harm. Or rather, that understanding the subtleties of decision-making and applying clinical evidence is more important to a medical student than policing the costs of care.
I am grateful to you both for raising these topics. I hope the treatment of Bayes’ theorem in my post didn’t strike you as superficial or misguided. But I worry that your argument creates a false choice. I see no reason students can’t be concerned about both the costs of care and the way we arrive at sound medical decisions. I’d even say they go hand-in-hand: understanding the subtleties of decision-making, and involving our patients in decisions, is the only way to foster high-value medical care that minimizes potential harm. In a sense, my concerns about cost and harm are the “what,” and your concerns about decision-making are the “how.”
That argument aside, I hope we agree students should have some concern for the potential of medicine to do harm: both financially and medically. I don’t think it’s beyond our purview: as Dr. Peter Ubel and colleagues have argued so well, just as we’re obligated to learn the adverse effects of our medicines, we must be aware of (and prepared to discuss) the “financial toxicity” associated with all forms of treatment.