Robert McNutt and Nortin Hadler respond to med student Karan Chhabra’s original post, “Actually, High Tech Imaging Can Be High Value Medicine” and the resulting discussion thread.
Thank you for your comments. First, we are happy you are so interested in medical practice and how to do it better. Please do not think for one second that our comments are critical of you.
However, since you persist in thinking that money matters, that you have the right to think that way during your care of a patient, and that economic principles help patients, let’s look again at this issue you have raised.
Nearly 20 years ago, Hadler published his first “Four Laws of Therapeutic Dynamics” (JOEM 1997; 39:295-8):
1) . The Death Rate is One per Person
2) . Never Poke a Skunk
3) . There has Never been a Quack without a Theory
4) . Institutions Die; People Live
Now we present, for the first time ever, the econometric corollaries, the McNutt-Hadler Credo for Value-laden Medical Decision Making:
1) Don’t think of money; think of what the money buys. No patient should be offered a pig-in-a-poke.
2) Don’t think for one moment that medical pricing is rational, let alone market driven. Medical pricing is designed to serve the greed of stakeholders, greed that seems to know no ethical boundaries. Caveat emptor is no match for “common practice” The only way the “consumer” stands a chance is if there are physicians committed to explaining the basis for clinical decisions in an unbiased, transparent, and ethical fashion.
3) If it doesn’t benefit the patient, we don’t care if they give it away – don’t prescribe or order it. (For example, no stable in-patient should have any of the following tests: amylase or lipase; any test for iron deficiency other than the ferritin; CRP, BNP, MRI after a CT of the head, or any chronic care medicine like a statin, iron tablet, heart healthy diet in a cancer patient, vitamin, a blood pressure medicine that costs more than the cheapest alternative, a non-generic medicine that is available in generic form, enteric coated aspirin, or bone scans in women looking for osteoporosis)
4) If it doesn’t benefit the patient, and the patient still wants it, we shouldn’t share the cost. If it’s useless but not harmful, the expense should be assumed by the patient. If it’s useless but harmful, it should not be available.
5) If it is relatively beneficial, the patient should be offered an opportunity to apply personal values and risk aversion to the clinical decision.
6) Spend anything it takes to save a life only if it is proven that it does. Dying in American should not be a profit center.
7) Do not let money influence decisions; avoid any conflict of interest; including going into a branch of medicine that forces you to make decisions that may be more gainful for you than for your patients; be financially neutral and patient oriented only. Better to starve than to knowingly disserve. Personal gain is no substitute for self-respect. Faust understood this.
As a physician, find every source of waste and discard it with your patient’s blessing. Know that much of “common practice” is not helpful for individual patients; that much of clinical evidence, particularly for small effects, is unreliable; and that to be a physician demands the highest standards of professionalism – economics be damned.
What we can do to help patients with the high cost of care is to stop using care that doesn’t matter, and making sure we spend what we must to help them when we know how to.
Without such a Credo, health is a commodity, diseases a product line, and physicians a sales force. We need a new generation of physicians to pull all of us back from this brink.
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).