What’s Wrong With Medicine? You Decide.

I have practiced medicine for over 40 years. I have yet to find a physician without a chronic disease in question who is smarter than the person with that chronic disease. I have been impressed that a patient’s numeric insights and intuitions when they are ill surpass their skills when they were not ill. All a patient needs is information, in all its glory and messiness, to know if the information is worth anything to them when they face a medical decision.  Patients, in my view, are the best information managers and evidence experts I have ever seen, and I know a bunch of evidence experts to draw upon for the comparison. My interpretation may be biased, but I have been doing shared consults with patients for twenty plus years and I have learned that patients are smart. Consider the following:

1. The man had been advised to have surgery. The man and his wife stared in stunned silence at the data on prostate cancer treatment outcomes with surgery. The study was described in detail including a description of the people who were studied. The wife finally spoke, “You mean to tell us you want my husband to have surgery when so few have been studied! You mean to tell us that not a single person of our cultural heritage has been tested in the study?” I responded and reminded, “I am not asking you to have surgery. We are going over information of potential benefit and harm that you must balance for your choice.” They were kind in response, refused to consider surgery or further discussion, and, instead, chose to enter a clinical study.

2. The patient had been advised to have a CT to screen for cancer. He exclaimed, “Let me get this straight. You are saying that out of nearly 55,000 people studied, there were only about 30-80 fewer deaths from lung cancer over nearly 5 years if a low dose computerized scan (LDCT) was done rather than a chest-x-ray?” I replied, ‘’Yes, that is correct. There were, remember, about 100 fewer patients dying of any cause if they received the LDCT rather than the chest-x-ray.

As you also know, alternatively, about 10 extra people getting the LDCT died or got a complication within 60 days of the exam due to the work-up of abnormal findings on the exam. That is your trade-off for having a LDCT; a potential small benefit in the future balanced by a potential small chance of dying or having a severe complication early due to a work-up”.  He replied, “I am not a scientist, but these numbers represent miniscule differences. The study could be wrong. I am not willing to take the LDCT scan based on the data”.

Medical care has been described as a, “philosophy informed by science”.  There is a subtle problem with this view, however. This comment suggests that evidence informs the philosophy of how medical care should be delivered. It may be, however, as others have suggested, that evidence might be produced in biased ways by the prevailing philosophy. If this is true, then we have to sit up straight and reconsider our philosophy of medical care.

So, here is what’s wrong with the present practice of medicine. The totalities of medical care delivery, the cost, the inequality, the profit margins for some and not others, the arguments, and political plotting are meted out by decisions made. Those who make decisions are those who define what the practice is.  The problem with medical care is that physicians decide. This is philosophically dysfunctional. Physicians should not, and should never have, made decisions for their patients. For sure, in an acute situation, acute care experts must make decisions. But, there is no such thing as a physician chronic care decision expert. Only patients are experts. They are the only ones who can know if one option is worth more than another based on the absolute differences engendered by the comparisons and their preferences for said differences.

The patients above compared the options proposed to them and chose in contrast to their physicians’ decisions. These people embodied the appropriate philosophy that medical care is theirs to define. Their idea is the fix for medical care. If physicians followed these patients’ philosophy, physicians could be worthy of being the patient’s partner; if physicians do not, they are doomed to follow a problematic philosophic stance. Trying to fix medical care based on a philosophy that allows physicians to be the decision makers will be like trying to float a sinking battleship with bubble gum. It is impossible to overcome a poor philosophy of care with edicts, ruminations, and patchwork insurance fixes. It is time to rethink the goals of best medical care; patients will tell us what evidence is worthwhile and what their care is worth. It will never work the other way around.

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12 replies »

  1. Doctors spend 12yrs building their throne. They demand much more than insurance or co-payment. They require their ego to be fed. With insurance and or cash a patient must beg for treatment. My experience in Tulsa.

  2. Yes. I am getting more consults about costs as patients face out of pocket for tests. Nearly every time, once informed, they forgo the test. The path to cheaper care is via informed patients making judgement about value. Thanks, Bob

  3. Dear pjnelson. Wonderfully put. In my book I say that medical decisions require a conversation, an informed communication rather than just with tablets or tabloids. I do not tend to think of informed medical decision making as a “responsibility” of patients, but, instead, an “opportunity” to contribute to their best individualized care. The crux of this piece, is, though, that a patient should be the decision maker uninfluenced by another’s opinions. Sharing information is a certainty, but deciding should be the patient’s prerogative. Thanks for comments.

  4. Great article! I understand that we got to be vigilant in what a doctor recommends. Why? Because every doctor recommends something different, that is why going to multiple doctors is great.

  5. Thumbs up for a great article. I never blindly follow a docs advice without context – I know my body better than anybody.

  6. Teacher, pastor, nurse, parent as well as physician share the domain we might recognize as a CARING RELATIONSHIP. Throughout my 40 + years of Primary Healthcare, a unified meaning has only recently come to mind for defining a Caring Relationship. I’d be interested in anyone’s own version. For me, a CARING RELATIONSHIP is a variably asymmetric interaction between two persons, over time, who share a ‘beneficent’ intent to enhance each other’s ‘autonomy’ by communicating with warmth, non-critical acceptance, honesty and empathy. Empathy representing the ultimate characteristic of a Caring Relationship. The communication attributes, of course, come from Carl Rogers, Ph.D., nearly 60 years ago. I might also recognize the current character of healthcare as being unable to accept that the spontaneity of a caring relationship cannot be limited by rigid time intervals.

  7. I think you are correct about the patient’s important place in the clinical leadership of his own case. But, you can’t have this without the patient’s entanglement–in some way–in his costs, because his choices should be affected by these costs [if we live in a rational world].

    At the minimum, he needs to be aware of what his care is costing the system, the insurance, so that he minimizes his own moral hazard a bit. And it would be nice if he has some skin in the game…to help bring prices down a bit. Even vouchers that are not spent and retain cash value will give him some skin in game. It is critical to be able to exert altruism in health care and still achieve patients’ awareness of costs. We need both.

  8. Thank you for kind comments. Population health should be, in my view, the accumulation of varying medical decisions by informed patients. It should not be, as often practiced, the average. Even our science must change to support an individual’s choice. I will argue, in a future blog, that the RCT is a poor individual patient science tool. We can do better. I see many institutions playing with the idea of shared choices, but patients come to me daily not knowing what their options are nor the marginal outcomes. A wholesale change in philosophy, production of information and communication of information, including to whom, is needed. I love your comment; it has to be done the right way with the physician willing to inform and allow choices other than those they are taught to promulgate.

  9. Very good article. This is the poster boy for new population health models that try to create treatment partnerships between physicians and patients, rather than just the physician. All that being said, physicians have perspective that we patients don’t have, and that is so valuable. We have just our sickness while the physician may have seen/treated hundreds with our sickness. It’s that informed perspective that creates value IF the physician uses it the right way. Well done.

  10. “The problem with medical care is that physicians decide” – indeed, and worse: Now CMS and for profit insurers set the parameters for physicians’ and patients’ freedom of choice.
    37 years here, and I share your views and vision of how medical decisions should be made. That’s why less than half of my male patients choose PSA testing; that’s why none of my patients take Zetia or niacin. And that’s why many of my visits run over their assigned fifteen minutes.

  11. Dr. McNutt… well done. Nicely written. Providing information and letting patients make their own informed decisions is the practice of medicine. I have only been at this for 15 years, but I thought this is how we all do it? Excluding emergency or acute situations where this is not possible, of course.