The Doctor is Always Right- Except When They're Not- Bias, Myth and Paternalism in Medical Decisions

A friend of mine was kind enough to drive his 85 yo mother to get a colonoscopy.  She had a normal study 18 months before.  There was some evidence of minor bleeding & her doctor just wanted to be sure.  This meant the "prep," with instructions to drink the last bit at 3 am, followed by a trip to the doctor's office at 530 am.  Another friend was told they had melanoma.  As you might imagine, this caused concern.  The doctor recommended a biopsy followed by 2 additional surgeries.  When I asked what stage melanoma, I was told it was stage zero; in terms of danger, this is just above freckle, the lowest potential for growth.

Both examples represent common medical experiences. In each case, there was an alternative- do nothing. For the older woman, it was reasonable to ask what the doctor expected to find and, if bad, what would be done about it.  I personally want to die with an undiagnosed cancer.  In the second example, surgery for the “near benign” required pain, risk and expense.  If removing the lesion via biopsy gave a 98.5% chance of not getting the disease, were the 2 surgeries worth the incremental improvements?

Each situation gets to the heart of "consent."  Ideally every procedure offers the patient a real choice.  After explaining the risks, benefits and alternatives, the patient chooses to proceed.  However this is rarely done.   Bias, myth and, on some level, well meaning paternalism all play a role.  

Bias- Mental tendency or inclination, especially an irrational preference or prejudice

Imagine spending 20 years learning a trade.  It is natural to believe you are helping, not hurting.  Physician's believe in their art. To expect all options are equally considered, goes against human nature.

Myth- a widely held but false belief or idea.

Although medicine is shrouded in science, we often do what we do because we do them. Practice is passed on from generation to generation. Many things are taken as "truths," without any real justification.  A recent Mayo Clinic Proceedings reviewed reversal of a 146 contradicted medical practice (MCP, August 2013). Medical knowledge is purported to be based in science but in actuality, this often not the case.

Paternalism- Though I walk through the shadow of death, ...thou art with me, thy rod and staff to comfort me. Psalm 23:4

Rod of a healer

It is difficult for both providers and patients to have a conversations as equals.  For the patient fear and anxiety go hand and hand with illness.   This is overlooked by those thinking computers will replace providers in the near future.  Most patients do not want to make life threatening decisions alone.

Providers may feel pressed for time and a responsibility to act as a filter for their patients, leading them to the right choice.  Unfortunately, well meaning desire can often result in an unbalanced discussion.  

In Seinfeld, Elaine was blacklisted as a bad patient.

I should note that most providers are not consciously motivated by financial gain.  Yes, treatment results in payment, but the vast majority of people believe that they are offering the best option.

What to do…Ask- what are you getting for the risk, what is the downside to waiting?

With all these well meaning forces, I would suggest a relatively simple approach of asking and when possible, consider watchful waiting.  For many patients, asking is intimidating.  There is a fear asking will degrade the relationship.  Most physicians are willing to explain there reasoning; and if they won’t, get a second opinion. Definitive answers are not always the best answers.  Finally, ask the harm in waiting.   Avoiding risk today may be better than possible risk tomorrow.

Congrats, You've won a shopping spree. Unfortunately, the stores are closing. Why you should worry about Medicare instead of Obamacare

After 30 years in healthcare, a someone finally explained Medicare to me.  Here is the short version. There are 4 parts (A,B,C, & D).  At 65 most Americans get parts A and B.  Part D is for drugs; the senior can be responsible for several thousand dollars/year.  Part C is the interesting one.  

"C" coverages lab, X-ray, hospitalizations, doctor visits, emergency transport- most things commonly thought of as healthcare.  You can choose to keep Part C which is free in most geographies or add a supplement reducing or eliminating co-pays.  Most seniors choose supplement plan "F."  For another $130/month (with the required $104 for Part B this brings the total to $235/month), the senior has access to any primary doctor or specialist, any hospital network accepting Medicare with no additional charges.  This is fantastic coverage.  I pay almost 10 times this amount and still have a deductible.  This is like a an unlimited shopping spree for a buck.  But unfortunately, many of the "healthcare" stores may be closing.

Here is the problem.  The healthcare costs a of money a lot more than $235/month.  The government has 2 choices.  Additional revenue could be raised, effectively charging seniors more for similar coverage.  This is DOA. Politicians like being politicians.  They, like most of us, think of themselves first.  Reducing entitlements, particularly Medicare, is suicide.  Alternatively, expenditures could be reduced.  This is what has been happening.  Hospitals, doctors, device manufacturers, labs, etc... are all being paid less.  

Although a popular public option, this may not be a good long term strategy.  Yes, the healthcare industry is bloated and mismanaged, but inefficiencies are not going to disappear easily.  As prices fall, businesses are going to fold- fewer hospitals, fewer doctors, less innovation.  I am not suggesting healthcare will disappear, but rather access will decline.  Like in any business without profit, store shelves become bare.  Politicians will keep their jobs.  Entitlements will be left untouched, but simply worth less. 

This has a ripple effect.  With all the dialogue around Obamacare (ACA as it is now again being called), it is easy forget the vast majority of expenditures are for the elderly.  Medicare is untouched.  If reimbursement for Medicare results in fewer choices and less access for the elderly, this will directly affect those participating in Obamacare; it's the same delivery system.

The ACA presumes all Americans need to pay for healthcare.  Although there is (bizarrely) not general agreement on this point, most believe a civilized society requires roads, schools and police, & care for the sick.  However, by segmenting the population into 2 groups (pay as you go for <65, and pay once for all you can eat for >65) seems destine to fail.  Ultimately every group must have some skin in the game when making medical decisions.  I am not suggesting the elderly should bear the full cost of their care but rather that price for care should be part of the decision.  When the doctor suggests a course of action, price should be at least part of the conversation.

Forget Obamacare.  It's a fly on the elephant's back.  American's have much bigger problems.  We need leaders who argue for what's right for the country, not for their careers.  We need lobbyists (yes, you AARP) who recognize that saving money for their members today may mean fewer services tomorrow.  People of all ages should pay something for more care.  This is the only way to actively engage the consumer in the decision process.