• Doctors are human (for the millionth time)

    I still have trouble believing the constant amazement at the fact that doctors are human. Sarah Kliff writes this morning on the new study showing that unnecessary heart procedures go on all the time:

    “We had one physician say something I thought was pretty amazing. ‘We know the evidence shows not to do this, but we’re still going to,’ ” recalled Grace Lin, the lead researcher on the study at the University of California San Francisco Medical School. “There were some very strong financial and emotional biases towards going ahead with the procedure.”

    I really don’t know why people have this expectation that doctors are somehow superhuman. They’re just like you and me (literally, in my case). They are susceptible to financial incentives.Ten cent coupons work. The financial incentives behind doing a heart procedure are WAY more than than that amount. Of course they will be influenced by that.

    I’m not saying that it’s the only thing that influences them. They are also biased by their experience and what they’ve been taught, as well as a desire to do good. But denial won’t help us do better. We have to acknowledge that these pressures exist, minimize them, and continually be on guard against them. This is just as much a conflict of interest as any other, but for some reason we don’t treat it as such.


    • Doctors will vehemently deny that they are influenced by financial gain but the evidence has shown over and over that they will vote for their own pocketbook (and develop elaborate rationalizations to justify their decisions).
      So… how do we take this financial incentive distortion out of medicine?
      Kaiser has one model (physicians on salary) which seems to work.
      The UK has the NHS which seems to work well also with physicians on salary.
      Physicians need to accept that any financial reward will influence their behavior… even a few dollars kickback from the lab on a procedure.
      This will be difficult since doctors are in denial.

    • File this with Austin’s earlier pieces on provider induced demand. Of course this happens. If you are in the field, you see it pretty often if you look for it. What is not surprising is that this occurred often enough at HCA to merit an investigation.


    • If we view physicians as superhuman it’s at least partly because they as an organization have encouraged this belief.

      “You can trust me, I’m a doctor.”

      “How dare you meddle in the relationship between doctor and patient?”

      Our entire medical system – and specifically the mechanisms by which we collectively decide what care we’re willing to pay for – both assume by default that doctors by virtue of being doctors know what to do for their patients in all circumstances, including when there is no actual evidence available to guide them, which is probably the majority of the time. That needs to change.

    • The most significant portion of the blame with respect to exceptionalism in medicine falls upon physicians. Although patients certainly have unrealistic expectations of the godliness of their doctors, physicians have a uniquely hypocritical perspective of their own ‘sovereignty’, for lack of a better term. On the one hand, the physician feels s/he is held up to an unrealistic expectation with respect to perfection in the OR or on the wards – not only do mistakes happen, but medicine does not possess all the answers. On the other hand, the physician feels s/he is uniquely immune to any influence beyond the evidence-based training received in medical school, residency and beyond.

      When a system of compensation provides such clear financial incentives for physicians to carry out unnecessary procedures it is no wonder that those very procedures are carried out more often than necessary. Similarly, pharmaceutical and device manufacturers are not run by incompetent people – they do not expend significant amounts of money on marketing to physicians because it doesn’t work.

      Yes, physicians are human. The problem comes when so many physicians believe they’re human only part of the time. It’s our responsibility, physicians and medical students alike, to change this dialogue of part-time exceptionalism. We need to come to the realization, as a profession, that we are full-time humans.

      Furthermore, it needs to be impressed upon the profession that it doesn’t matter whether or not we can prove, scientifically, that the profession is being influenced by flawed compensation models and external corporate interests. What matters is that our patients are beginning to believe it. As soon as the relationship of trust between the physician and patient begins to break down, whether or not the reasons are founded, health outcomes will fall, all because we can’t admit we’re full-time humans.

    • All people are biased at least a little bit (OK maybe not some depressed people and autistic people). The advantage in the medical market over other markets is that your GP can be your advocate. GP’s do not do much of the high dollar work for you directly, but mostly farm it out, so if you let them know that you are paying directly they are less biased in favor of more care.

      IMO the most common and troubling bias among doctors is over confidence. They assume like most of us that everything will go well. You can have a situation where a procedure if done without error produces a benefit but that there are enough errors that a less invasive treatment or no treatment nets out better in the real world. yet that confidence cause the Doctor to use the more invasive treatment.

    • “But perhaps the most important of Arrow’s insights was the recognition of what he called the “uncertainty” inherent in medical services. By this he meant the great asymmetry of information between provider and buyer concerning the need for, and the probable consequences of, a medical service or a course of medical action. Since patients usually know little about the technical aspects of medicine and are often sick and frightened, they cannot independently hoose their own medical services the way that consumers choose most services in the usual market. As a result, patients must trust physicians to choose what services they need, not just to provide the services. To protect the interests of patients in such circumstances, Arrow contended, society has had to rely on non-market mechanisms (such as professional educational requirements and state licensure) rather than on the discipline of the market and the choices of informed buyers.”

      from “The health of Nations”, Arnold S. Relman, http://www.pnhp.org/news/Health_Nations.pdf

    • This article should be retitled “Doctors are Greedy”. Many of these decisions are not mistakes, they are calculated choices that financially benefit the doctor. I can’t tell you how often I have seen surgeons prescribe surgery when NO rational human being would even come close to complying.

    • That “doctors are human” — that they succumb to the conflict of interest inherent in deciding the need for their own services — has generated a policy consensus against fee-for-service compensation. But this consensus misunderstands where the conflict of interest originates.

      “The conflict of interest arises not from fee-for-service payment but from physicians’ monopolistic authority over two distinct services: deciding what medical procedures are needed and executing the procedures they select. The conflict does not disappear when payment switches from fee-for-service to its opposite–-capitation. Indeed, then the conflict becomes even more acute–-physicians have an incentive to withhold their expertise from costly patients who need it the most.”

      The quoted analysis appears in the blog post, “Is Fee-for-Service Really the Problem?” at . This blog post argues for breaking the physician monopoly over medical practice: “Whoever executes medical procedures must not be the party who decides what procedures are needed.”

      The entire health care system depends on how physicians exercise their monopolistic authority. Yet, human beings do not have the capacity to exercise effectively the authority conferred on physicians. In this dependence on such authority, the health care system lags centuries behind the domains of science and commerce. Breaking that dependence requires building a new system of care, a system wholly unlike the non-system we have now. For further discussion, see the foregoing blog post and the 2011 book on which it is based, Medicine in Denial, http://www.createspace.com/3508751.

      Full disclosure: I am the co-author of the referenced blog post and book. For some background, see http://theincidentaleconomist.com/wordpress/more-on-standards/#comment-17864. For the book’s table of contents, overview and introduction (full text), see http://www.thepermanentejournal.org/files/MedicineInDenial.pdf.