Which End of the Telescope Matters Most?

A new question is arising with greater frequency in the discussion of how to restrain excessive growth of medical costs. Perhaps, an answer lies in more, better and independent help for patients in making the tough decisions modern medicine presents to them.

While this is not entirely a new idea, as the general need has been building for some time, a new reason in support of the idea is that more doctors are becoming available for a useful post-practice career.

Interesting information has been pouring forth from brilliant, well informed and thorough people like Steve Brill in Time Magazine and in books from H. Gilbert Welch , Over Diagnosed, and David Goldhill , Catastrophic Care; all who have been reporting and analyzing modern medicine largely from the macro perspective of collections of  unfortunate and unhappy “cases” and how there is either excessive use of tests and procedures in search of too few successes and/or too much cost for too little patient benefit.

They look at a lot of modern medicine from two very different points of view – like looking though the two ends of a telescope.  Either one sees something up close in comprehensive detail or one sees a wide range with insufficient detail to provide much  guidance to any individual.

Keen observers who are looking at the whole picture tend to see much wasted effort in the quest of modern medicine to eliminate diseases and extend life statistically among studied population groups. Yet, the same observers give only little attention to the individuals found in larger groups, who might have benefited from some procedure, even if only in rare and remote cases.

While the broad perspective is a very important and worthwhile endeavor, when that perspective hits on particular patients, who may be outliers statistically, and who think “do anything and everything you can,” then broad statistical cheese binds and turns quite sour.

When most patients are fully informed, they tend to opt for maximum help, almost without regard to any odds, particularly when they are NOT confronted personally with cost.

There are basically and logically only two ways to deal with those situations:

One is not to fully inform the patient—which goes against the grain of most modern thinking and practice.

The other, is to say to the patient that, unless the odds in their particular case can favor them by a specific significant margin, insurance, public or private, cannot pick up the tab and therefore it must be purely up to them to self-pay.

That seems on its face to be rational, except it obviously strongly favors rich over the less well-off patients, itself a questionable practice in modern society.

This is not a situation like the badly labeled “death panels” which help with end of life heroics, largely in hospitals.

This set of issues is more like saying, because statistically only 1 in 100 people, who get a certain test, is likely to experience any benefit, then it is not worth administering that test to anyone, because the overall cost, benefits and collateral risks [like false positives and excess radiation etc.] would not justify giving the test.

However, any one of those 100 people could fairly say, “but I might be that one person–“Help Me!”

How does society decently reconcile that dichotomy and dilemma and provide an answer acceptable to that patient AND manage at the same time to control the tsunami of rising medical costs.

First, is the process of establishing bench marks of what are the statistically reliable odds that a procedure is, or is not, worthwhile. Much of that process inevitably is personal and subjective because of the large number of collateral variables in any given case-such as age, general health, family histories etc., but it must be utilized.

Second, there is the understandable tendency of doctors and patients alike to “do something.” Action vs. inaction is favored by most people in most cases, including their doctors (who fundamentally are biased to some extent because that is how they make their living) which needs to be tempered by balanced judgments.

A way to address this dilemma would be to encourage the creation of a new branch of medicine called, say, Independent Medical Consultants [IMC] whose task would NOT be to tell patients what to do or not do. The sole task of IMCs would be to explain the existence and relevance of the statistical facts and standards and, to give patients a wholly independent view of all the pros and cons of action vs. inaction in their situation.

That way medicine could avoid the tragic mistake of not fully informing patients of all relevant knowledge and possibilities, and could reduce the inevitable bias of “attending physicians” to do something.

The country is awash today with a growing number of experienced doctors, from virtually all branches of medical practice, who have taken down their shingles out of frustration with the ethical, practical and economic issues surrounding their practices.

Some of those retired, but still quite young, very smart and experienced, doctors might congregate in appropriate groups of expertise, to be selected solely by patients [never to be recommended by their practicing doctors], and they could/would “educate and inform” patients of practicing doctors.

The IMC consultants should be paid solely for the value of their time given to any case based on their perspective and expertise gleaned from their decades of experience. They must be free from any actual or implied bias related to any past, present or future benefit.

That whole process would benefit both the patients AND their various doctors and insurers, who in turn would likely begin to see fewer unnecessary procedures and consequently the insurers should value and support the consultations and pay for them.

Since the IMC consultants would not be “practicing” but only ‘educating/informing,’ they should not be subject to the same risks and costs of malpractice as practitioners etc., obviously unless they could be shown to have been intentionally misleading or improperly incentivized in any way.

As with practicing doctors, IMC consultants should be selected by patients for their clearly established integrity, knowledge and experience, as distinguished from superficial popularity stemming from historic social and professional connections, which too frequently can be quite misleading.

This approach to the whole practice of medicine just might get the overall ‘business’ of health and medicine back on the professional track it used to be on before it became such a big lucrative affair (about 20% of our economy) which has led the world into the  serious and expensive distortions in modern medicine.

At least it might be worth a try.


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