That's not always possible, and it's not always good advice, but it's very important to put the entire enterprise in perspective, particularly as we consider restructuring our health care system. Specifically, I've come across two recent articles -- both subscription only -- that remind us that Ivan Illich had a point after all. In the July 1 JAMA, Charles Kilo and Eric Larson -- both of them well established on the Dark Side, holding M.D.s -- review the harmful effects of health care. They actually name That Which Can Not Be Named: "On balance, the data remain imprecise, and the benefits that U.S. health care currently deliver [sic] may not outweigh the aggregate health harm it imparts."
Uh oh. Now that would be a pretty serious waste of 17% of the U.S. economy. Direct physical harm from adverse effects of treatment is well known and justified as the inevitable consequence of placing bets where the odds are on your side but you will sometimes lose on the flop or the turn. However, the truth is that physicians very often do not have good information about the odds of benefit or harm associated with particular treatments. This is partly because adverse effects often emerge only after long experience, long after drugs are approved, viz Rofecoxib or a lesser known debacle, the Swan-Ganz pulmonary artery catheter which sold millions of units for billions of dollars for 35 years before it was ultimately found to be harmful.
However, as Kilo and Larson note, "[B]oth physicians and patients generally embrace techology enthusiastically -- implicitly trusting in its benefit before adequate assessment is made."
But there is also emotional harm, such as anxiety from false-positive test findings. One which they do not mention but which I have thought about a bit lately is the opposite effect -- the considerable distress patients often feel when doctors tell them that symptoms such as chronic pain, for which the doctor can find no physical cause, are of psychological origin. This can make people feel stigmatized, disbelieved, and devalued.
Then there is the opportunity cost. Every dollar spent on a useless or harmful treatment is a dollar not spent on something else, be it feeding a hungry child or improving public education. Either of the latter would do far more for the public health than medical intervention can do. "Although health care's objective should be to improve health, it's primary emphasis has been on producing services." We simply have no good measures of the overall impact of health care on population health.
Ian Scott in BMJ (also off limits to the rabble) discusses errors in clinical reasoning. His literature review includes the following highlights:
- The correct diagnosis is missed in 5-14% of acute hospital admissions.
- Autopsy studies find diagnosis error rates of 10-20%.
- Even with the correct diagnosis, up to 45% of people do not receive the recommended evidence-based care.
- From 20-30% of investigations and prescriptions are possibly unnecessary
His point is that a lot of this has to do with the ordinary human fallibility of physicians. Doctors suffer from the same biases in decision making and sometimes erroneous shortcuts in reasoning that plague us all. There are other structural and cultural causes of medical error, of course, which may be just as important. But it is salutary for physicians as well as patients to keep in mind always that they are engaged in an enterprise characterized by a great deal of uncertainty and potential for error, which nonetheless has a strong bias toward action.
Rather than producing more medicine, we need to produce somewhat less, but distribute it more equitably and wisely. This is one way of understanding the fundamental struggle that is going on in Washington right now. As the Washington Post reports (in the small window of opportunity remaining before it closes the impending sale of its newsroom to lobbyists), the health care industry is currently spending $1.4 million a day on lobbying. You read that correctly folks, that is $1,400,000 every day to buy the votes of Max Baucus and Joe Lieberman. And why are they doing this? As reporters Dan Eggen and Kimberly Kindy write, "The aim of the lobbying blitz is simple: to minimize the damage to insurers, hospitals and other major sectors while maximizing the potential of up to 46 million uninsured Americans as new customers."
Exactly. They want to get paid to provide services to 46 million more people, but they don't want to have to prove that they are actually doing those people any good. We need rationing. We want rationing. Rationing is good, rationing is wise, rationing will save you money, rationing will make you happier, rationing will make you healthier. Please bring on the rationing.