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Doctor, What Would You Do If You Were Me?

The views expressed are those of the author and are not necessarily those of Scientific American.

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“Effectiveness” is at the forefront of the health policy debate. Effectiveness is the assessment of whether any particular medical intervention actually advantages patients when prescribed in practice settings. To be considered effective, the intervention must result in a clinically meaningful improvement for an adequate percentage of patients. Furthermore, it must not result in a clinically important adverse outcome in too many. Clearly, “effectiveness” is a value-laden construct. How is “meaningful improvement” defined and by whom? How is “important adverse outcome” defined and by whom? How are “adequate percentage” and “too many” defined and by whom?

“Cost-effectiveness” is even more value-laden. It is legislated to be off-the-table in the machinations of the Affordable Care Act for reasons that vary from fear of rationing to fear of compromising profit margins. But no one can exclude cost-effectiveness from the patient-doctor dialogue. Considerations of co-pays and deductibles often weigh heavily in the valuation of interventions.

The greatest advance in clinical medicine in my time in the practice, fast approaching 50 years, is that today patients and their doctors can assess effectiveness as collaborators. No longer does an imperious pronouncement by a physician suffice. Rather, the patient should occupy the driver’s seat with the physician as navigator. For each option in intervention, the patient asks, “Based on the available science, what is the best I can expect?”

For nearly 50 years, no prescription drug could be marketed unless the FDA was convinced that it had a tolerable benefit-to-risk ratio based on scientific studies. The bar for devices (like hip replacements) and procedures (like liposuction) is not as high, but there is usually some informative clinical science of this nature. The science is generally designed in the hope of demonstrating a favorable benefit-to-risk ration. Hence, patients and interventions are chosen to measure outcomes in the best case. However, make no mistake; neither the fact of FDA approval nor common practice is an adequate response to “What is the best I can expect?” If the best case falls short in your mind, why would you acquiesce to the intervention?

Consider Pill A, which reduces a blood chemical known to predispose to heart damage. The “best case” science says that if 100 adults take the pill for 5 years, perhaps 2 will be spared non-fatal heart damage and 10 will suffer muscle pain. However there is no suggestion that anyone will be spared death before their time. Would you take Pill A? Even if it was free? Consider Pill B, which reduces a blood chemical associated with damage in many body organs and with death before one’s time. Scientific studies of Pill B, some lasting a decade, have proved disappointing both in terms of preventing body damage and causing toxicity. But these studies were done on early versions of this category of pharmaceutical. Would you take a new version or a combination of these agents?

Consider Procedures A and B, both designed to overcome pathology in blood vessels that is associated with organ damage. Procedure A is “minimally invasive”, though it has a 1-2% incidence of catastrophic complications. Procedure B is major surgery with a 5-10% incidence of major complications related to the procedure and a 20-30% incidence of a prolonged period of recovery. Again there is a robust scientific literature saying that neither intervention will improve longevity. The literature that either improves symptoms is highly inconsistent. Nonetheless, these procedures are still offered because they are performed differently today than in the older disappointing studies and they are offered only to candidates thought to be particularly appropriate. If you were deemed “appropriate” would you acquiesce to either procedure?

Pill A is a “statin” for high cholesterol. Pill B is an oral hypoglycemic to lower blood sugar in Type 2 diabetes. Procedure A is stenting for plaques in coronary arteries (or elsewhere) and B is bypass grafting. All are plausible, even sensible, even current common sense. All are sanctioned by august professional bodies and all are covered by health insurance. There is no “right or wrong” answer to the question about patients in general acquiescing to these options. But there is a right answer for you.

Many are capable of rendering the best case science transparent; there are even independent groups of scientists devoted to this exercise. And many more are capable of prescribing and performing according to guidelines and standards. But none of these people can come up with the right answer for you.

That’s why you would be advantaged by a physician who wants to support your valuation of the options. That’s the way you’ll find the shoe that fits.

Dr. Nortin M. Hadler About the Author: Dr. Nortin M. Hadler is a graduate of Yale College and The Harvard Medical School. He trained at the Massachusetts General Hospital, the National Institutes of Health, and the Clinical Research Centre in London. He was certified a Diplomate of the American Boards of Internal Medicine, Rheumatology, Allergy & Immunology and Geriatrics. He joined the faculty of the University of North Carolina in 1973 and was promoted to Professor of Medicine and Microbiology/Immunology in 1985. For 30 years he has been a student of “the illness of work incapacity”; over 200 papers and 12 books bear witness to this interest. The third edition of Occupational Musculoskeletal Disorders (LW&W 2005) provides a ready resource as to his thinking on the regional musculoskeletal disorders. In the past decade, he turned his critical razor to much that is considered contemporary medicine at its finest. His assaults on medicalization and overtreatment appear in many editorials and commentaries and 5 recent monographs: The Last Well Person. (MQUP 2004) and UNC Press' Worried Sick. (2008), Stabbed in the Back. (2009), Rethinking Aging. (2011) and Citizen Patient. (2013).

The views expressed are those of the author and are not necessarily those of Scientific American.

Comments 11 Comments

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  1. 1. rshoff 10:25 am 04/2/2013

    “Rather, the patient should occupy the driver’s seat with the physician as navigator.”

    All due respect, this is a cop out. Never have I seen a physician allow me to take the time to discuss my ideas, thoughts, or concerns, much less ‘drive’. Physicians need to dramatically change if they are willing to allow patients into the drivers seat. Need I point out another SA blogger that brought up the questions surrounding legitimate use of placebo? Does that sound like a drivers seat to you!? Invisible prices for medical procedures are like invisible lanes the driver must stay within. Insurance companies that negotiate directly with the dr -mainly via interfacing computer systems- but put the liability smack dab in the middle of the patients lap. Yet the patient can’t intervene between the doctor and the insurance. And if we try? Whew, there goes our medical coverage AND our medical care. So with all due respect, the patient is being screwed by all of you!

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  2. 2. rshoff 10:27 am 04/2/2013

    … in the back seat.

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  3. 3. hashimoe 11:18 am 04/2/2013

    I have been a surgeon for 30 years and have found that increasingly the American public, when it comes down to their OWN health, want whatever procedure has ANY chance of making them better. And they think that when they have a procedure they will ALWAYS have a good result. Anything short of that is dissatisfying or downright malpractice (just watch TV commercials during the daytime). Telling them there is a 50:50 chance of improvement translates into, “So then I’ll be all better?” You can give all the facts, try and form a ‘partnership’ and ask for input but in the end the patient only wants to get better and they come to you and ask you to fix them. I try to have detailed discussions with patients but find most people say, “Doctor, YOU decide,” and abrogate their responsibility. Of course I exaggerate, but unrealistic expectations, complaints and lawsuits from one in a thousand patients tears my heart out and takes some of the joy out of Medicine. It didn’t used to be this way.

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  4. 4. rshoff 2:02 pm 04/2/2013

    Perhaps physician’s time is what’s is in question with the idea of building a partnership. Including the fact that patients are people, from a variety of knowledge, experience, age, etc. The physician may need to assess the patient’s skills and personality before determining their role. This all takes time. Relationship building over a long period of time and communication during a visit. Obviously being bounced between doctors on a variety of contracted physician networks and having 15 minutes for an appointment is not enough to develop a true partnership. Thank you insurance companies that are beholden to stockholders.

    Of course patients want the best diagnostic and treatment options for themselves and their families. Anything else is just crazy. If my neighbor has an eyebrow lift paid for while I hobble around with a bad back and leg neuropathy, you bet I’d want ‘the best’. When I see my elderly parents needlessly suffer for things that should be treatable if the doctor took the time to truly diagnose and treat their conditions, you bet I want the best. Of course we all ‘want the best’.

    This employer provided private sector insurance based healthcare system does not work. It does not work for anybody involved in patient diagnosis, treatment, or care. It’s broken. It’s dead. It’s past tense. Maybe statistics indicate it’s the best in the world, but it’s not the best in the world for most Americans on the street.

    Perhaps the patient should be in the driver’s seat and the physician a navigator, and the insurance company just that: An indemnifier to the contract holder. But that boat sailed years ago. Probably decades ago. It’s too late.

    Dismantle the entire system now! Single payor is not great, but it’s better than a system that cares about everything and everybody but the well-being of the patient. Isn’t diagnosing and treating the ‘patient’ the entire reason for the existence of healthcare? Entirely? As in 100%? Expand Medicare as the National Model and collect revenue via taxation.

    There is no money to be had in providing people with good medical care. And you and I both know that money rules. Right now we are paying for world class care, but only some receive it. At least the single payor model would put us all in the same boat. We ALL sink or NONE of us sink. THAT would be motivation enough to make it work.

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  5. 5. bakerw11 2:26 pm 04/2/2013

    Rshoff, I understand your frustrations. As a physician about to retire, I’ve seen many changes in the way medicine is practiced over the last 30 or more years. Currently, many physicians are “owned” by hospitals. These physicians care for patients with complicated illnesses and multiple medical problems. If the doctors don’t see enough patients in a day, they likely will hear from an “administrator”. I have been fortunate to have been in private practices where the goal was to treat the patient and to look at the patient who has a malady, not a malady which happens to be “attached” to a patient. Therefore, I was a bit put off by your initial comments.

    I do agree that we need a single payer system. Medicare is far more efficient than the private insurance companies who need to please their stockholders and provide upper level management with handsome salaries. Granted, we need to eliminate fraud, improve efficiencies in health care, and avoid over-testing. Other modern countries are far ahead of us in this respect.

    I would encourage you to read one or more of Dr. Hadler’s books which speak to me ever more so now that I’m close to age 70 and am experiencing some of the maladies which he addresses.

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  6. 6. rshoff 2:49 pm 04/2/2013

    bakerw11 – Thank you for reading my comment even though it was off-putting. While I believe there is truth in my observations, please accept my apologies for attacking good people who are physicians and administrators that are doing a phenomenal job within our current system to help people. I do apologize for that and claim my passion is driven by frustration and sense of fairness, but there is also truth to my comments. thanks again. I will check out Dr Hadler’s book on your recommendation.

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  7. 7. rshoff 3:05 pm 04/2/2013

    btw, bakerw11, thank you for being in there for 30 plus years. It’s unfortunate that we will be losing your medical experience and expertise, but understandable that you want to take time. good luck.

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  8. 8. rshoff 4:34 pm 04/2/2013

    Ok, sorry for so many comments! I just watched Dr Norton Hadler speaking on an NC People podcast about his book ‘Rethinking Aging’.

    First of all, he’s very attractive to watch on the video. But secondly, and to the point, what he has to say is profound and an essential balance to the over-medicalization we have come to believe will prevent us from becoming ill or increase our longevity.

    These concepts added to a fair delivery system would go a long way in helping us all.

    Reading the books next… starting with ‘stabbed in the back’!

    Ok, enough said.

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  9. 9. Evansdale 9:23 pm 04/2/2013

    My wife’s doctor recommended a prescription to lower blood pressure. My wife did some research and decided not to take it. She made an educated risk v side effect decision that was good for her.

    The doctor fired her and me too.

    We would dearly like to have a reasonable discussion with our doctors about risk v benefit of treatments. However, we have not yet come across any doctor prepared to do that. It is always their way or the highway.

    I would hoped that a Dr would welcome the chance to work through options with an educated patient who understands the issues and what the results of these studies mean. However, all we seem to find are doctors who want “compliant” patients not those who question the benefits of a “recommended” course of action.

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  10. 10. dubina 4:14 am 04/3/2013

    My bother was diagnosed with lung cancer several weeks ago. He first got an x-ray (for a physical complaint), then a CT scan, then a PET scan and a brain MRI to look for possible metastasis. The MRI was clear, but the written report for the PET scan was not encouraging. Nevertheless (so I was told), the lead oncologist was optimistic that his facility could treat my brother’s cancer and put it in remission.

    My expectation, after reading a lot of related stuff on the Internet, was that the oncologist should have given my brother a stage for his cancer and some corresponding life expectancy, give some course of treatment. That prognosis would be drawn on corresponding vital statistics. But no such assessment / prognosis was forthcoming.

    My bro decided to get a second opinion. The next facility did not agree with the first facility regarding its PET scan report, but their recommended treatment (generally speaking) was the same: cytotoxic chemotherapy; then, possibly radiation; then, possibly surgery. Did the radiological scans matter in that case? I wondered.

    He was given a ballpark estimate for response rate (RR): the sum of partial response and complete response to the recommended course of chemotherapy. He got another MRI, (to check and verify or deny a troubling part of the first radiology report). After that, I thought, the cancer could be staged and my brother informed for the first time of his chances for survival. So far as I know, that information has still not been presented.

    Thus, I think rshoff is right. Doctors do not have enough time to inform their patients of their conditions and their chances, and most of those patients do not really want to know. Doctors and hospitals act in their respective professional self-interests, that is, to practice medicine as they know it while nature takes its course. That should be enough. People are inclined to think doctors have godly powers to heal and cure when they do have, to some extent, but not entirely. The illusion of physicians’ powers to heal is strong, not easily dispelled.

    Meanwhile, a friend in the UK calls his personal experience the “health service conveyor belt”. Our (US) healthcare system is supposed to be wonderful, but it obviously leaves a lot to be desired.

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  11. 11. bucketofsquid 5:55 pm 04/10/2013

    An increasing number of countries have longer life expectancies than the USA and all of them have nationalized health care. If I remember correctly, the first nationalized health care system was for coal workers in Germany. The Kaiser (emperor in English, from the Roman word Kaesar, which we spell Caesar and mispronounce with an s sound) instituted it in the 1840s before he was officially a Kaiser in the minds of the rest of the world.

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