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Overriding Our Try-Anything Instinct

04 May

There are a lot of reasons why U.S. health care is so expensive: high prices, supplier-induced demand, insulation from costs via insurance coverage, etc. One of our problems is that we generally dislike being sick and are especially averse to death. Call it survival instinct, human nature, or something else, but we all pretty much want to live forever despite knowing that each of us will eventually, one day, die. When that moment seems imminent, our brains stop being rational and start getting real. Anything the man or woman at the hospital bedside can offer us–even if it is a longshot–seems worth doing. But it gets worse than that.

Sometimes, we get more diagnostic tests than we ought just to rule things out. That might happen because the physician is trying to cover themself from lawsuits or because we as patients are stuck believing that more care is always better care. “Give me all the tests. Check all the blood work,” we say. “Oh, and I’ll take a full-body MRI while we’re at it. I don’t want you to miss anything.” As David Leonhardt writes in The New York Times recently, “This try-anything-and-everything instinct is ingrained in our culture, and it has some big benefits. But it also has big downsides, including the side effects and risks that come with unnecessary treatment. Consider that a recent study found that 15,000 people were projected to die eventually from the radiation they received from CT scans given in just a single year–and that there was ‘significant overuse’ of such scans.”

What Leonhardt is getting at is what is commonly called “flat of the curve medicine.” The following graphic should make the concept quite clear:

In short, the more health services a person uses up until point A, the better their health will be. From point A to point B, using more health services results in no gains in health status. Beyond point B, using more health services results in a decrease in health status, because the risks of such services outweigh the small gains they represent. It should be obvious that we ought not wish to go beyond point B. However, it should also be obvious that we should not wish to venture along the flat of the curve beyond point A towards point B, because doing so is inefficient–a waste of resources with nothing to show for it. Indeed, redirecting those resources to provide care for those who do not yet enjoy access to a “point A” level of care would produce the greatest benefits to the population as a whole and would do so without taking away anything of value from those already on the flat of the curve. It is in this way that a “redistributive” policy can be universally beneficial and not a zero sum game.

To those who say that such an idea is feasible only as a though experiment–that drawing conclusions about where point A resides amounts to nothing more than rationing or that denying an individual the option of naming their own point A amounts to an infringement upon their personal liberties–I have to let you know that such decisions are made at present by medical providers. For a time I was employed in a hospital laboratory and had the opportunity to attend the weekly meetings of the “Tumor Board.” While enjoying lunch, a diverse group of radiologists, pathologists, oncologists and others presented cases of cancer patients and debated the various merits of a variety of treatment approaches.

This doctoring by committee approach rather often concluded that the patient was too old, the cancer too advanced, the likelihood of remission too low, the side effects of the treatment not worth it–and the decision was made to leave the cancer untreated. Is that a death panel? If so, we need not fear “ObamaCare” because doctors are condemning patients to death already. Or is it an efficient use of medical resources, a genuine understanding of the factors involved, and an appreciation of the fact that the patient may not be able to fully and rationally evaluate these factors?

I risk the ire of those patient advocates who despise the paternalism inherent in medicine, but I think that the Tumor Board is the best example for how complicated medical decisions should be made. Sometimes “No” is the best answer. Unfortunately, patients rarely want to hear that word, let alone utter it themselves. Consequently, we end up pouring resources down the drain with very real significance in the lives of the people for whom those resources made no difference and for whom they could very much have made a life-changing difference. One person’s “No” may not change the outcome for them, but it could be the doorway to a vital “Yes” for someone else.

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1 Comment

Posted by on May 4, 2010 in Uncategorized

 

One response to “Overriding Our Try-Anything Instinct

  1. Jan Baer

    May 4, 2010 at 11:02 am

    This is a very interesting topic and deserves our attention, since end-of-life health care costs can be huge.Will generational differences affect the choices patients make?My mother commented wryly twenty years ago that as soon as she enrolled in Medicare, doctors took a sudden interest in her health and tested her for everything possible. Her point was that they knew Medicare would pay for the tests and they earned money ordering them. Yet it never occurred to her to say "No, thanks."Many older patients have done what the doctors told them, regardless whether it made sense to them personally, and often with great stress and inconvenience.The next younger generation may be better informed, yet when they reach that critical point of need, will they possess the same judgment? It is precisely when we are weakened by illness that we are presented with difficult choices and have the least ability to choose intelligently; indeed, in many cases the choices are made by emotional family members.Poignant examples would be three different cases of pancreatic cancer, and the three choices made by those patients. The first tried treatment up to a point, since he was just 40 years old and hoped desperately to be the rare survivor of this dreadful form of cancer. He eventually weakened until he could no longer manage the treatments and died a little more than a year following diagnosis.The second declined treatment and died a bit more than a year after diagnosis.The third was persuaded to try every available option, though the cost was huge and the long trips for week-long treatments were exhausting. She died just beyond the one-year mark after diagnosis.Thanks for the thoughtful topic.

     

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