I’m new to this whole social media thing. But I like the fact that it attracts a semi-lunatic set of people who aren’t content with the medical status quo and want to make a difference.
So, I want to talk about something that I reckon is just about the most important healthcare issue facing those of us privileged enough to be living and working in the first world.
For my money, the elephant in the Health living room is in the budget. Like many doctors, for a long time my wife (a nephrologist) and I (an emergency physician) have shaken our heads in disbelief at the crazy inequities of the health system. Why for instance does total health spending (public & private) continue to rise as a proportion of GDP in Australia? (7.5% of GDP in 1995, 8.3% in 2000, & 8.8% in 2005? (according to the Australian Institute of Health & Welfare)
And why is total health expenditure in the USA nearly double ours (incl public & private) with worse outcomes & far worse inequities?
Because the money is going to the wrong places and into pockets rather than into real improvements in health outcomes. This is ‘the elephant in the living room': something everyone knows or suspects but is never discussed.
- Governments fear to discuss the issue (because healthcare reform is seen as just too hard because of all the well-funded vested interests — look what happened to Hilary Clinton and then Barack Obama when they tried to take it on in the USA)
- An ill-disciplined & lazy media ignores it
- An ill-informed public is too easily bamboozled by cynical & emotive pleas for more funding by those same vested interests who are profiting at the expense of the public purse
- Individual doctors either lack the time and resources (like most busy people juggling jobs and family) or just happen to have some of those vested interests I just mentioned.
Many doctors in countries like mine [Australia] have a strong commitment to high quality, equitable healthcare. But we are well aware that (a) important ethical decisions get made ‘on the hop’ by doctors every day, and (b) the decision-making process can be opaque / arbitrary / self-serving / up to personal whim.
A case in point:
The cardiologist, the vascular surgeon and a nephrologist were managing an elderly vasculopath with significant renal impairment, who developed angina as a hospital inpatient. After a great deal of discussion with the patient, his family and the three teams, all agreed that his angina would best be managed conservatively, because of the risk that a coronary angiogram would push him into end stage renal failure. After five days, a changeover in the medical term led to a brand new cardiology trainee walking into the patient’s room to inform the patient that he had booked him for an urgent coronary angiogram the next day. Nothing had changed except the trainee, who hadn’t bothered reading any of the medical notes for the last five days. For the record, the patient and his family told the trainee to go to hell.
I was on duty in my Sydney ED on the day of a nursing home fire last year. Some very frail, very elderly, very badly burned patients were transferred in and I was faced with an urgent question: to palliate or resuscitate? The intensivist, the plastic surgeon and I arrived at acceptable decisions on a case-by-case basis. But I couldn’t help thinking at the time that, had the ED physician, intensivist and plastic surgeon been different individuals, perhaps very different clinical management decisions would have been made… just as well-intentioned, and just as shaped by personal beliefs and experience rather than evidence.
So what’s the real problem here?
It’s not about what is actually the best treatment in any given case. (But how that decision is reached merits a whole rant in itself.)
And it’s not whether healthcare should be public or private. (It doesn’t matter who pays the bills if the person who decides the best treatment and in the Australian private system sets the cost in the form of a ‘gap fee’- is also the person who reaps the financial benefits.)
In my opinion, it’s the very system that allows the most important health care decisions (such as resuscitation orders, interhospital transfers and very expensive procedures) to be made by individuals who are given an extraordinary licence to do so, with neither adequate oversight nor formal training in the ethics and economics of their decisions.
It staggers me that simply having the title ‘doctor’ confers this power, and that decisions like this are made every day, by the specialists who stand to gain the most from such decisions and also by doctors in training with little experience. A striking analogy is suggested in a New Yorker article by Atul Gawande just sent to me: imagine if you were building a house and you paid an electrician for every outlet he recommends, a plumber for every faucet, and a carpenter for every cabinet. Would you be surprised if you got a house with a thousand outlets, faucets, and cabinets, at three times the cost you expected?
I recently discovered that there is a whole branch of study devoted to ‘clinical practice variation‘, particularly where such variation is ‘supply-sensitive': that is, based more on individual doctors’ preferences rather than actual benefit to the patient. The concept was defined by the The Dartmouth Institute for Health Policy and Clinical Practice and published in the Dartmouth Atlas. I’ll quote from them here:
Effective care refers to services that are of proven value and have no significant tradeoffs; the benefits of the services so far outweigh the risks that all suitable patients should receive them.
Preference-sensitive care comprises care for conditions for which there is more than one treatment option, each with its own benefits and tradeoffs.
Supply-sensitive care represents services for which the supply of physicians and other resources — such as hospital beds — strongly influences the amount of care delivered.
In other words, effective care can be rephrased as ‘We should do this… so we will.’ And supply-sensitive care equals ‘We can do it… so we will.’
It’s no surprise that supply-sensitive care is the most expensive, but it is disappointing that in many cases it is no more effective than the cheaper alternative. The references listed below all cite examples of comparable regions whose populations have very different rates of certain treatments (orthopaedic procedures for example) without any difference in long-term outcome.
And the worst news? Supply-side care is the type of care that we practise. Every time a junior doctor orders a ‘Serum Rhubarb’ because the boss might just want it and you don’t want to look stupid on the ward round, and every time an ED doctor orders a CXR for a kid with bronchiolitis or orders a CT abdomen for the patient with appendicitis ‘because the surgeons will want one’, that’s supply-sensitive care happening right there.
And you’re not immune just because you’ve got grey hairs. Quoting from a 2010 MJA article:
Research commissioned by the Clinical Excellence Commission provides particular insight into variation in clinicians’ prescribing behaviours regarding red blood cells. The study found that most senior doctors interviewed were not particularly interested in learning more about inappropriate transfusions [because] they believe their current practices are not deficient, and that it is others who need to be encouraged or educated to change their practices.
So there is a problem. It’s been defined and measured. In countries like the USA you can compare hospitals based on their care versus their outcomes. In New South Wales, the Garling Report discerned clear variation in practice, observing that much clinical care reflects clinician or organizational preference, not patient needs.
Does it matter? Why should any of us get all hot under the collar about it?
Well, it may depend on where you stand in the equation: a supplier of supply-sensitive care may not be that interested in decommissioning the Gravy Train, and in a country where ‘socialist’ is a pejorative term, the rest of us probably don’t fancy the thought of being called bolshy bastards by our colleagues.
For me the best analogy is climate change: action now appears painful & can always be deferred. But the private and public costs of healthcare are spiralling in our country, and eventually they will be unsustainable. At that point, even our politicians will have to toughen up and make some hard decisions. And I would rather that the tough budget and ethical decisions are made now, with time to discuss and reflect, rather than made by panicky policy makers with a tenuous grasp of the issues.
Let’s be selfish: by the time I get to the ripe old age when I need to open the healthcare cupboard for my own care, I hope there’ll still be something in it.
What can be done?
Well, part of the answer is to develop and disseminate best practice guidelines, and there are plenty of excellent organisations worldwide that are doing just that.
But leading a horse to water won’t make it drink, and just providing cantankerous, individualistic and possible greedy doctors with a whole bunch of guidelines won’t be enough on its own. I shudder to even think it, but perhaps the answer is to give up a little bit of our vaunted autonomy.
H.L. Mencken once said, ‘For every complex problem, there is a solution that is simple, neat, and wrong.’ But one solution that has often appealed to me (when watching fee-for-service interventionalists signing up ED patients for benefits of doubtful utility) is the ‘traffic light system’: divide treatment decisions into:
- GREEN: those which most stakeholders agree are worthwhile (e.g. coronary stent in a 30 year old with STEMI) and that a doctor can prescribe with complete freedom;
- AMBER: those which must meet certain criteria before they are allowed e.g. stent in an independent 80 year old: perhaps such decisions would have to be approved case-by-case by a specialist from an unrelated specialty or by the hospital general manager;
- RED: those which a majority agree are inappropriate & which are simply not allowed (e.g. stent in a 100 year old). (Apologies to all those 100 year olds who were hoping to make it to 200.)
Well, I don’t know what to do from here.
I have no idea if there is a ‘constituency for change’ out there among the medical community in general, let alone critical care doctors. But I’d like to find out. I reckon it would be in the public interest to get the conversation started in an open forum. It would be refreshing to see a large number of doctors publicly put their hands up and admit that our profession is out of control and we are wasting money and precious resources. Wouldn’t that be something?
And perhaps we could build on that and start a public conversation with all the stakeholders: government, hospitals, clinicians, public health experts and the community.
So here’s a list of what I reckon are the pertinent questions:
- The key question is ‘How should healthcare decisions be made?’ Or rather, ‘How do we spend the healthcare budget?’
- Are there treatments we all agree deliver value for money to our patients?
- Are there specific treatments that we all agree are poor value?
- Should the medical profession as a whole take responsibility for treatment decisions that most of us consider to be wrong? Personally I consider that we should. We are best placed to understand and advise on the issues, and the public looks to us to provide the best possible care and dispassionate advice.
- Would any doctor who took on this battle be prepared for the inevitable media backlash when disgruntled colleagues (and angry patients) discover they are on the losing end of the process? This might be the biggest stumbling block.
I’ll sleep more soundly at night if we at least try to do something about the issue. As members of the profession best placed to understand the intricacies of the system, it’s about time we demonstrated to our patients that we actually merit the respect we demand.
For the record, all my opinions are my own and I do not presume to speak on behalf of my hospital or anyone else.
So, what’s the most expensive piece of medical equipment in the world? Well, according to Gawande in his New Yorker article, it’s a doctor’s pen.
References and links
Want to read more? Try these:
- Gawande, A. The cost conundrum. New Yorker, June 2009 [link]
- Godlee, F. Tackling practice variation. BMJ 2011. 342:d1884 [link]
- Kennedy PJ, Leathley CM, Hughes CF. Clinical practice variation. Med J Aust. 2010 Oct 18;193(8 Suppl):S97-9. PubMed PMID: 20955142. [Fulltext]
- The Dartmouth Atlas of Healthcare
- Wennberg, JE, Thomson PY. Time to tackle unwarranted variations in practice. BMJ 2011. 342:d1513 [link]