This post isn’t going into the detail covered in Our Healthcare Sucks about “Why Doctors Do the Things They Do”.
Instead, this is about why they don’t do that which the clinical evidence of “best practices” demonstrates they should do. Doctors are notoriously slow in changing their practice behaviors. Most practice as they were trained.
If they’re older, they’re more likely to practice as they were trained decades ago. Younger doctors have been shown to practice more aggressively and cost more because of their training that favors high-tech medical interventions when low-tech, high-touch approaches may be better (especially for chronic disease conditions). Arecent studyshowed that doctors with less than ten years experience in clinical practice had per patient costs about 50% higher than those with ten years or more experience.
This doesn’t mean they’re practicing better medicine. Younger doctors also show greater disdain for their obese patients – as discussed here in a recent blog post – which is ignorant, ill-advised and unprofessional.
“The Best Healthcare in the World”?
I discuss in Our Healthcare Sucks how the National Committee for Quality Assurance has found that diabetics in America receive recommended screening and monitoring services only 25% of the time – along with other data documenting the dismal state of American healthcare.
For all those who beat their chests about America having “the best healthcare in the world”, do they really think that 25% of recommended quality measures, or clinical best practices, is anything to brag about?
It’s data like these that led me to the title for the book – and for this website. There’s no other rational conclusion, unfortunately.
“Stick Your Best Practices”
So why don’t our doctors readily adopt medical best practices recommended by their peers, as generally occurs in other professions?
A recent article in the journal Health Affairs proposed five reasons that doctors are so slow to adopt scientific evidence in their medical practices. The following diagram illustrates these five reasons:
Even when they try to stay current with the evidence, it’s often difficult to do so. Nor are clinical guidelines always objective or without their own faults – as amply discussed in my book.
Of course, the key driver, as always, is money. As the lead author of the study in Health Affairs stated at the forum in which the study was presented:
“Fee for service payment is the real culprit in that it provides a potent incentive to adopt treatments that are well reimbursed, regardless of the evidence.”
“Physicians and patients in the U.S,…have a pro-intervention bias ‘even when the marginal benefit of doing so is small’…This played out in cardiology with a tendency to open up even minor blockages (with cardiac stents) that were not clinically meaningful.”
Marginal Benefit or Patient Injury?
Here’s where I go a step further. It’s not just that these interventions often have only a marginal benefit – they often have no benefit or even injure patients who don’t really need the intervention.
The stent example is a good case in point. Cardiac stent procedures often offer no advantage over more conservative – and less profitable – medication management. But a study in The New England Journal of Medicine I cite inMedSmart Patients (soon to be released)found that an estimated 5-30% of these invasive procedures can actually CAUSE heart attacks that often go unnoticed at the time.
Our cultural and medical preference for interventions – for “doing something” – sees only upside to doing so. Seldom is the downside, often substantial, acknowledged or respected for the potential harm it may cause.
Doctors were once taught to intervene cautiously and seldom – to “do a lot of nothing”. While this seems counter-intuitive in today’s culture, it’s actually today’s culture that’s often counter-intuitive.
The wisdom of medical caution is to allow the body the time it needs to heal itself to the maximum extent possible – aided by personal behavioral changes that help promote an anti-inflammatory diet and lifestyle.
This is generally most applicable to chronic conditions that have proven largely unresponsive to high-tech medical interventions.
The following 3-minute video discusses one such example – that of back pain, one of the leading causes of physician office visits and unnecessary medical imaging. The spinal fusion surgeries that often ensue may be the biggest medical rip-off in America, with rates varying twenty-fold in the highest use regions of the country compared to the lowest. If you or anyone you care about suffers with chronic back pain, spend a few minutes watching this video.
And even if you don’t, it’s worth watching as an example of how best practices are often ignored in ordinary medical practice. Which is why second medical opinions are now so essential before agreeing to any invasive medical procedure.
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