Healthcare Myopia: Looking for Dr. Welby
to Our Healthcare Reality
Most Americans know our healthcare system is broken. Yet surveys show we continue to regard doctors more highly than virtually any other profession.
In fact, the latest Gallup Poll data show that Americans’ trust their doctors’ honesty and high ethical standards. Their “approval ratings” on this count increased from a low of 47% in 1994 to 70% in late 2012 – behind only pharmacists (75%) and nurses (85%).
Yet healthcare spending – driven largely by doctors – remained essentially flat for the rest of the 90’s. Healthcare spending has almost doubled since the year 2000, however, while doctors’ approval ratings have climbed. And, according to the highly respected Kaiser Family Foundation, employees’ contributions to their health insurance premiums have increased by 2 1/2 times since 2000.
How to explain this apparent disconnect between out-of-control medical spending that’s largely due to medical mismanagement of various kinds and the continuing high public regard in which our doctors are held?
The simplest explanation is that the blame for our broken healthcare system is largely attributed to pharmaceutical and health insurance companies, which bear the brunt of the burden in public opinion polls.
This is a comfortable “escape” for us because exonerating our doctors from culpability, even subconsciously, permits us to feel safe in their care. Who wants to be sick, after all, and have to worry about whether our doctors really have our best interests at heart? It’s just too much to comprehend, especially in such a compromised state.
It’s easier to just blame it on “Big Pharma” and be done with it.
If only it were that simple…
Pervasive Conflicts of Interest
The esteemed Gary Schwitzer did a quick wrap-up at MedPage Today of recent conflict of interest reports in the media. Seeing them all bundled together like this helps us appreciate just how pervasive these are in a healthcare system in which millions of Americans continue to place their trust.
And the conflicts aren’t limited to academic research bankrolled by “Big Pharma” or the other usual suspects. They extend instead to the very practice of medicine itself. Indeed, they’re enabled and even encouraged by a fee-for-service payment scheme that rewards doctors and hospitals for doing more to patients instead of more for them.
This table from Our Healthcare Sucks summarizes the financial conflicts-of-interest between patients and their doctors inherent in America’s fee-for-service payment system – a payment scheme that will remain dominant for many years to come.
What happens when something as fundamental as how your doctors earn their livings promotes such obvious conflicts-of-interest between their patients’ best interests and their families’ incomes? You end up with a debacle of a healthcare system with an embarrassing 51% efficiency rating and medical mistakes that take the lives of hundreds of thousands of Americans annually.
This really shouldn’t come as a surprise. If it does, look at the above table again.
How could it turn out any other way?
Doctors Are Only Human
So the high degree of trust that doctors enjoy in American public opinion is more a matter of wishful thinking than an objective assessment of the facts.
We may enjoy watching TV shows like House and Scrubs that explore the profession’s human shortcomings, but in our hearts and minds, we’re still watching reruns of Marcus Welby, M.D.
This is a dangerous delusion.
Even if you’re lucky enough to have a stellar doctor as your primary care physician – and many of them still exist despite the general deterioration in medical ethics I describe in Our Healthcare Sucks – you’re likely to be referred to many specialists over the course of your life.
And one predictable byproduct of Obamacare is that undersupplied, underpaid and overwhelmed primary care doctors will refer even more aggressively to specialists. Doing so will shorten their office visits and help them keep up with the increased demand for primary care that Obamacare will trigger.
But ask yourself this: In a healthcare system where unnecessary medical interventions that pad the bills of unscrupulous doctors and hospitals are rampant, how likely is it that NONE of the specialists you encounter will engage in such practices?
Remember, many of today’s mainstream medical practices, including “defensive medicine” that over 90% of doctors admit to practicing, rely on deceiving patients into accepting interventions they don’t actually need.
With pervasive fragmented care, barely 50% efficiency, and 50% more medical mistakes than other first-world countries, is it realistic to remain naive about the risks such widespread malfeasance poses to you and your family – both fiscally and physically?
Remove the Rose-Colored Glasses
Like actual myopia that can be induced by certain medications or treatments, our need to see our doctors in often unrealistic terms can be induced by our interactions with them. A reassuring manner and geniality are often mistaken for medical competence and concern, while those with the worst bedside manners may sometimes be best for our medical needs.
It’s best to try to separate the two.
Myopia is managed with corrective lenses that help get your vision back in focus. The corrective lens for your healthcare is evidence. Don’t just take your doctors’ word for treatments or other medical interventions they may recommend. Ask what the statistics are for benefit from the intervention – and get not just the relative benefit, but the absolute benefit.
For example, cholesterol-lowering statin drugs (Lipitor, Crestor, etc.) are touted as cutting the risk of heart attack or stroke in those with no history of heart disease by up to 50%. This represents their relative risk reduction and has helped them become the best selling class of drugs on the planet.
What they don’t tell us, at least as clearly, is the absolute reduction in risk. The truth is only 1 in 100 people taking these drugs to prevent disease will actually benefit.
Cutting the risk from 2 per 100 people to 1 per 100 does indeed reduce relative risk by 50%, but it’s only a 1% reduction in the absolute risk of these events (from 2% to 1%). This means that only 1 person in a 100 receives this benefit (the absolute risk reduction), while 99 out of a 100 receive no benefit. For them it’s just more expense, side-effects, and risk of treatment-induced disease that may include insulin resistance, type 2 diabetes, and obesity.
For more on the hidden financial ties between doctors and pharmaceutical companies and the failure to require broader disclosure of same, see this press release from the Association for Medical Ethics asking the White House to enforce the provision in Obamacare requiring such disclosure. The fact that it hasn’t been enforced three years after Obamacare’s passage speaks to the vehemence of the medical profession’s lobby in Washington, which is second to none.
in the following video, Dr. David Newman of the Mount Sinai School of Medicine (no relation to the Newman of Seinfeld fame) explains how clinical trials often confuse relative and absolute risk reduction, association and causation, and other “scientific” sleights-of-hand that mislead us into accepting over-medication and over-treatment.
Women concerned about their risk of breast cancer from their daily alcoholic intake may want to pay attention, along with those on statin or blood pressure drugs.
CAUTION: Although the randomly-controlled trials (RCTs) Dr. Newman advocates are superior to observational and other less-powered types of studies, they can also be manipulated by choosing select subjects to study, addressing the wrong question, and other tricks pharmaceutical companies use to overstate the benefits (and understate the risks) of their drugs.
For more on the Number-Needed-to-Treat (NNT) for many healthcare interventions that may help you better judge whether the medical intervention you’re being prescribed is worth consenting to – and you have the right to NOT consent to any medical intervention – click here.
In this “age of information”, your doctors probably don’t even know most of these probabilities of benefit, OR of harm. So make sure you pay attention to the Number-Needed-to-Harm (NNH) as well.
Lies of Omission
Like much of the deceit in our healthcare, these are mainly lies of omission. But they’re no less unethical and can cause unnecessary expense and other hardship.
And the more invasive the medical intervention, the more harm it may cause.
The problem is that when we’re not facing a possible diagnosis requiring a medical intervention, our healthcare is distant and fuzzy – like myopia.
It’s “out of sight and out of mind”.
And by the time we’re confronted with medical choices, our near-sighted clarity of vision is clouded by fear (see “America’s Health Scare System“).
To correct this, we need to understand the risks of any treatments we’re considering as clearly as the risks of the suspected medical condition itself.
By learning to respect these treatment risks for the often very real risks of injury they pose, we can correct our too-rosy, too-trusting view of our healthcare interventions.
And that can both save us medical expenses we’re increasingly responsible for personally and lower our risk for treatment-induced injury that’s far more common than most of us appreciate.
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