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Dr. Donald Berwick and “patient-centered” medicine: Letting the woo into the new health care law?

There’s been a bit of buzz in the health blogs over President Obama’s decision last week to use the mechanism of a recess appointment to be the director of the Centers for Medicare and Medicaid Services (CMS). Recess appointments, for those who may not be aware, allow a President to put a nominee in place when Congress is in recess in order to have him in place without the messy process of having him approved by the Senate. True, the Senate still has to approve a recess appointment by the end of its term, or the seat goes vacant again, but it’s an excellent way to avoid having nasty confirmation fights during election years. Of course, both parties do it, and the reaction of pundits, bloggers, and politicians tend to fall strictly along partisan lines. If you support the President, then a recess appointment is a way to get around the obstructionism of the other party. If you don’t support the President, it’s a horrific abuse of Presidential power. And so it goes. Either way, I don’t really care much about the politics of how such officials are appointed so much as who is being appointed.

The man who was appointed last week to head CMS is Donald Berwick, M.D., CEO of the Institute for Healthcare Improvement. His being placed in charge of CMS will likely have profound consequences not just for how the recent health care/insurance reform law is implemented but for how the government applies science-based medicine to the administration of the this massive bill. Most of the criticism of his views that I’ve seen thus far comes from conservatives, who do not like Berwick’s apparent penchant for health care systems like the British NHS. Ironically, it’s views held by Berwick that will likely come into direct conflict with his mandate to hold down costs that are the problem with Dr. Berwick, at least to me. It is in these views where there is much that is admirable. Unfortunately, I also fear that there is much about Berwick’s views that are very friendly to the possibility of allowing the infiltration of woo into the U.S. health care system as well, and these fears begin with what Berwick is most known for, a term he calls “patient empowerment.”

What a grand word! After all, who doesn’t want to be “empowered”? Certainly not me. Perhaps that’s the reason why it’s become the new buzzword in a movement known as “patient-centered” care. Old fart that I am, when I first encountered the term I was a bit puzzled by exactly what “patient empowerment” means. After all, I’ve always thought I have been practicing patient-centered care, ever since my first days in medical school. Apparently these days it means something different, at least if this article from about a year ago in the New York Times is any indication. It’s an interview with Dr. Donald Berwick, who advocates what he himself calls a “radical” patient-centered care, having at the time recently published an article in Health Affairs entitled What ‘Patient-Centered’ Should Mean: Confessions Of An Extremist. It was unclear to me then and it’s unclear to me now whether Berwick was being sarcastic or flippant in his characterization of himself as an “extremist.”

What is “patient-centered care”?

Patient-centered care seems, at least from the wording of the term, like an unequivocal good, like mom and apple pie, but is it? Let’s start with the good. In his Health Affairs article from a year ago, Dr. Berwick attacked some aspects of the health care system that richly deserve attacking, specifically the inflexibility of so much of it:

Three years ago, a close friend began having chest pains. She headed for a cardiac catheterization, and, frightened, she asked me to go with her. As I stood next to her gurney in the pre-procedure room, she said, “I would feel so much better if you were with me in the cath lab.” I agreed immediately to go with her.

The nurse didn’t agree. “Do you want to be there as a friend or as a doctor?” she asked.

“I guess both,” I replied. “I am both.”

“It’s not possible. We have a policy against that,” she said.

The young procedural cardiologist appeared shortly afterward. “I understand you want to have your friend in the procedure room,” she said. “Why?”

“Because I’d feel so much more comfortable, and, later on, he can explain things to me if I have questions,” said my friend.

“I’m sorry,” said the cardiologist, “I am just not comfortable with that. We don’t do that here. It doesn’t work.”

“Have you ever tried it?” I asked.

“No,” she said.

“Then how do you know it doesn’t work?” I asked.

“It’s just not possible,” she answered. “I am sorry if that upsets you.”

Moments later, my friend was wheeled away, shaking in fear and sobbing.

What’s wrong with that picture?

Most doctors and nurses, I fear, would answer that what is wrong with that picture is the unreasonableness of my friend’s demand and mine, our expecting special treatment, our failure to understand standard procedures and wise restrictions, and our unwillingness to defer to the judgment of skilled professionals.

I disagree. I find a lot wrong with that picture, but none of it is related to unreasonable expectations, special pleading, or disrespect of professionals. What is wrong is that the system exerted its power over reason, respect, and even logic in order to serve its own needs, not the patient’s. What is wrong was the exercise of a form of violence and tolerance for untruth, and–worse for a profession dedicated to healing–needless harm.

To the extent that hospital policies are rigid, inflexible, and not necessarily in the patient’s best interest, Dr. Berwick remains on firm ground. In counterpoint, I will admit that I’ve had the occasional request by a family member to be in the operating room when I’m working and personally I don’t in general think it’s a good idea to allow friends and family in the operating room. I do, however, think it would be acceptable for everyone, as is done with pediatrics, to allow a family member or friend into the O.R. until the patient has gone to sleep. Be that as it may, I don’t disagree at all that many hospitals have policies and procedures that are not patient-friendly, much less patient-centered. Indeed, I’ve at times referred to such policies as “patient-hostile” and encountered them when visiting family members in the hospital. Coming from that perspective, I can say unequivocaly that Dr. Berwick was perfectly correct to castigate such policies. He even described three maxims of patient-centered care that are indeed quite admirable:

  1. “The needs of the patient come first.”
  2. “Nothing about me without me.”
  3. “Every patient is the only patient.”

The first maxim is self-explanatory. The second refers to the need to collaborate with the patient, not to make decisions without informing the patient and discussing them with him. The third is more or less a restatement of the first, at least in my book. Dr. Berwick, however, takes it farther:

The experience (to the extent the informed, individual patient desires it) of transparency, individualization, recognition, respect, dignity, and choice in all matters, without exception, related to one’s person, circumstances, and relationships in health care.

While this sounds on the surface quite reasonable, as in many things the devil is in the details, more specifically in the interpretation of what these things mean. There is no doubt that the age of the paternalistic, “doctor knows best” model of health care is gone. For the most part, this is a good thing, although at times I’ve discovered that there are actually quite a few patients who actually want their doctors to tell them what to do. They become uncomfortable, sometimes even angry, when I present options to them, discuss the pros and cons of each option, and in essence leave the choice to them with my advice as to which option I consider the best. Indeed, early in my career, I actually got feedback from my division chief that I was perceived as being too wishy-washy and indecisive by some patients, as though presenting options suggested indecision. Maybe back then I just wasn’t that good at doing it yet, and I got better with time. At least, I hope so. In any case, it’s a fine balance, and, I suspect, patients expect more decisiveness from surgeons, who are going to cut into their bodies, than from internists, who are not. Be that as it may, I fully accept that every doctor-patient relationship should represent a collaborative effort in which patient needs and wants need to be taken into account and, wherever it doesn’t conflict with science- and evidence-based medicine, patients’s wishes should be paramount.

That’s where Dr. Berwick and I part company. He doesn’t think that clear science- and evidence-based guidelines should trump patient desires:

First, leaving choice ultimately up to the patient and family means that evidence-based medicine may sometimes take a back seat. [Emphasis mine.] One e-mail correspondent asked me, “Should patient ‘wants’ override professional judgment about whether an MRI is needed?” My answer is, basically, “Yes.” On the whole, I prefer that we take the risk of overuse along with the burden of giving real meaning to the phrase “a fully informed patient.” I contemplate in this a mature dialogue, in which an informed professional engages in a full conversation about why he or she–the professional–disagrees with a patient’s choice. If, over time, a pattern emerges of scientifically unwise or unsubstantiated choices–like lots and lots of patients’ choosing scientifically needless MRIs–then we should seek to improve our messages, instructions, educational processes, and dialogue to understand and seek to remedy the mismatch.

I’ll give Dr. Berwick credit. He’s an idealist. I’ll test his idealism in a minute.

What “patient-centered” medicine means: Patients as consumers

In order to find out more about what “patient-centered” care means, let’s move on to an interview in the NYT with Dr. Berwick from June 2009:

When you are in a position of having to deny and exclude patients, it is draining on the spirit. I actually think the mode I am counseling would be more satisfying or joyous for caregivers. Not all of the time or always, but it would be a better place to be. You would be putting yourself at more of a level with the patient, as more of a peer. And you wouldn’t have to carry on as if you were mythical. Medicine is imperfect and doctors know that.

I wasn’t sure I liked where Dr. Berwick’s train of thought was going then, and now, a year later, I’m sure I have some serious misgivings about it. First off, these days it’s a bit of a straw man. Physicians, by and large, have come down off their pedestals, at least in part. Even so, I would posit that professional expertise still matters. Dr. Berwick seems to think that it should take a back seat to patient wants, which is reasonable occasionally but most definitely not in many situations. In fact, Dr. Berwick seems to view patients as consumers more than anything else and physicians as service providers whose primary purpose is to satisfy these consumers, just like any other service provider or merchant. Worse, my impression at the time I read his interviews was that Dr. Berwick seems to think that medicine is easy:

Medicine is not nuclear physics. Most adults and kids can basically understand. There can be uncertainty in medicine, but if there’s mystery, something is wrong.

Medicine’s so easy, even kids get it? Is that like “So easy, even a caveman can do it?” I wonder what Dr. Berwick would make of the case of Daniel Hauser, the 13-year-old who, with the indulgence of his parents, refused life saving chemotherapy and radiation for his Hodgkin’s lymphoma. Perhaps I’m not Dr. Berwick’s intellectual equal (being nothing more than just a dumb surgeon and all), but personally I don’t find medicine that easy at all, at least not keeping up with the science and evidence and applying it to individual patients. Heck, and I’m a subspecialist. The breadth of knowledge that I have to keep up with isn’t nearly what it is for an internist like Dr. Lipson, although, granted, I’m supposed to substitute depth for breadth. Maybe my communication skills are simply inferior to those of Dr. Berwick, but I don’t think it’s easy (as Dr. Berwick seems to be implying that it is) to explain complex medical issues in language a patient with no background in medical science can grasp. Indeed, I always wonder if and how I can do better. In essence, Dr. Berwick is advocating that we move away from a professional model of medicine to a more consumerist model. In this view, he is the perfect enabler for pseudoscience in medicine. After all, if evidence-based medicine should “sometimes” take a back seat to patient desires, then there’s no reason to deny patients quackery if they request it, is there? Certainly Dr. Berwick doesn’t provide any guidance on this score that I’ve been able to find. How far outside of evidence-based medicine does a patient desire have to be before a physician can properly refuse to acquiesce to it? It would seem there are no limits.

Then there’s the word “sometimes.” I wonder what Dr. Berwick means by that word. He seems to argue that, if patients make choices that conflict with science-based medicine, then over time we physicians should be able to persuade them why such choices are not in their best interest. If not, he is saying, then it is our fault for not getting the message through well enough. While there’s some merit to the contention that it is our responsibility as physicians to present science-based medicine in a way that patients can understand and explain to them why certain choices are not justified by the evidence and that we all too often fail in that task, what should we do when patients have heard the message, tell us that they understand, but reject the message? For example, take the example of the patient asking for an MRI that isn’t indicated. What would Dr. Berwick do if he had explained to the patient that the MRI wasn’t indicated, laid out the evidence for that position, and the patient said he completely understood but wanted the MRI anyway? There’s nothing in Dr. Berwick’s writings or statements that indicate to me any guidelines whatsoever that allow a physician practicing his brand of “patient-centered” care to decide when it is acceptable to refuse a patient’s request for non-science-based medical interventions. The best he can come up with is this:

I can imagine just as easily as my critics can a crazy patient request–one so clearly unreasonable that it is time to say, “No.” A purely foolish, crazy, or venal patient “want” should be declined. But my wife, a lawyer, told me long ago the aphorism in her field: “Hard cases make bad law.” So it is in medicine: “Exceptional cases make bad rules.” You do not successfully rebut my plea for extreme patient-centeredness by telling me that, on rare occasions, we ought to say, “No.” I say, “Your ‘rare occasions’ make for very bad rules for the usual occasions.”

See what I mean? Dr. Berwick dismisses exceedingly unreasonable requests as “rare.” They’re not. I’ll give him an example of one such unreasonable, non-science-based request that is not at all rare and wonder how he would respond to it. Regular readers of this blog can probably guess where I’m going with this. Of course, before I get there, I could always ask what Dr. Berwick would do if a patient wanted him to zap his liver flukes “zapped” à la Hulda Clark to cure his cancer, but I hope that he would consider such a request to be a request “so clearly unreasonable that it is time to say, ‘No.’” One hopes that Dr. Berwick’s vision of patient empowerment would have at least that as a limit. I’m not so sure, though, because Dr. Berwick has given no examples for a patient-centered physician to use as guidance for when it would be acceptable to say “no,” presumably because he considers such examples to be so rare. Unfortunately, there is another request that thousands of pediatricians all over the nation face each and every day that is not evidence-based and, even worse, endangers public health.

That’s right. I’m talking about the antivaccine movement, which has placed so much misinformation in the public sphere that thousands upon thousands of parents have been sufficiently frightened that vaccines will make their children autistic, thanks to propaganda efforts by useful idiots like Jenny McCarthy, that they refuse vaccines for their children. Let’s say that a Berwick-like physician has used every tool in his patient-centered armamentarium of “education” and “information exchange” to try to persuade these parents that vaccination is safe and effective. Let’s say they still refuse. What would Dr. Berwick do then? He is, after all, a pediatrician, and this is a common problem that pediatricians face. Come to think of it, the fact that Berwick seems blissfully unaware of this particular threat to public health does not leave me with the impression that he’s actually hooked into what’s going on “in the trenches,” so to speak.

The problem to which Berwick seems oblivious is that this is an example of a non-science-based patient request that is not at all rare and that is incredibly resistant to the “information exchange” that he touts above all. It is also a request that doesn’t just affect that patient; it endangers public health. What would Dr. Berwick do about that? It doesn’t even have to be the anti-vaccine movement. Patients ask for or even demand non-science-based care all the time. Antibiotics for viral infections is an excellent example, and thanks to physicians’ overuse of antibiotics, among other factors, bacteria are becoming more and more resistant to once powerful antibiotics. These are issues that don’t just affect individual patients who demand care not based on science; declining vaccination rates and bacterial resistance to antibiotics potentially endanger everyone.

I believe in the collaboration between me and my patients in order to solve their problems if we can. However, contrary to Dr. Berwick’s belief, most patients are not my “peers,” at least not in the professional sense. They may be my peers in the human sense, but working together to try to treat their medical problem is not the same thing as their being my professional peers. I view the collaborative nature of the doctor-patient as a consultation. The patient is coming to me for my expert opinion, and I try to deliver, at the same time trying to educate the patient about her disease process and why science-based medicine recommends what it does. I try as much as possible to take into account what the patient wants and provide science-based options acceptable to the patient. For example, a while back I very strongly advised against a bilateral mastectomy on a patient who had been diagnosed with a very tiny pre-invasive breast cancer (ductal carcinoma in situ), had no family history of breast cancer, no risk factors, and a bilateral MRI that showed no suspicious lesions in the opposite breast. I spent an hour explaining my recommendation for a lumpectomy and radiation therapy and why bilateral mastectomies were not indicated. Even though I likened it to killing a mouse with a Howitzer, because it is within the range of evidence-based practice I expressed a willingness to do a simple mastectomy of the side with the DCIS with immediate reconstruction by a plastic surgeon if that was what the patient really wanted, while again explaining why removing the other breast without evidence that it has cancer would not prolong her life or even lessen her chance of dying of breast cancer. In the end, she seemed to understand, but she clearly did not accept. She never came back.

Of course, regardless of where I’ve practiced, there have always been other surgeons in the area who are more than happy to do bilateral mastectomies on almost woman with cancer or DCIS who wants the procedure, regardless of how tenuous or nonexistent the evidence supporting such an option is in a specific patient’s case. It is easier just to say yes, as Dr. Berwick suggests. In fact, it’s more profitable, too; a surgeon can bill a lot more for a bilateral mastectomy than for a lumpectomy. In academia, I’m fortunate in that my salary doesn’t depend on the number of operations I perform; the same is not true in private practice. Indeed, Dr. Berwick’s “patient is always right” sort of misreading of patient-centered medicine could easily lead to the vast overutilization of resources beyond what we see now. How Berwick will be able to implement such a view and at the same time keep costs down, as is a major stated purpose of the new health care reform law, I have no idea. Worse, patient=centered care, at least as I interpret it from Dr. Berwick, can cause a major conflict of interest in that physicians and hospitals often make more money by delivering more care. There’s already a huge incentive in the medical system to give the patient what he wants, if what he wants is more tests, more procedures, more medicine. Dr. Berwick’s vision, if realized as he envisions it, would vastly exacerbate that conflict of interest.

I also can’t help but wonder about liability concerns. If a doctor orders an unnecessary test or provides an unnecessary treatment that causes harm, he’s still on the hook for malpractice. Indeed, he should be even more on the hook for malpractice for the very reason that the test or medical intervention was not medically indicated and not evidence-based! Lawyers would have a field day: “Why did you order that test that caused my client harm? Because my client asked for it? Do you believe the test was indicated based on scientific evidence and the standard of care? No? Then why did you order it anyway? Who has the MD? You or my client? My client depended on you for your best evidence-based medical advice, and you failed him.”

And the lawyer starts counting his share of the judgment.

In the end, I cannot agree with Dr. Berwick that science-based medicine should “take a back seat” to patient “empowerment.” Indeed, upon reading Dr. Berwick’s ideas, I wondered if he actually practices medicine. It turns out that he has not, as Dr. Douglas Farrago found out at the time:

He ends his interview by stating that “we have to fix the health care system so that it gives doctors the time to do the job they want to do”. Funny, nothing he recommends saves time or saves money or makes the job any easier. This begs the question: does Dr. Berwick actually see patients anymore and how many? I called his office and it turns out that he does not. If fact, the person answering the phone states he hasn’t “in years”. Maybe it is time for him to get his hands dirty again?

Or not. Berwick strikes me as a very well-meaning person with some good ideas about how to make our health care system less rigid and more responsive to patients’ needs, both medical and nonmedical. Unfortunately, he also appears to be naive to the point of my wondering whether he has any clue what it’s like to practice medicine in the real world or even in the idealized world of academics.

Berwickian “patient-centered care”: An enabler of woo?

Berwick’s “patient-centered care,” as we have seen, is an idea that has the potential to improve our health care system if implemented properly. Unfortunately, Berwick’s vision of it would in essence give the patient what he or she wants all the time. Not only would it be very expensive, but it provides no rationale for leaving out woo. In fact, in February 2009, Dr. Berwick participated in the Institute of Medicine’s Summit on Integrative Medicine, where Dr. Berwick was featured with luminaries of the movement trying to infiltrate unscientific medicine into the then embryonic health reform bill such as Dr. Dean Ornish, Dr. David “a more fluid concept of evidence” Katz, Dr. Mehmet Oz, and Senator Tom Harkin, creator of NCCAM. All they lacked was Rustum Roy and Deepak Chopra. Some of the slides in Dr. Berwick’s presentation are not reassuring. For instance:

Integrative Medicine is health care that offers you the best shot at getting what you really, really want.

Dr. R.W., the physician who coined the term “quackademic medicine” described Berwick’s contribution to the conference thusly:

Even without regard to what he had to say it’s significant enough that Donald Berwick, M.D., CEO of the prestigious and (up to now!) very mainstream Institute for Healthcare Improvement, lent his good name to this woo fest. But what he had to say was rich. After introductory remarks about how happy and honored he was to be there he mentioned homeopathy and acupuncture, not to criticize them as health claims, but only to warn that they shouldn’t compete with each other, or with other modalities, for limited health care resources. In other words, let’s stop fighting and work together. (Groan). He praised the IOM for its contributions to the design of health care, starting (now get this) with “traditional, allopathic and curative care and now migrating into this distinguished and important new arena.”

But here’s the bomb. Berwick, who seems to believe that healthcare should be like any consumer industry, said that quality is defined by patients’ perceptions. This is his idea of patient centered care which he defines as the patient having all the control. The IHI’s metric for quality, he said, is (watch this, now, emphasis mine) “…give me exactly the help I need and want exactly when I need and want it.”

Think about that for a moment. The woosters and quackademicians of the world point to surveys like these which show that patients, in large numbers, really seem to want woo. They support their unscientific promotions by saying that because so many patients seek it out it must be valid. Adherents of science based medicine often point out the silliness of such thinking. Now, though, this argumentum ad populum is given new life and legitimacy because the Institute of Medicine and the Institute for Health Care Improvement endorse it!

Unfortunately Dr. Berwick’s philosophy is custom-made to be an enabler of the very woo that we so frequently rail against on this blog. After all, if patient empowerment and “patient-centeredness” trump science- and evidence-based medicine (except in “rare” circumstances that Dr. Berwick declines to define), then there really is no reason not to give the people what they want when they want it, how they want it, all the time, so to speak. In fact, Berwick even has a slide that says:

They give me exactly the help I need and want exactly when and how I need and want it.

Berwick’s philosophy could so easily be turned to say: Patients want woo? Give it to them! They don’t want to vaccinate? No problem. Just keep trying to “educate” them. And if you want to try to use education and “information exchange” to persuade a patient who is unpersuadable, good luck with that. Unfortunately (and I do mean that; it is truly unfortunate), insurance companies don’t exactly bend over backwards to pay for lots of time spent educating patients. I wish they did, but they don’t. Truly, Dr. Berwick is, as I said, an idealist, and it is true that the current medical system is, all too often, not patient centered in any meaningful sense of the term. Sadly, his idealism is not grounded in the real world and, worse, it does not place science- and evidence-based medicine on even close to the same level as it does to turning patients into “consumers” and physicians into people who cater to those consumers no matter what.

No matter John Weeks at The Integrator Blog is so happy.

Posted in: Politics and Regulation, Public Health, Science and the Media

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61 thoughts on “Dr. Donald Berwick and “patient-centered” medicine: Letting the woo into the new health care law?

  1. Kylara says:

    Off the main point, but this: —”In counterpoint, I will admit that I’ve had the occasional request by a family member to be in the operating room when I’m working and personally I don’t in general think it’s a good idea to allow friends and family in the operating room. I do, however, think it would be acceptable for everyone, as is done with pediatrics, to allow a family member or friend into the O.R. until the patient has gone to sleep.”— would be an interesting topic for a post on its own. It’s been very curious to see how these policies operate and how strange some of the rules are. My husband was incensed when they told him if I had a planned C-section he could be there, but if it was an emergency C-section he was barred. (This distinction made sense to me, but not him.) But, more weirdly (to me), observers were NOT allowed to watch circumcisions at the hospital, unless it was done as a bris, in which case you could literally have a party in the nursery during the procedure.

    I honestly feel like my vet is considerably more upfront with me about when I can and can’t and should and shouldn’t observe procedures. They’ll flat-out say, “It’s too upsetting for owners to watch.” I KNOW that’s why observers are barred from many hospital procedures, and it’s a perfectly good reason — medical care can be gross and even “violent” — but nobody ever says that. They just say, “It’s hospital policy” or “Our insurer won’t allow it.” That’s frustrating as an answer.

  2. Scott says:

    “Should patient ‘wants’ override professional judgment about whether an MRI is needed?” My answer is, basically, “Yes.”

    As I see it, there are two somewhat-linked questions here which really ought to be clearly disambiguated.

    Question #1: Should the MRI be allowed to take place? In this question, it seems to me that the physician’s professional judgement as to the risks of the procedure should be the primary reason to say “no.” If the procedure is sufficiently low-risk, and the patient wants it after being informed of those risks, then it seems reasonable to do it. (And the scope for such procedures to result in malpractice claims should be strictly limited by statute.) BUT, if the physician judges that the risks are too great, then they should certainly refuse.

    Essentially, I’m here arguing that “the patient wants it” should be factored into the risk/benefit analysis as a (modest) benefit.

    Question #2: Should insurance pay for the MRI, or should it be out-of-pocket? I’d answer this one with a pretty simple “no.” If the patient wants it, maybe they can get it so long as the procedure is simply innocuous – but if they’re asking for it just because they want it, as opposed to there being a real medical benefit, THEY should the one paying for it.

  3. Calli Arcale says:

    Frankly, I think Berwick’s friendliness towards woo is the least of our worries. It’s his friendliness to overtreatment that’s the real problem, and woo is part of overtreatment.

    Most people who use “woo” do so not independently but as an adjuct to science-based medicine. Chemotherapy plus homeopathy. Physical therapy plus acupuncture. They are using it “just in case” or to make things just that little tiny bit better.

    I’ve got water intrusion in my basement, and have been spending the last few days educating myself on how groundwater seeps through the floor/wall joint. It’s interesting how the same problems which apply in medicine apply also in that sort of situation — especially since although the construction industry is regulated, it is largely the sort of consumer-based industry that Dr Berwick wants for medicine. It is thus very much a caveat emptor industry, and you can definitely be defrauded, hoaxed, spoofed, and otherwise screwed over if you are not careful.

    One thing that is commonplace is less effective cheap solutions, which people use not realizing they’ve picked something not backed by a lot of evidence, and then have to replace when it fails to solve their problem or causes worse problems in a few years. Another thing that is commonplace is going overboard in the wrong place — overtreatment, basically, adding useless additional fixes to the main, effective one. The result is very expensive for a lot of people.

    When we’re talking the construction industry, the worst case scenario is usually financial headaches down the road or a loss of property values. (Usually. Sometimes structural or electrical problems can kill.) When we’re talking medicine, the costs are more immediate.

    If doctors give patients whatever the patients want, we will see even more antibiotic resistant bacteria. Or, what if a patient has had good experiences with sulfa drugs (“I never got a yeast infection while I was on sulfa!”, which may be coincidence only) but has been found to have an infection which is resistant to sulfa? Does a doctor indulge the patient’s insistence, even though the patient’s request is clearly harmful? And not all that unusual, I’ll wager. Requests for inappropriate treatment are not rare, or we wouldn’t have the antibiotic resistance problems that we have. Indeed, I think this problem is more pernicious than antivaccination, because I think it is more widespread.

  4. moderation says:

    Bravo!

    Dr. Berwick’s point of view is an example of the laziest form of the practice of medicine there is … give the patient what ever makes them happy. A “McDonald’s Drive Thru” version of the practice of medicine – “I’ll have the medical happy meal – a chest x-ray and antibiotics for my 2 days of cold symptoms and a CT for my headache … does that come with a Vicodin bonus prize?”. In effect allowing patient self diagnosis and treatment. Why would you even need a physician?

    Patient communication is perhaps the hardest part of being a physician and even for those to whom it comes to rather naturally, it is still a skill that requires years to refine. I want a partnership with my patients, not to be their waiter. Additionally, it is even more important as a pediatrician to be an advocate for your patient, as you are dealing with a individual who cannot make informed decisions for themselves.

    For as much talk as there has been about “bending” the curve of healthcare cost down … Dr. Berwick’s attitudes about unrestrained patient choice and possible inculsion of ineffective alternative / integrative / complementary medicine would appear to run completely counter.

  5. cervantes says:

    I don’t think the anti-vax example is very compelling. The actual answer is, there really isn’t anything the physician can do but give information and try to convince the people. You can’t vaccinate people against their will. Competent adults can refuse any and all medical advice for any reason or for no reason at all; and people have considerable latitude regarding their children, albeit state laws place varying degrees of compulsion on them in extreme circumstances. Medical doctors just have to accept this. People are autonomous and they are allowed to make bad decisions.

  6. Calli Arcale says:

    I think another reason why the anti-vax example is weak is because the anti-vaxxer really isn’t asking the doctor to do anything at all. They’re refusing the doctor’s advice is all. No doctor can (or should) compel a person to accept treatment, no matter how sensible the treatment is. There are gray areas when it comes to patients who are insensible, emergency care, and children, but we’re for the most part talking about patients who are able to make decisions for themselves.

    That’s why I think the antibiotic overuse argument is more compelling. It’s an everyday thing that already happens far more often than it should, leading to needless complications in the individual and to serious complications for society at large. Other drugs could be listed as well. The alt-med types blame doctors for giving patients pills instead of recommending diet and exercise changes, but how many of these doctors are pushing the pills precisely because it’s what their patients actually want? The majority, I suspect.

    Berwick acts as if nobody ever asks for pointless therapies with real adverse effects — just seemingly benign stuff like MRIs. But for every patient who asks for a pointless MRI, how many are asking for antibiotics for a cold, or requesting the removal of a benign mole, or demanding a joint replacement? Yes, that does happen. I know someone who had a knee replaced despite being an exceptionally poor surgical candidate with a generally hostile attitude towards physical therapy who had done poorly with her last knee replacement. She essentially shopped until she found an orthopedist who was willing to do it. And indeed, it went very badly, actually scaring the pants off the orthopedic surgeon.

    We’re going to see more of that, now that the makers of artificial joints are allowed to advertise on television, directly to the public.

  7. Agree with cervantes and Calli, vaccination is not the best example, due to the fact that Doctors can not/do not vaccinate against the will of the patient (or patient guardian).

    I like Calli’s example of antibiotics, something that the doctor might consider withholding that is over-requested. Another example would be pain medication. If the patient thinks that a monthly supply Vicodin is really the best thing for their mild bursitis and the doctor thinks the patient is drug seeking, is it really patient-centered to give them the Vicodin? I don’t think so.

    But, I agree with you, Dr. Gorski, I don’t think these cases are rare.

  8. JMG says:

    I think capitalism is the perfect solution to overtreatment and University of Google patients. The patient can have everything they want, as long as they pay for it. MRI – sure, that’s $2000, not counting to your deductible. Visitor in the operating theater, $200 scrubs charge for the changing room, the person to explain the procedures, and the cleaning of the clothes afterward. In the most brutal case – refusal to do the biopsy on the golf ball in your breast, $500000 for the treatment once it reaches stage IV.
    I’m sure people will find “woo accepted, self determination desired” insurance; just don’t drive the premiums up for everybody else because you knew better.

  9. It’s lovely to consider being an empowered healthcare consumer. Setting aside the restrictions of insurance companies and so on who limit choices, there are many underserved populations where even one local internist is hard to come by. Here in Geographic Isolation there were no internists until about six years ago. Any specialty beyond basic ER and small-town-hospital care requires travel time of at least one hour.

    Similarly, doctors should be empowered to protect their vulnerable patients from unvaccinated kids.

    When my son was two, he required IV hydration. The nurses sternly tried to exclude us from the treatment room, but we insisted. We stayed out of the way and kept his attention focused on us by telling stories and chatting with him. Rather than thrashing around screaming, he was shaking but relatively calm. Of course it was hard to place the line in a dehydrated kid, but easier than in a thrashing dehydrated kid.

    This distraction technique also worked really well in the ER when he needed stitches. Maybe some adults need a way to divert their attention from their fear of a procedure. Could a nurse or some other health care professional, who could be trusted not to freak out, step into that role?

  10. I’ve never really liked the patient as (educated) consumer concept. I want the doctor to give me my options AND his professional recommendation of what to do. I’m paying for my doctor’s expertise. I don’t want to play doctor for myself, no matter how much info I am provided.

    When I talk to a contractor, I want to know my options for repairing my roof, but I also want her recommendation. Heck, if what I want to do for my roof repair is a bad idea, I want my contractor to tell me so and explain why, and I want her to decline the job if she can’t ethically do what insist she do.

    (From my Twiter: #TAM8 Did anybody notice Dawkin’s intentional use of female pronouns for generic, gender neutral references? Too bad English lacks such.)

  11. Nescio says:

    I was just watching the news here in the UK about the reforms that are planned for the NHS. The health minister was quoted as proposing patient centred care and was quoted as saying, “Nothing about me without me.” I had just read the exact same phrase on this blog, so it startled me a little. It seems health reformers in the USA and in the UK are reading from the same hymn sheet. That worries me a bit. Perhaps I should feel reassured, but I don’t.

  12. Dr Benway says:

    Customer service isn’t going to give us the human relationship between patient and provider that everyone wants.

    When the treatment team is burdened with duties of marginal real benefit to the patient, its focus is diluted and its emotional connection to the patient weakens. Direct care is shunted to less expensive, less trained staff so the more highly trained staff can get their paperwork done.

  13. desta says:

    Nicely written. Long, but you use the length to bring out what’s disturbing in some seemingly innocuous statements.

    And really? Medicine is easy such that a kid can understand it?

    1. Then what do we need medical care for? Let’s all just have a coop with our own chemo/radiation equipment in case as lay people we have to diagnose ourselves.

    2. Speaking of radiation, some of medicine does overlap with nuclear physics. Why, there’s even a field of study called medical physics. I’m sure that’s real easy to understand. Considering the average college student I teach has had such stellar high school preparation that they struggle with basic arithmetic and algebra, yeah.

    See, now Dr. Gorski was being all subtle and well reasoned, and here I go getting snarky.

    Thanks for the nice article, as always.

  14. bennett4490 says:

    Initially I was going to get all pissy about this article – as I teach patient-centered care as THE way to practise medidine…but when I actually read all of it, I realised that what this guy Berwick was talking about was patient LED care, which is something else entirely.

    In my mind, patient led care is doing whatever the patient wants. Some ethics courses teach this as an acceptible approach to practising medicine – frankly I think it is lazy, undermines the medical profession and leads to worse care of the patient.

    Patient-centered care is practicing medicine taking into account (and addressing) the patient’s fears, expectations and understanding. If patients are scared, reassure them – if they are confused, explain things – if they have unreasonable expectations, give them the facts and most likely outcomes. Half the battle is just taking the time to discover these things.

    This guy has hijacked the phrase and it’s going to confuse the hell out of a lot of people. The UK has led the way in training and assessing their doctors in patient-centered care, and I can tell you that the curriculum they use is NOT patient-led care by any means.

    Of course we’re not going to win every time, but simply bowing down to misguided or misinformed lay people isn’t the best way to provide their care…I would rather guide and inform them properly, and have them make a truly informed decision WITH me.

    There is good evidence that patient-centered care truly does lead to happier patients, but also things like better health outcomes, fewer unnecessary tests and referrals, fewer followups and less healthcare costs. I have yet to see that evidence for patient-led care…I doubt it exists.

    Bennett

  15. tcw says:

    Good to know about this guy, I only saw headlines about him. Patient autonomy is not the absolute ultimate, doesn’t supercede the conscience of the physician (“No, I will not prescribe more percocets”), and stands in relation to the ethics tetrad of physician-patient relationships. Berwick needs a primer on those. Although an overused term, professionalism is defined by having knowledge that most everyone doesn’t have, and hence one can regard or disregard the advice, but cannot force the professional to do what one wishes.
    I would quibble that I think medicine is “easy”, but it is the AMOUNT of knowledge that makes it hard (disregarding surgical fields for the sake of argument). P-chem and advanced math was more difficult in college and I didn’t have a clue about some subjects even thought I studied as best I could, but that was without multiple choice tests/boards. Med school superficially touches on a million subjects. For example, if a doctor just had to know about hypertension day in/day out, then an eighth grader could do it. The amount of knowledge to drive a car is similar to the amount to take care of some diseases, but repetition makes it “easy”, until the semitruck is coming at you in your lane.

    “Nothing about me without me.” Fine. But in socialized medicine you will stand in line with the rest of the poor lads saying the same thing, waiting to see the specialist.

  16. Samantha says:

    Being a complete layperson with regards to medical matters, the idea of “Patient-Centered” medicine sounds all sorts of great to me – until I start to think about the clinic I go to. They started out very reputable, with some great staff, and I loved my PCP. Unfortunately, they weren’t turning enough of a buck, and have turned into an “everything for everyone” sort of place. Counseling? Yup. Physical Therapy? Yup. Acupuncture? Naturopathy? Homeopathy? Chiropractic? All of the above. Plus the vanity of Medi-Spa stuff (microdermabrasion, laser hair removal, etc.) and they’ve recently become a member of the “Centers for Medical Weight Loss” network. In their quest for the ultimate in patient-centered medicine, they’ve sacrificed quality care for quantity. The last thing I want to see is ALL clinics ending up like this in the quest for “patient-centered” care.

  17. moderation says:

    I am a little less dismissive of the antivax component of the post. Let’s pull right from the headlines: The California Whooping Cough Outbreak (http://abcnews.go.com/Health/ColdandFlu/whooping-cough-epidemic-california-lax-vaccination-blame/story?id=11000305). Until he states otherwise Dr. Berwick’s point of view would seem to dictate that patient preference always be preiminent. How far would that go? If the outbreak were bad enough, could the gov’t require vaccination to attend public schools or large public events? Could they mandate vaccination to hold certain jobs … say in healthcare.

    Certainly the “antibiotic on demand” argument is more directly applicable but the idea that there be complete deferral to patient preference cheapens all forms of expertise – be it a doctor, a physicist, a musician or a contractor. It is a slippery slope that Dr. Berwick steps onto when claiming that expertise is a form of democracy and we are all equals regardless of training.

    I am not sure how comfortable I will be with Dr. Berwick in control of distribution of limited medical resources … with his appearent desire to accomodate a patient’s every wish, up to and perhaps including a significant amount of woo. I think this is why there needs to be an open approval process where questions such as these can be asked, regardless of which party is doing the recess appointment.

  18. Mark P says:

    Where does Berwick sit on the huge issue of patient woo and self-centredness which is diet?

    If a patient is anemic due to an inappropriate diet, will he recommend expensive medical treatment, or get the person to change diet?

    Do obese people get to continue expensive treatment when they refuse to attempt any alteration in their behaviour?

  19. wales says:

    Interesting piece. Various comments have been made about why the anti-vax example is not compelling. IMO, its primary weakness is that vaccination is a “preventive” medical intervention. By virtue of that fact alone, it is not analogous to the other interventions discussed here by DG (MRI, breast cancer options), which are not preventive but are diagnostic or treatments addressing an existing condition.

    Patients should have the right to make autonomous decisions about diagnosing or treating existing conditions, and should have at least at much autonomy in making decisions about “preventive” medical interventions.

    As for whether or not Berwick still sees patients and whether or not that hearsay information (from Farrago, a doc pedaling [no pun intended] a device called the “kneesaver”, testimonials and all, but no scientific proof of efficacy…..) has any bearing on the validity or relevance of Berwick’s opinions, one should also then question the validity or relevance of other expert opinions, such as those of Paul Offit, another pediatrician who no longer maintains a clinical practice.

    If you read Berwick carefully you’ll see he isn’t supportive of a forced and bewildering patient autonomy, rather he advocates for patient choice: “In the end, if you are being cared for by a doctor or nurse who doesn’t give you what you feel is choice or control, find someone else. But only if you want that. Some patients don’t want that and it’s a perfectly good choice, too.”

  20. Calli Arcale says:

    If you read Berwick carefully you’ll see he isn’t supportive of a forced and bewildering patient autonomy, rather he advocates for patient choice

    True, but is patient choice always best? One of the examples Berwick raised was MRIs, suggesting that in the interests of patient choice, if the patient really wants that extra testing, the doctor should humor them. But why? MRIs are expensive, and that money has to come from somewhere. They can also find results that may alarm the patient but not need immediate treatment — results of an MRI are not as simple as Hollywood would have us believe. (That is to say, the doctor can’t look at it and go, “yep, you have a malignant brain tumor.” They are one piece of data only, and not an unambiguous one.)

    If he’s willing to humor a patient’s request for a pointless MRI, will he be willing to humor a patient’s request for more invasive and riskier tests? Do we need to be running bloodwork on everybody? Does a healthy 35-year-old need to get a colonoscopy just to rule out possibilities? Tests can have risks in and of themselves, and one of the biggies is that they are expensive. And that money has to come from somewhere. The trend to more and more tests is contributing to our healthcare crisis, by increasing the cost of healthcare for very little actual gain.

    So while I think you’re right, wales, that he wouldn’t really endorse the patient essentially cutting out the middleman and making all their own medical decisions with the aid of Google, he is advocating a slippery slope. And patients requesting things contrary to their interests is not the rare occurrence he claims it is.

  21. wales says:

    Just noticed an error on my part. The “kneesaver” being peddled by Farrago is a kneepad used in baseball. The “kneesaver” I found on Google was a bicycle pedal extension (hence my lame attempt at humor).

    Yes Calli, testing has its risked, as has been talked about so much lately with the over-screening, over-diagnosis and over-treatment epidemic. That was a slippery slope as well, incorporating excessive screening recommendations as “standards of care” while putting many patients at risk. Risks abound, but I am always for autonomy. I guess as a super conservative consumer of medical services and products, I would never find myself at risk of overconsumption and cannot relate to that mentality. I suspect there will always be some physicians willing to cater to those patients who wish to overconsume their services and products.

  22. Calli Arcale says:

    Addendum: I think that the *spirit* of what he was saying is correct, which is of course why it normally seems so inoffensive; I liked what bennett4490 said about patient-centered versus patient-led care. It’s always about the patient, always has been, and doctors/nurses/etc should always remain mindful of that. But at the same time, while the patient is not subordinate to the physician, neither should the physician be subordinate to the patient.

  23. Draal says:

    I’m all for the patient getting whatever they want. It’ll save drug seakers time and money by not having to shop around for a doctor to get scripts. Medicinal marijuana for everyone!

  24. JMB says:

    Thank you Dr Gorski for this article.

    Since Dr Bertwick is such a fan of the British NHS, then it is apparent that we can save money in healthcare by rationing the way the NHS does. That means we cut back on healthcare administered in the last two years of life (among other cuts). Unfortunately, that means our life expectancy at age 75 will drop from 10.7 years to 10.2 years. So we will give up grammy living 6 more months, but then we can have all the homeopathy and acupuncture we want.

    http://mjperry.blogspot.com/2009/08/life-expectancy-higher-in-us-than-uk-at.html

    http://www.cdc.gov/nchs/data/nvsr/nvsr58/nvsr58_21.pdf
    (table 1)

    http://www.statistics.gov.uk/downloads/theme_compendia/AA2008/AA2008.pdf
    (table 5.22 – in these tables, there is a 1.4 year difference)

    When someone stops practicing medicine and pursues only academic publications and speeches, it is easy to gravitate to what sounds good, as opposed to what really works in practice. It becomes too easy to pick out statistics and corollaries of the data to have an impact, than to paint an accurate but complicated picture of the facts behind the statistics (and put the audience to sleep). Our life expectancy at birth isn’t the best. Our life expectancy at age 65 is right there with the best.

    Mixing British rationing with our political system will have some ugly consequences. One of the more obvious paradoxes of mixing our systems is that the NHS is moving to eliminate funding for homeopathy, while our healthcare reform is legitimizing it. Only politicians making deals for votes will embrace such paradoxes. Can rational rationing pay for woo?

  25. JMB says:

    I wonder how Dr Berwick handles Munchausen patients. Of course, since he is a pediatrician, it would probably be Munchausen by proxy patients.

  26. JMB says:

    I guess Dr Berwick will have us modify our Hippocratic oath, from “Above all else, do no harm.” to “Above all else, do what the patient wants.”

    Don’t think that there is no harm from an MRI. Patients have been injured from metal objects getting sucked into the magnetic fields. A few have died from the superconducting magnet quenching. Patients with tattoos often suffer skin burns. Pacemakers and pain pumps often fail after an exam.

  27. BillyJoe says:

    JMG,

    “I think capitalism is the perfect solution to overtreatment and University of Google patients. The patient can have everything they want, as long as they pay for it.”

    But what about limited resources?

    All medical resources are limited and if they are used up uselessly by those who can pay, what happens to those who actually need them and can’t pay.

    Australia has a much fairer system where, in general, those who need medical investigations and care are the ones who get it.
    If that’s socialism, so be it.

  28. Scott says:

    But what about limited resources?
    All medical resources are limited and if they are used up uselessly by those who can pay, what happens to those who actually need them and can’t pay.

    Money is ultimately the limiting resource. Requiring patients to pay for the overtreatment they want (a) will use less of ALL resources, since many won’t pay but would have happily exploited their insurance; and (b) will result in MORE resources for everyone else because the profits from their unnecessary procedures can be used to fund everyone else.

  29. Draal says:

    “Patients with tattoos often suffer skin burns.”

    See Myth Busters as they debunked this myth.

  30. Calli Arcale says:

    wales:

    I guess as a super conservative consumer of medical services and products, I would never find myself at risk of overconsumption and cannot relate to that mentality.

    I know what you mean, because I tend to be conservative in that regard as well. I’ve got some chronic health issues that need ongoing treatment, and that just makes me even more unwilling to jump and get treatment for other stuff. I feel like I’ve seen the doctor more than enough.

    I have trouble relating to the overconsumers, except in the sense that I’m actually *related* to overconsumers: my maternal grandparents. The knee surgery I mentioned earlier wasn’t the only example. Oddly, they’re not good about going in when there are signs of a serious condition, but once they do go in, they want EVERYTHING done, and they want the BEST care that money can buy. This is not out of character for them, because it’s how they view life in general. Grandma insists on Coach purses, not cheap knock-offs from Target, because if it’s more expensive, it’s better, and she deserves the best. I think that’s the mindset behind most of the overconsumers; they’re not hypochondriacs, they just feel that they deserve the best, especially when it comes to health care, because if you don’t have your health, you don’t have anything. You can justify pretty much anything once you start using that logic.

    It’s actually kind of scary to watch, truthfully, because I see them galloping towards their own perdition sometimes. There’s definitely an element of unrealistic expectations to it, and these are very intelligent, well-educated people. They just only hear what they want to.

  31. Kylara says:

    “Maybe some adults need a way to divert their attention from their fear of a procedure. Could a nurse or some other health care professional, who could be trusted not to freak out, step into that role?”

    Yes. I have to undergo a fairly routine and slightly uncomfortable procedure now and then, but the first time I had it done the doctor wasn’t very good at it AND had a terrible bedside manner AND I was young, and the upshot was it was painful and terrifying the first time, so it still triggers panic and upset. My doctor is aware of my past history (it’s noted in my chart) and usually my husband comes with me to hold my hand and talk to me to keep me distracted, but when my husband isn’t available, the doctor will call in a nurse to hold my hand and hand me kleenex and keep me distracted. The nurses are so good at the hand-holding and comforting I assume they do it a lot.

    Regarding overtreatment, another problem that I don’t think was mentioned is that patients subjected to overtreatment, even if they asked for it, may later resist necessary treatment. My husband was given an unnecessary MRI from an abundance of caution on the doctor’s part, which he did agree to, but which was VERY expensive (we weren’t up to our deductible yet) and which we later discovered wasn’t really indicated but hunting for a very unlikely needle in a haystack rather than starting by determining we had a haystack on our hands. (Um … yeah, this metaphor’s getting worse, not better.) Anyway, he’s now deeply suspicious of ALL medical imaging and routinely refuses to get it done because he’s decided it’s all too expensive and that doctors order it to CYA, not because it’s necessary. He recently broke his shoulder, only got an X-ray because I forced him to, and then complained bitterly about how it was unnecessary until the films came back with the break!

  32. The Blind Watchmaker says:

    2 comments.

    First, the “patient centered” phrases used above should not be confused with rebranding of sorts of primary care into a “Patient Centered Medical Home”. The latter is an attempt to reorganize primary care practices to better suit the ever growing complexities of delivering quality care to a growing patient population by a limited doctor supply. It is an attempt at efficient delivery of care. PCMH is designed around a team approach, delivered through electronic health record systems, group visits, physician extenders as well as traditional E&M visits with the doctor. Although it is currently in its infancy and a bit idealistic, I don’t think that Dr. Berwick is referring to the Patient Centered Medical Home.

    Second, if Dr. Berwick feels that we should be ordering MRI’s for anyone that wants one, then our system is going to go bankrupt. As an internist and a pediatrician, my partners and I spend a great deal of time telling patients why they don’t need an MRI for every little thing. Even after careful attempts at educating them om the indications for this expensive procedure, many are not satisfied. In fact, many people come to the office with notes in hand from a spouse or family member stating something like, “Make sure that he orders an MRI of (insert body part here)..”. I might be able to talk the patient out of it if an MRI is not indicated, but the family member on the other end of the note usually calls demanding to talk to the ‘uncaring’ doctor who is ignoring their spouse/parent/etc.

    I hope that Dr. Berwick is prepared to have Medicare pay for all of these tests just to make people happy.

  33. a says:

    As a long time observer of the medical industry (both my parents have had chronic illnesses), I have deduced that some doctors are problem solvers, but most doctors are cattle herders. When you get a doctor who is a problem solver, then you do not need Dr. Berwick to mandate patient-led care. The doctor is involved in the medical problem, and seeks the cause and long-term solutions. The doctor explains the current information and offers to do further research as necessary. The patient is already empowered, because the doctor listens without being dismissive.

    Dr. Berwick’s patient empowerment is directed more at the cattle herders – the ones who listen to your issues without actually hearing. These doctors are merely interested in getting you out of their office so they can see the next patient. They’re too busy to devote proper attention to your problem, but too sure of their own knowledge to direct you to a specialist. You can usually identify them because they don’t take/read proper notes from previous visits.

  34. E says:

    This one particular well-known patient, and as a result patient advocate and author, constantly pushes “doing your own research.” It’s almost to the point where it seems it should be ‘a must!’ She says she engaged in that right from the start and as a result claims to receive superior medical care from doctors.

    As a patient myself, I have a problem with that approach. Upon diagnosis, I went home, climbed into bed, and basically stayed there for what seemed forever. Regardless of having worked in an academic science library (under a librarian with one of the most brilliant minds I’d ever known), the last thing I wanted to do was go start doing medical “research.” And I was diagnosed with a disease to which I’d never, not even once, heard of – hyperparathyroidism. So that was a case where “research” would certainly have been understandable. But in spite of any curiosity, I was just too damn tired and overwhelmed.

    At my next appointment, into the exam room came a very sweet nurse hauling a quarto (oversized) tome of medical illustrations that she signed out from a library in order to show me exactly where the parathyroid glands were.

    From everything I gather about Dr. Donald Berwick; he’d choose the patient advocate over me. That scares me. As it should everyone else…

  35. rwdrwd says:

    Thanks for linking to my post on Berwick’s participation in the Institute of Medicine’s woo fest.

    One of the big problems with Berwick is one that doesn’t follow partisan lines and you’ve nailed it here—his radical, no, worse, flaky, views on patient centered care.

    You are the first blogger with a large audience to address this. I did so for my much smaller following in several posts, some that long predate any discussion of Berwick for CMS chief:

    http://doctorrw.blogspot.com/2010/06/integrative-medicine-community-extatic.html

    http://doctorrw.blogspot.com/2010/06/donald-berwicks-vision-for-patient.html

    http://doctorrw.blogspot.com/2010/05/not-only-evidence-based-medicine-but.html

    http://doctorrw.blogspot.com/2010/05/donald-berwick-im-extremist.html

    http://doctorrw.blogspot.com/2010/05/donald-berwick-let-evidence-based.html

    http://doctorrw.blogspot.com/2010/04/is-berwick-one.html

    http://doctorrw.blogspot.com/2009/04/double-evidentiary-standard.html

    http://doctorrw.blogspot.com/2008/08/what-does-patient-centered-mean.html

    And more.

    Berwick has been a hot topic of conversation in hospitalist circles for several years. The Society of Hospital Medicine worships him. I have always had a more skeptical view.

  36. wales says:

    Calli, I hear what you’re saying about a certain overconsumption mentality. The fallacy is that spending more money guarantees better medical care. I think that has been disproven with regard to medical care, with regard to leather products however, your relative may be correct.

  37. Calli Arcale says:

    I’d agree if she was buying the purses for longevity, but she isn’t; she won’t use the same purse for more than a year, and usually not even that long. (She obviously has more money than I do, but at her present spending rate, that won’t last.) Purses are a harmless use of money, though, compared to the excessive surgeries.

    It is strange, someone who has to be forced to go see her asthma doctor because she’s so out of breath she can’t get to the end of a sentence, but is eager to go under the knife to have large portions of her anatomy rearranged. Part of it may be her natural impatience, too.

    My grandfather, though of the same overconsumption mentality where my grandmother is concerned, isn’t so eager for surgery himself, but he’s got a unique situation thanks to his experiences in WWII. In his case, general anesthesia is sometimes riskier for the *staff*, as he has woken up from surgery believing that he’s been captured by the Nazis on more than one occasion. (Luckily, people coming out of anesthesia aren’t very coordinated, but he was always very embarrassed afterwards.)

  38. BillyJoe says:

    Scott,

    “Money is ultimately the limiting resource.”

    There are two additional limiting resources in medicine – manpower and time.
    The medical manhours available to spend are limited, so it is imperative to spend it wisely and equitably.

    “Requiring patients to pay for the overtreatment they want (a) will use less of ALL resources, since many won’t pay but would have happily exploited their insurance; and (b) will result in MORE resources for everyone else because the profits from their unnecessary procedures can be used to fund everyone else.”

    I’d like to see computer modelling of that scenario in action.
    I don’t think it works.

  39. Scott – How do you account for the working 25 year old that has not had adequate income or time to accumulate a health care nest egg and goes into kidney failure due to a congenital disease? There is no way they could pay. In the U.S. they’d end in bankruptcy court or not get the treatment and die. The idea of insurance is to spread around the cost of catastrophic care to a greater pool.

    Please show me one model of pay-as-you-go health care that adequately serves the poor or middle-class in anything beyond minor illnesses and routine doctor visits.

    Or, show actual data on how many dollars are spent annually on “over-consumption” due to insurance payments. As someone who deals with insurance companies quite often in the course of getting care for my son, I can say mine seems to be quite vigilant about uneeded care.

  40. Jann Bellamy says:

    A distinction should be made between the patient’s objectives and the means by which that is accomplished, and who makes these decisions. As Dr. Berwick likes examples from the legal profession, here’s how we do it, FWIW:

    “. . .the client [has] the ultimate authority to determine the purposes to be served by legal representation, within the limits imposed by law and the lawyer’s professional obligations. Within those limits, a client also has a right to consult with the lawyer about the means to be used in pursuing those objectives. At the same time, a lawyer is not required to pursue objectives or employ means simply because a client may wish that the lawyer do so.”

    from:
    Comment,”Allocation of Authority Between Lawyer and Client”
    Rules Regulating The Florida Bar
    4 RULES OF PROFESSIONAL CONDUCT
    4-1 CLIENT-LAWYER RELATIONSHIP
    RULE 4-1.2 OBJECTIVES AND SCOPE OF REPRESENTATION

  41. Scott says:

    There are two additional limiting resources in medicine – manpower and time.
    The medical manhours available to spend are limited, so it is imperative to spend it wisely and equitably.

    Investing more money results in more man-hours being available. It’s not an independent resource.

    I’d like to see computer modelling of that scenario in action.
    I don’t think it works.

    Leaving aside whether computer modelling would be an appropriate way to investigate such, why don’t you actually provide some kind of reason to not think it works? It’s very basic economics.

    Scott – How do you account for the working 25 year old that has not had adequate income or time to accumulate a health care nest egg and goes into kidney failure due to a congenital disease? There is no way they could pay. In the U.S. they’d end in bankruptcy court or not get the treatment and die. The idea of insurance is to spread around the cost of catastrophic care to a greater pool.

    I think you did not carefully read what I said. I’m specifically advocating requiring patients to pay for their own overtreatment. So your example is completely and utterly unrelated to my comments, as dialysis for kidney failure is not overtreatment!

    Please show me one model of pay-as-you-go health care that adequately serves the poor or middle-class in anything beyond minor illnesses and routine doctor visits.

    Please show me one word that in any way hints I’m suggesting a pay-as-you-go model for anything other than unnecessary overtreatment. Alternatively, please explain how having unnecessary overtreatment paid for by insurance or taxes is relevant to adequately serving anyone.

    Or, show actual data on how many dollars are spent annually on “over-consumption” due to insurance payments. As someone who deals with insurance companies quite often in the course of getting care for my son, I can say mine seems to be quite vigilant about uneeded care.

    In case it evaded your notice, we’re talking about Dr. Berwick’s advocacy of the idea that a patient who wants an MRI should get an MRI regardless of whether it’s medically indicated. That’s by definition overconsumption, and similarly by definition not something for which actual data exists because it’s still (thankfully) an advocated position rather than one that’s in effect.

  42. Scott, my apologies. I thought that you were talking about a complete a-pay-as-you-go system that I have heard advocated by folks (radio call-in, bloggers, commenters). I have heard people suggest that if everyone paid for everything out of private health-care saving plans if would control health care costs.

    I missed that you were talking about only unneeded care. Sorry to go off on you based on a misreading of you comment.

  43. Scott says:

    Think nothing of it. Communication has been achieved, everyone understands what everyone meant, and no offense has been taken.

  44. JMB says:

    @Draal Mythbusters is not a good scientific source. The vast majority of people with tattoos will successfully complete an MRI exam. Anybody with a tattoo has to be warned of notifying the mri operator of any warmth developing in the tattooed skin. When the operator is warned, either the rapidity of the sequences is slowed down, some sequences are dropped, or the patient is moved to a lower strength magnet. According to technologists experience, the most common problem is with people who have permanent mascara tattoos. They forget that the permanent makeup is a tattoo, don’t complain about the warmth until it burns, and end up with painful swollen eyelids, just like a sunburn. The amount of heating of the tattoo is dependent on the type of tattoo ink, the strength of the magnet, and the sequences used for the study.

    All MRI scanners have monitors for radiofrequency energy deposition, the SAR calculations. Since SAR warnings are heeded, patient injuries due to overall tissue heating are rarely a problem. I know of an MRI technical person who was being a guinea pig for teaching scans in a new unit. The MRI operator ignored the repeated SAR warnings, and the MRI technical person ended up in an ICU for several days with cerebral edema. Of course, the SAR warnings are calculated for ideal patients without tattoos. SAR calculations are concerned with more generalized tissue heating, not focal heating as occurs with tattoos.

    Many will also complete an MRI with no obvious ill effects who have a pacemaker or neural stimulator. The most common problem is the damage done to the batteries in the device. The batteries often need to be replaced after the MR exam. The typical cost of replacing the battery is $600. If a pacemaker malfunction is not recognized on a timely basis, there can be more serious consequences.

    The real problem with doing tests in patients without specific indications is that the value of the test approaches zero very rapidly. The positive predictive value and negative predictive value are very dependent on the incidence of disease in the population undergoing the test. The doctor recommending a test is doing so because based on the patients’ history, and physical exam findings, the a priori probability of disease is sufficiently high that the positive predictive value of the test will be greater than a random chance. When patients are free to act on their own estimate of a priori probabilty, a positive test may literally mean nothing. If treatment is started or more invasive test are performed based on a positive test with low positive predictive value, then the risk versus benefit ratio may not be correctly calculated. The patient may suffer the risks without receiving the benefit. That is the most serious problem with a relatively safe test such as an MRI being performed on a population of patients with a low a priori probability (due to self referral).

  45. I liked what bennett4490 had to say. It seems to me that the correct idea of patient-centred medicine (Jo Blow’s case) is when in opposition to procedure-centred medicine (today’s tracheostomy and tomorrow’s spinal surgery). This is not in any way “cave in to all patient demands”.

    I’ve had some experience with a friend recently running afoul of what looks a lot like a procedure centred approach. Or may be just over-worked doctors. His needs were many and diverse, and had to supplied by many different physicians and other professionals across the hospital. Who did not talk to each other!!! They desperately needed patient-centred case management and much better communications.

  46. BillyJoe says:

    scott,

    “Investing more money results in more man-hours being available.”

    Manhours is a limiting resource regardless. There are only so many radiographers to perform the test and only so many radiologists to read them. Their numbers cannot be increased indefinitely.

    But I think JMB has an even better reason to avoid payer demand:

    The real problem with doing tests in patients without specific indications is that the value of the test approaches zero very rapidly. The positive predictive value and negative predictive value are very dependent on the incidence of disease in the population undergoing the test. The doctor recommending a test is doing so because based on the patients’ history, and physical exam findings, the a priori probability of disease is sufficiently high that the positive predictive value of the test will be greater than a random chance. When patients are free to act on their own estimate of a priori probabilty, a positive test may literally mean nothing. If treatment is started or more invasive test are performed based on a positive test with low positive predictive value, then the risk versus benefit ratio may not be correctly calculated. The patient may suffer the risks without receiving the benefit. That is the most serious problem with a relatively safe test such as an MRI being performed on a population of patients with a low a priori probability (due to self referral).

  47. wales says:

    I disagree with the premise that patients who autonomously choose to overconsume medical services are a primary source of higher medical insurance/medicare costs (i.e. the patient who insists on an unnecessary MRI). Overprescribing/overtreating physicians have much more impact on costs.

    http://www.newyorker.com/online/blogs/newsdesk/2009/06/atul-gawande-the-cost-conundrum-redux.html

    “McAllen’s spending was almost identical to El Paso’s in the early nineteen-nineties. By the late nineties, however, it had become one of the most expensive regions in the country for Medicare and it has continued that way. Yet, public data show no sudden decline in health status or income for the McAllen population. The biggest changes? A dramatic rate of overutilization during a period that saw a marked expansion in physician-owned imaging centers, surgery centers, hospital facilities, and physician-revenue-sharing by home-health agencies.”

    “One methodological question is whether Medicare spending patterns differ from private-insurance spending patterns. There are indeed differences, because the prices Medicare pays doctors, hospitals, and others for services are not the same as the prices that private insurance pays. But, as a series of Dartmouth studies have shown, when it comes to how many services are provided per patient, the utilization patterns for the over-65 Medicare population are similar to those in the under-65 population.”

  48. Chris says:

    All I can think of when I read this is the effect on bacteria if doctors give in to patients wanting antibiotics for viral infections.

  49. JMB says:

    @wales

    “I disagree with the premise that patients who autonomously choose to overconsume medical services are a primary source of higher medical insurance/medicare costs (i.e. the patient who insists on an unnecessary MRI). Overprescribing/overtreating physicians have much more impact on costs.”

    I don’t think it’s one premise or the other. There is a synergistic effect between doctors over-ordering and patients over-requesting. When the entrepreneurial doctor orders the MRI of the head and cspine for that headache the patient has had for 20 years (and makes money for ordering the test because they own the machine), then the patient thinks they are getting better care because more “high powered” tests are performed. When others in the community then learn how their friend had all of these high powered tests, then they feel they should have one too. So the doctor overordering the test gives the community of patients the impression that they need the test.

    The doctor who prescribes an antibiotic for the patient has the same effect. The patient will forever after expect to get antibiotics for a virus. Now the next doctor dealing with the patient will be faced with spending 15 minutes trying to explain why the patient does not need antibiotics, or spend 30 seconds writing the script to keep the patient happy. Imagine how often a pediatrician is faced with that choice.

    So in place like McAllen, Tx, I would bet that it was a small cadre of entrepreneurial doctors (sometimes recruited by a nonmedical entrepreneur) that started the ball rolling and the synergistic effect of supply and demand in medicine. Because of the effect on the community of patients, the other healthcare services were more or less dragged along or face loss of their patients. Patients thought they would get better care from the overprescribing/overtreating doctors. The principled doctor would have to close their office and move on, because patients have a difficult time distinguishing more care from better care. Sometimes patients also think that the financially successful doctor must be better than the financially strapped doctor.

    I am sure that Dr Berwick understands the well documented relationship in healthcare that increased supply leads to increased demand. It is interesting that he does not recognize the synergistic relationship between excessive care ordered by the professional provider, and the subsequent expectations of the community of patients. Allowing the patient to demand an MRI (or other unnecessary tests or treatments) that is not indicated will slow, and possibly derail the return to evidence based medicine. But remember, the USPSTF has moved beyond “evidence based medicine” to “evidence informed medicine”.

  50. Zoe237 says:

    The overuse of mris bothers me, and I certainly hink people should pay oop for unnecessary tests. Patient controlled care has the potential to drive up my insurance costs. Let’s not fool ourselves though, many doctors are test and overtreatment happy too. It’s a little too easy to blame the patients rather than the system, a system that financially rewards those who order more tests and procedures. Capitalism is most definitely not the answer in something like health care that should be a human right for everyone.

  51. Zoe237 says:

    I disagree with the premise that patients who autonomously choose to overconsume medical services are a primary source of higher medical insurance/medicare costs (i.e. the patient who insists on an unnecessary MRI). Overprescribing/overtreating physicians have much more impact on costs.

    Whoops, should have read the last half of the comments. I can see my point has already been made, more succinctly.

  52. JMB says:

    Zoe, in the 60′s, many state governments had the political willpower to outlaw doctors selling drugs to the patient that they prescribed. That eliminated the financial incentive to prescribe medication (but they do get free lunches). The federal and state governments have had the opportunity to make sure that doctors didn’t profit from the tests they ordered, or the treatments they recommended, for over 25 years. They have failed to act. You can say that overutilization is a fault of capitalism. I would say that is the fault of the government failing to pass simple effective rules without loopholes placed by lobbyists.

  53. BillyJoe says:

    JMB,

    Thanks for your input.

    It has certainly put the whole question into perspective: both why it is detrimental, from the point of view of medical outcome, to accept that patients who pay should be able to get whatever medical investigations they want; and how the problem of patients getting what they want (regardless of whether or not they pay) results from the interdependence of doctors and patients.

    We had an interesting situation in my state of Victoria recently. Some enterpreneurial doctor set up a string of clinics offering ECG stress tests. Patients who wanted a stress test would simply ring up and make an appointment to have this performed. And, of course, there were advertisements in newspapers and radio inviting them to do so. They need not have any symtoms at all.

    The whole thing was financed via Medicare Bulk Billing, so that the patient did not have to pay anything. After too long a lapse, Medicare finally stipulated that stress tests could only be bulk billed if ordered by a doctor working independently of these clinics. The whole enterprise thus came to a crashing halt. Fortunately. Because the upshot was perfectly healthy people ending up with coronary angiograms. And patients already under the care of a cardiologist getting duplicate tests!

  54. BillyJoe says:

    Zoe,

    “Capitalism is most definitely not the answer in something like health care that should be a human right for everyone.”

    :)

    I am not against capitalism, measning that I think it has its place, but I think medicine is an example of the limits of capitalism. And I think those who promote unfettered capitalism are living a pipe dream that has already turned into a nightmare as the recent turn of events in financial markets would testify.

  55. JMB says:

    @Billy Joe,
    The American healthcare system has never been completely unfettered capitalism. Unfettered capitalism cannot be justified for any but the simplest markets. The problem is that the government has not smartly managed the regulation necessary to make it efficient. How can a market be efficient when consumers don’t even know the prices they are paying for services? How can a consumer make a rational choice when they are afraid they are dying? How can a patient know when the doctor is being influenced by the additional money they will make for the procedure they are recommending?

    Before the 90′s, nearly all American hospitals associated with medical schools were “safety net” hospitals, required to treat patients regardless of ability to pay (in return for federal and state monetary support). A patient with a breast lump, without insurance, was more likely to have a biopsy and surgical resection within two months of discovery than most patients in countries with socialized healthcare (although American military medicine also had delays measured in months). More charity patients received helicopter ambulance service, or were on the operating room table in under 60 minutes after major trauma than in other countries. Regulated capitalism in healthcare provided more Americans with necessary healthcare services in the 80′s than available in other countries.

    The federal and state governments backed off the support of the safety net system. Now, most academic medical centers no longer have the mandate. Patients in need of medicaid often have to wait over a year to be accepted. Perverse incentives for doctors to do more were never effectively addressed. Overutilization of tests because of medical liability was never addressed. The politicians have the gall to insist that healthcare reform would not ration healthcare, but then appoint the most prominent physician advocate for rationing. And there are signs that treatments known to be ineffective will be paid for. Welcome to American politics.

    I applaud your state of Victoria for having the political will not to repeat the mistakes made by USA governments. I suspect more of the medical entrepreneurial strategies will be exported to other counties. Learn from our mistakes.

    It will take political will to implement rationing based on evidence based medicine without allowing pseudoscience in the door. I’m not too optimistic given our recent history.

  56. weing says:

    JMB,

    You hit the nail on the head. I would also not blame capitalism for the problems with our financial system. The way I see it, our illustrious politicians regulated it so that profits were privatized and risk was socialized. I haven’t waded through the recent financial reform bill to see if that has changed. I doubt it has.

  57. Calli Arcale says:

    I agree with weing; you hit the nail on the head, JMB.

    JMB:

    When the entrepreneurial doctor orders the MRI of the head and cspine for that headache the patient has had for 20 years (and makes money for ordering the test because they own the machine), then the patient thinks they are getting better care because more “high powered” tests are performed.

    In general, I think shifting the focus from what will make the patient well to what will make the patient satisfied is dangerous, because that’s the point at which marketing becomes involved. I know marketing’s a necessary evil, but care must be taken to ensure it does not drive care. Doing extra tests to be on the safe side can make patients feel that you are more concerned for their welfare, and patients like that. In the classic example, giving them antibiotics makes them feel like you have listened to their complaints and taken them seriously, not like that other doctor who just patted them on the back and said they’d get over that nasty cold in a few weeks. Not surprisingly, this mirrors why many people favor alternative practitioners — they appear to care, because they’ll give a patient some sort of treatment, even where many MDs might just pat the patient on the back and say “you’ll be fine”.

    You’re absolutely right that there’s a synergistic effect, and it’s probably silly to blame doctors *or* patients — blaming anyone for starting it is a bit of a chicken-and-egg thing.

  58. Calli Arcale says:

    ARgh; forgot to close my blockquote. First quoted paragraph is JMB. Rest is me.

  59. Steve S says:

    Sorry for being real late, But I wanted to see what a politician whould have to say about the situation. I got two responses from the Obama administration and he didn’t even address the issues. The following is one from Senator Byron Dorgan of North Dakota.
    Here is a letter that Senator Byron L. Dorgan wrote July 14, 2010 in response to my inquiry about CAM being included in the health care bill.

    Dear ______
    Thank you for your email about complementary and alternative medicine (CAM) provisions in the health reform law.

    The health reform law was designed to put Americans back in control of their health care. That’s why thousands of Americans across the country participated in community discussions about our health care system during the health reform debate. Based on reports from these discussions that were sent to the Administration’s Health Policy Transition Team summarizing these groups’ opinions experiences and ideas, including support for CAM, these provisions were included in the health reform law.

    It has been reported that 38% of adults and 12% of children are using some form of CAM in the United States and pay nearly $34 billion in out-of pocket costs for CAM treatments, totaling 11.2% of the total out-of-ocket health care expenditures in the United States. That said, I appreciate hearing your concerns with the provisions, and I will monitor their impact closely.

    Thanks again for contacting me, ______

    Sincerely
    Byron L. Dorgan
    U.S. Senator

    Now you have it, if that is what the American People want then we will pay for it.

  60. JMB says:

    @Steve S, thanks for sharing that. Perfect example of American politics at work. What was sold to us as a moral obligation to support peoples health has turned into, give the masses what they want so we will have their vote. I don’t feel any moral obligation to pay for someone else to have their homeopathic or naturopathic remedies, for antibiotics for viral sore throats, or for their Viagra. I do feel a moral obligation to provide medical care that will make a difference, and do participate in supporting local charity clinics. I don’t think the local charity clinics provide homeopathic or naturopathic remedies or referrals, and I doubt that they pay for Viagra. I guess that’s the difference between Universal Health Insurance and Universal Healthcare. The public views having health insurance as the ticket to getting what they want for less. Healthcare implies we are going to provide those medical interventions that will improve the patient’s health.

    The charity clinics I work with actually express fear that Universal Insurance will put them out of business. If we were to provide Universal healthcare, then the charity clinics tend to be the most economically efficient clinics, and certainly discourage overutilization.

  61. interrupted says:

    RE: “patient needs and wants need to be taken into account and, wherever it doesn’t conflict with science- and evidence-based medicine”

    My assumption would be that “patient-centered medicine” is a response to the “evidence-based medicine” ideology. Certainly, being patient-centered and science-based are not in conflict. One point, it’s rather irritating when EBM is used as a synonym for science-based.

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