Monday, November 23, 2009

Answering Questions

On the average of three times a week, I get calls from people asking my advice on issues related to health.  The requests for advice fall into two categories.  They may be about individual medical decisions such as from a family member thinking about whether to have knee surgery, an executive in a managed care company asking about home care options for a chronically ill child, or a senior executive in an unrelated industry asking about a complex issue involving an employee or even a family member.  They may also be about health policy such as the call from a businessman asking me to explain how the provisions of the current health care bill passed by the Senate may affect his business.  While many of these people have other experts they can turn to, I believe that they call me because of a number of factors.  They know that whether speaking about individuals or about matters of finance and policy, I will think about what will contribute to delivering the best health care available in a caring, efficient manner, and they also know that I will not make a decision for them but will instead help inform and support them in their decisions.  My goal is always to frame and clarify a question rather than give an answer.

My Philosophy of Medical Decision Making

Whether the question is “macro” (policy) or “micro” (individual) I approach these questions with a certain philosophy that has three major components.  The first is that is that the best medicine and the least expensive medicine is the most personal, that is it is the most customized for the particular patient in that particular situation.  The second is that everything in medicine has side effects (and often hurts) so that all decisions for evaluation and care must be made with thought.  The third and the most important is that each individual is the only true expert on themselves and therefore they are in the best position to make their own decisions.  My view is that health care is too important to be left to the sole discretion of your doctor or an insurance company.  The best model is one in which the doctor is a partner and an advisor making decisions for you only if you want him or her to do so.  The most important role of a doctor is to make the complex simple and help each individual have all the facts they need to make the right decision for themselves.  In the same way, the best insurance product, whether designed by the private marketplace or by government, is the one that makes needed care easily accessible and helps people make the right choice for themselves. 

Micro Example: Everything Hurts

I have always believed that a minor medical procedure is a procedure that someone else has.  Everything that is done to me or a family member is major.  Lest you think I am some sort of monster who only cares about myself, I believe that to be true for everyone.  An article this month in JAMA is related to this point by carefully evaluating post operative pain in woman who have had breast cancer surgery at 2 years after the surgery.  The study showed that about 50% of women had chronic pain at two years and that they had pain even with breast conserving, minimal surgery.  How many of them knew to expect that?  How many of us are truly told about the potential side effects and long term results of medicines, surgeries or even of diagnostics studies?  (Did you know that the average CT scan exposes you to more than 100X the radiation that a chest x-ray does?)   Even the simplest test can put someone at risk.  A good physician should be someone who explains the potential risks and benefits of anything you have done to you, in a way that is understandable to you. 

Macro Example: The True Expert

The debate over health care reform is partly being driven by the fear that a new program will impinge upon individual’s rights to decide (with their physicians) what the best course of therapy is.  People are afraid of losing whatever autonomy and flexibility they currently have with the new proposed legislation.   They are afraid that the new health care system that Congress may unveil will only decrease their control over their own health care decisions.  An article in the New England Journal of Medicine makes that point.  While this article states that according to polls people want health care reform, it also says “most Americans do not believe they will be better off if the current legislative proposals as a whole are enacted. Most, but not all, of the polls show that among people who see the plan as affecting them personally, more believe they will be worse off personally and in terms of the cost and quality of their care than believe they will be better off (CBS, October; NBC, October; Gallup, October).”  Thus far the political debate has not focused on whether we will be giving people more information when they need it and whether we will support the individual’s right to make their own decisions.  Instead we are caught up in political posturing on both sides of the aisle and the bill that is being produced tries to satisfy everyone by saying “yes” to everything except individual autonomy.  Until health reform recognizes the patient as their own true expert, it will be hard to achieve optimal care at the lowest cost.  In both policy and practice, I do have more faith in the public than in the “expert” legislators.