When ‘No’ Turns Positive in Medical Care and Education

The medical word of the month is a most definite “no.”

The word is featured, explicitly and/or conceptually, in recent opinions published in two of the world’s most established media platforms – the New York Times and the New England Journal of Medicine. The combined message relates to a previous point I’ve made here and elsewhere, that if doctors would or could take the time to provide full and unbiased information to their patients, people might choose less care of their own good sense and free will.

Let’s start with David Leonhardt’s April 7 column, In Medicine, The Power of No. In this excellent essay he defines the difficulty: “deep down, Americans tend to believe that more care is better care.” Then he details the problem:

…It’s not just CT scans. Caesarean births have become more common, with little benefit to babies and significant burden to mothers. Men who would never have died from prostate cancer have been treated for it and left incontinent or impotent. Cardiac stenting and bypasses, with all their side effects, have become popular partly because people believe they reduce heart attacks…

Advocates for less intensive medicine have been too timid about all this. They often come across as bean counters…

After outlining the situation – too much and sometimes harmful medical care, combined with a population reticent in limiting any form of consumption – he offers three steps by which we might “learn to say no.” Those would include:

1. Learning about when treatments work and when they don’t. (This is problematic, he admits, citing the Institute of Medicine which reports that too often data are “incomplete or unavailable.”)

2. Giving patients the available facts about treatments. (This doesn’t happen as it should, he explains, for reasons including doctors’ persistent paternalism.)

3. Changing the economics of medicine, to reward better care rather than simply more care.

So, as I understand Leonhardt’s proposal, he’s saying that if we knew more, we’d be less demanding and ultimately more satisfied with the medical care we receive. And because more care is sometimes harmful, besides expensive, the consequence of saying “no” would be a big plus – in terms of quality and costs.

Moving on –

On April 8 the New England Journal of Medicine published a perspective piece, Cost Consciousness in Patient Care – What is Medical Education’s Responsibility? by Dr. Molly Cooke. This essay parallels Leonhardt’s in that it first reviews our medical overconsumption problem and then suggests specific steps to ameliorate it.

A major distinction is that Cooke addresses physicians and her proposal applies, for the most part, to their medical education. She considers that, at least historically, doctors are not trained to consider costs in the process of rendering medical decisions. The primary concern, we’re taught, is doing what’s right for our patients. The second, it seems, is an ivory-tower sort of wisdom:

…Academia celebrates the “high knowledge” of medicine: pathophysiology, molecular biology, genomics. Even evidence-based medicine, although it deemphasizes fundamental mechanisms, is regarded as acceptably intellectual in comparison with “low,” real-world concerns such as cost…

After mentioning physicians’ conflicting financial incentives in practice and many doctors’ hesitation to speak about or even consciously consider costs, she proposes three changes in medical training. In her terms:

1. We must be honest about the choices that we make every day. (What she intends here, as I read it, is that because physicians do indeed ration our time and other resources, we should be up-front, i.e. conscious about such value-laden decisions.)

2. We must prepare every physician to asses not only the benefit or effectiveness of diagnostic tests, treatments, and strategies, but also their value.

3. We must broaden our programs so that all trainees receive a foundation of exposure to health care management and health services delivery. (That we can afford for doctors-in-training to spend more of their time on the business of health care, I’m not convinced, but her point is that at least they should have a clue about how the real world of health care works and how much things cost.)

What Cooke says, in sum, is that for physicians to effectively counter the unsustainable medical expenses in the U.S., we should adjust medical education to train doctors to think – actively and consciously – about the economics of health care.

Now it’s easy to tie these two pieces together. The points are that regular citizens and doctors, both, need to learn more about the value of tests, procedures, treatments and other health care commodities. Just piling it all on blindly doesn’t yield the most value.

I’m reminded, lately, of a simple fact about numbers I knew in high school, that when you put together two negative numbers by multiplying them, you get a positive. Maybe, in the real, messy, complicated world of medicine and health care delivery, we can entangle these two learned no’s – patients choosing less and doctors recommending less – and get a bona fide, positive outcome

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