The Physician Selling, The Patient Buying: Should Patients be Considered Consumers in a Medical Care Market?
It all boils down to autonomy, the principle of ethics that permits the patient the right to make their own medical decisions. But these days, patient autonomy seems to be extended beyond decisions of whether to accept, reject, not start or terminate treatments. Patient autonomy seems to have been extended into areas of clinical decision-making which have always been the responsibility of the trained and treating physician. It has become a patient’s activity to make requests for tests and treatments, essentially selected by the patient from a pool of possibilities not presented by the patient’s physician but by advertisements and the internet and the next-door neighbor. It thus appears that patients are behaving like consumers, entering a market environment with their cash provided by their insurance or government and expecting their physician to provide them with the components of healthcare the patient desires just as the patient will select the items off the shelf or table in that market. And so the physician as expected will follow through on those requests whether it is a procedure, a test or a treatment, irrespective of the physician’s medical opinion. And so the clinically unnecessary and unneeded procedure or drug is provided by the doctor and the cost of medical care continues to rise.
The question is whether this is the way the patient-doctor relationship was supposed to end up, the doctor selling and the patient buying? Wasn’t there supposed to be something different in that relationship? Wasn’t there supposed to be a relationship based on professionalism, mutual trust and both parties, together setting a goal beneficial for the patient but still meeting rational criteria set by the profession of medicine? What do you think?
For more on this topic, read the Op-Ed presentation by Paul Krugman in the April 21, 2011 issue of the New York Times. ..Maurice.
posted by Maurice Bernstein, M.D. @ 10:24:00 PM
13 comments
13 Comments:
I think there's some sort of happy medium. The old paternalistic "doctor knows best" is certainly not something I'd like to return to. But no, I don't think the patient should be able to order anything they want, at least not if insurance is paying for it.
However, a patient can order whatever they want right now - don't need any doctor. If labcorp runs it, there's some internet company that'll let you order any of it yourself, self-pay. Personally, I think that's fine. You want it, you pay for it. You don't know how to read/understand the results, go pay some doctor to do so.
Part of the reason, I guess, that I'm not saying "just leave it up to the doctor's judgement", is that over the years I've seen so much bad judgement by doctors, that I don't have faith in it.
I know some doctors that myself and my family have a good relationship with, and I trust their good intentions. But even the good ones make mistakes. So going on the "two heads are better than one" theory, I think the patient should have some input. Granted, the input from some makes more sense than others.
But if a doctor doesn't think a test is medically necessary, then I think they should be allowed to say so. Patient still wants it - fine, run it (as long as it isn't harmful). Patient pays.
Hmmm.. except maybe if the patient is right, and the test makes the diagnosis, then the doctor should pay up :)
TAM
Krugman’s remarks were made in response to the Republican rhetorical tactic of cloaking every political issue in the guise of “consumerism,” and was more-or-less rejecting the model of patient as consumer. He wasn’t, however, really doing any heavy thinking about the medical system itself, it was just a useful prop to talk about how the parties are framing issues.
When you write that “patient autonomy seems to have been extended into areas of clinical decision-making which have always been the responsibility of the trained and treating physician,” it’s hard to know precisely what you mean without a specific example. In my experience (mostly an inpatient and consult doc rather than a primary care person), only the most aggressive and/or fixated patients come in with specific test requests. Sometimes they have done reading on the internet or as you note, talking to the next-door neighbor, and want to contribute to the dialogue with a doc, and that’s an attitude that should be welcomed by good docs, not seen as a challenge onto their sacred territory. (By the way, you seem to use the phrase “next-door neighbor” with a mild amount of scorn, but it’s not as if many docs don’t get some of their medical knowledge a similar way through professional chit-chat—or worse, through drug reps.) Anyway, I see a distinction between autonomy, which we should welcome from patients, where they are active participants in their care, and consumerism, which reduces the interaction to pure marketplace ethics.
What’s the difference? Two brief examples: in a marketplace model, patients can demand any amount of plastic surgery they desire, but in a “professionalism” model, plastic surgeons have an obligation to refuse surgery to patients with psychiatric conditions such as “body dysmorphic disorder” where no amount of surgical enhancement will ever suffice. Second, there’s a whole cult of “Lyme Disease” folks here out east that are convinced that Lyme is the cause of any number of maladies and some demand long-term (i.e. years) of antibiotics to “cure” it, and again most docs would consider it unethical to treat such patients. (I even saw a patient once who was convinced that the Lyme had penetrated her teeth, and managed to convince a dentist to remove all of her teeth for treatment. That dentist seems unethical to me.) In both cases, you have a situation where it’s totally reasonable to grant a “consumer” their wish, but not a “patient.”
Another important distinction that you touch on is that patients do not “consume” health care per se, but rather health insurance. If we replaced our current (screwed up) model with another (even more screwed up) “pure capitalist” model, then it would be totally in-bounds to withhold treatment until full payment was rendered, either by insurance or out of pocket. Nowadays that is for the most part frowned on.
One last point: you mention the influence of advertisements on the whole “patient as consumer” model. It’s true, and although there are a variety of reasons why I think direct-to-consumer advertisement does more harm than good, docs can hardly look down their noses at that practice while being the beneficiaries of the largesse of drug companies via drug-rep goodies, dinner talks and the like. It’s just another aspect of the game. Best, Billy
Thanks to TAM and to you Billy for your insights. I think that medical diagnosis, prognosis and appropriate possible options of therapy should be left to the physician who is trained and usually has the experience to make these decisions. This information should be then communicated to the patient or surrogates, with education and it should be up to them to decide on the wanted course to follow amongst the options provided by the doctor.
What I meant by "patient autonomy seems to have been extended into areas of clinical decision-making which have always been the responsibility of the trained and treating physician" is the areas of diagnosis, prognosis and the options appropriate for therapy. In terminal illness situations,often the family members or the patient set their own decision about the prognosis or approach for further care irrespective of the conclusions presented by the physician and requests that the physician accept their view. This is an example of the "consumerism" aspect I was trying to suggest. Perhaps this is the physician's fault for inadequate education of the patient and family. But it does contribute to the rising cost of medical care in this country. ..Maurice.
Maurice, you say "I think that medical diagnosis, prognosis and appropriate possible options of therapy should be left to the physician who is trained and usually has the experience to make these decisions. This information should be then communicated to the patient or surrogates, with education and it should be up to them to decide on the wanted course to follow amongst the options provided by the doctor."
I understand a doctor preferring it that way, but to some extent, I think those days are gone. Whether that's good or bad can be argued of course.
There's just too much information out there. The internet has changed our world, and I think it's changed this part of medical care. Many people are going to go out and research their condition, or symptoms. If you're lucky, they're on Mayo's website, not Joe's magic cure website.
I'm one of those who doesn't just leave it up to the doctor. In the family, there is a lot of medical background though, so I think we research better than some. Ideally, I'd leave it up to the doctor. But, we've had more than a few times where the doctors weren't right, and our research actually did prove to be correct. So just accepting the diagnosis and going along with the doctors suggested therapy would have been harmful.
Another example - we've turned up a variety of a test that the doctor wasn't aware of - and was grateful for the info. Doctors time is more limited, they don't have time to research every detail, or keep up on all the new research on some of the rarer things. No one knows everything. The doctor is taking care of many patients - the patient is only concerned with researching one person's problems.
Now, we do not go in demanding that a doctor just do something. But we are very interactive, and discuss possible diagnoses, tests, treatments, etc. Thankfully, we don't come up with crazy stuff, and have some very good and respectful doctors, and it is a collaberation. To me, this is the best it can be.
Doctors do, however, have my sympathy when presented with demands for things that have no reasonable medical basis. I think now, rather than just being able to say "I'm the one with the MD, I know best", doctors are going to be in the position of having to convince people.
I know a veterinarian, who is faced with similar, who feels it's best to encourage the internet research by pointing the people to a reputable site to read up, rather than trying to discourage them from researching at all.
TAM
TAM, here are my questions to you. I am teaching first and second year medical students in medical school and have been doing that for 25 years along with my medical practice. Students spend 4 years in medical school before going on to internship and residency, an additional 3 or 4 years or more in additional training. In medical school, the teaching for each student of current science and clinical skills is intensive and comprehensive and costs the students plenty in terms of their personal lives and the financial burdens accumulating.
If, in the beginning of the 21st century, all it takes to make a valid diagnosis and appropriate treatment is access to the internet or clinical conversations with others in sort of a medical social network what exactly are we doing in our medical schools and in the subsequent training facilities? Am I wasting my time? Are all the students wasting their time and money too?
I think that each party, the patient and the doctor, should work together knowing the other one has information which is needed to make the final clinical decisions. It should be a collaborative interaction. I agree the doctor doesn't know everything and even in the day of the internet and the pharmaceutical advertising, neither does the patient. But all those years of medical training should not be thrown out the window otherwise maybe we should begin to change the way medicine is taught. ..Maurice.
I don't expect doctors, in most cases, to like patients doing their own research. Or patients wanting more input into their treatments. I don't blame them really - if I spent all those years going to scool, I would probably be personally annoyed that someone wouldn't just take my advice. But I think it is a new reality.
And there's that old country saying, even a blind hog roots up an acorn now and then. Patients can turn up something useful, sometimes.
Talking about our cases, I'm perhaps not being complete fair - there is a lot of medical background in our family.
But a smart patient can probably become as educated on a specific illness as a doctor. *smile* I'd take you on re. current practices in a pheochromocytoma diagnostic workup, and I bet I'd win. Depth of knowledge on that one topic, I have.
However, the doctor has years of study, as you pointed out, and a breadth of knowledge. I'm betting I know more than you about one specific condition. However, I don't know squat about most of the rest of them. And that is key.
I think that part of what does need to be tought now, is how to deal with patients that want to make more of their own choices and do their own research. I think this is another area that doctors must learn to guide those patients. Rather than hope they won't read the net, which is pretty much a futile hope, suggest to them how to find reliable sources to read more.
And perhaps some practice, in communications skills classes, on how to deal with patients misinterpreting their reading, or unreliable sources of info, and how to do that guiding. People don't always "steer" well I know.
I have seen other doctors say, that an educated patient can be a great resource for the doctor. With a more rare condition, send them off to research - which the doctor probably doesn't have a lot of time to do.
The other thing is - any particular doctor isn't always right. Sometimes research indicates to the patient the need for a second opinion. That's happened to us. Like everyone else, some doctors are better than others.
TAM
Maurice, I realized I didn't answer this one directly.
"If, in the beginning of the 21st century, all it takes to make a valid diagnosis and appropriate treatment is access to the internet or clinical conversations with others in sort of a medical social network what exactly are we doing in our medical schools and in the subsequent training facilities? Am I wasting my time? Are all the students wasting their time and money too? "
I think quite a bit of the time, a person with average intelligence could make a likely diagnosis using the internet etc. Often even figure out the treatment.
But only some of the time.
The doctor's knowledge is needed to make sure they're right. I'm sure, quite a few times they aren't. And for more unusual and complicated cases, the layperson probably can't do it. As far as treatment, while the layperson can probably find the standard treatment, perhaps they have other conditions that need to be taken into account, for which the doctor's breadth of knowledge is needed.
So I think the doctor is still ultimately responsible for diagnosis and treatment recommendations. The patient may just have more knowledge (or misinformation, sigh) coming in.
TAM
One of the comments you see often about the US health insurance debate is that patients need some "skin in the game". In the insurance debate, this invariably refers to money--patients need to be paying for tests/care/treatments to understand the value of them.
I think it is the reverse of this that turns paternalistic medicine on its head: when it comes to my personal health and wellbeing, my doctors don't have any skin in the game. If I die, or am miserable on a treatment, or am not adequately treated then unless the doctor is grossly negligent (and subject to professional or financial penalties as a result), the only person harmed by that is me. Given that it is my skin in the game, and I neither can nor do expect my doctors to perfectly understand every condition I might have nor the vagaries of my personal response to medications or my priorities in life (which, with a chronic illness are just as important as many clinical considerations) it is unreasonable to expect me not to do my own research and make my own considerations. I think this is what TAM is getting at.
Does this make me a consumer? Absolutely not. Being a consumer implies I have a choice about whether to purchase a service or not, can price shop, all of these things. A choice between purchasing a service and dying is no choice at all. A choice in an environment where it is near-impossible to get the necessary quality information about a service (rate post-op infections, for example) is similarly not a choice. I think the best model lies somewhere between consumer (which is simply unrealistic) and the old paternalistic model, and that any doctor who expect their patients to follow their advice without question needs to consider their reasons for feeling that way, just as any patient who expects to be able to order up whatever service they wish needs to think about why they employ a doctor.
--PG
PG, I thoroughly agree with everything you wrote in your commentary. I want to emphasize to you and the others writing or reading here that in my teachings to my first and second year med students, I have never given them the impression that when they become physicians and take responsibility for patient care that they should look at themselves as the "boss". In fact, they should look to their patients as an "equal" member of the team. Equal in the sense that without the patient's or in some cases the family's or surrogates participation in revealing history, allowing examinations and testing and compliance in therapy much of the skill and knowledge of the doctor will not lead to a diagnosis and will not be helpful for the patient. Yes, it is true that it is the patient who is under the burden of illness and all the personal physical and mental risks that are associated with the illness, the workup and the final treatments. The physician's risks are just professional and usually, in the end, not life-threatening.
I am not against the idea of the patient "thinking for themselves" as they size up their possible diagnosis or treatment. But I do think they, at the same time, seriously consider what the skill, knowledge and experience of their doctor is bringing to them as they personally and autonomously make their own medical decisions. ..Maurice.
This is not the way it should be-the patient treated as the consumer the doctor the seller.There are many new ways to heal some of which are not taught in medical school such as nutrition and I mean an in-depth knowledge of nutrition and cutting edge findings that the average doctor either doesn't believe in or doesn't have the time to research-he would rather write you a prescription no matter what the side effects are than to rely on foods and natural products because that is his arena ,the one he knows best is prescription medication and that is getting to be so very old thinking. Doctors don't really care because they sometimes don't understand it but you should care about what you put into your body. If you had a problem and solved it with natural products that weren't harmful, you would be a believer but not until that time. I know of doctors who argued with other doctors about health treatments. There is a new breed of doctor out there who does incorporate natural healing products etc. into his practice but those doctors are hard to find. The patient is really forced to learn as much as possible for his or her own good health. The doctor -a regular GP- has become more of a salesman but he has a very wary client who knows more than what he thinks about how healing should begin. You don't like to be the one who tells the doctor what should be happening but times are changing and some doctors are not keeping up with those changes. There are some doctors where I live that I would definitely listen to because they know way more than I do but when you go to the ordinary run of the mill doctor and he runs on about this or that test you should have but neglects the things right in front of him-you better start thinking for yourself and know how to say no and stick to it.Just like the group I was going to I always was pawned off on a nurse practitioner never talked to a doctor and they should have been concerned about a situation like that. Doctors must change. Would you have respect for a doctor who would do this to you? And you must realize that what I have talked about is just the tiniest tip of the iceberg.
Janice
Janice,
I work in a major academic medical center, and I don't think I could find a primary care physician or subspecialty internist who would not advise patients to eat better (as in Michael Pollan's "Eat food. Mostly plants. Not too much."), exercise, and not smoke as the most critical pathway to health before doling out any medication, so I'm not really sure what you mean. Your caricature of the prescription-happy doc who takes no care to advise people to eat well seems grossly distorted to me based on the professional company I keep.
You also state that "there are many new ways to heal some of which are not taught in medical school such as nutrition and I mean an in-depth knowledge of nutrition and cutting edge findings that the average doctor either doesn't believe in or doesn't have the time to research." Would you please provide a reference of a cutting-edge nutrition study as an example?
Thanks in advance, Billy
Well, you are judging by your experience and I am judging by mine. It is difficult for you to imagine that doctors can be so indifferent but that is the reason for my post. I certainly don't mean all doctors are like that.
A cutting edge study to me would mean someone investigating more than the obvious benefits of a food, someone who will go in and try to prove a suspicion of greatness lying dormant. Something that would benefit the health of people for years to come. But most of all , nothing will be accomplished if he doesn't believe in the healing power of food and incorporate that knowledge in his practice. There are doctors who do these things but from what I have read it mainly comes from having a problem of their own that medicine could not help. There is a doctor I could mention Dr. Sherry Rogers who has written many books describing how she got to the point of investigating things on her own. Her books are very interesting . I think her first book The E.I. Syndrome tells her story.Wellness against all odds is really good. Now she is what I would consider cutting edge.
Janice
Its interesting and in many ways disturbing how successful industry has become in marketing medical services, that is convincing patients that they need/want certain drugs/procedures/test.
On reflection these are merely means to what patients really want - health and wellness. Unfortunately for industry, its (I think) impossible to sell these later ideals, so to get around this hurdle there has been a (intentional in some cases, accidental in others) conflation of health with health care/services.
Of course, as any competent MD knows there is no clear proportional relationship between the two. Indeed, more health care may often lead to less health, as is exemplified by the disproportional deterioration of patients who are forced into prolonged ICU stays where, almost by definition, there is the most and the best of health care available in the system.
Efforts must be made to effectively re-educate the general public on what it is that they want. Health, not (necessarily) health services. The family doc has some say in this still. Patient autonomy not only allows but in many ways demands that doctors have serious discussions about what it is that patients really want.
-Dmitri
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