Saturday, August 1, 2009

Is the public this naive?

In today's Wall Street Journal, there is an article titled "Imagine Doctors, Patients Talking" that demonstrates the naivete of the public, or at least this journalist, on the doctor-patient relationship. The article implies that it is the doctor that is the sole reason for driving up health care costs.

It starts out with advocating more "intimate" office visits with your doctor, like having a dinner conversation. Sure it would be great to spend two hours with each of your patients to discuss their health care but if the new health care bill is allowing more patients to visit their doctors while lowering payments to doctors, those dinner conversations will instead become more like a drive through at the In N Out.

Then the article leads with snarky remarks like "If there's a history of mutual honesty and transparency" and "Doctors should be forthcoming about discussing the alternatives." I would say that in most if not nearly all less-than-honest relationships with patients, it is the patient that lies to the doctor. "Doctor, I'm agonizing. I need more pain meds." "Doctor, I don't have enough money to feed my children. I can't make the copay." "Of course I take all my meds as prescribed doctor but I still can't get my blood pressure (glucose level, acid reflux, INR, etc.) under control." So the writer is implying that doctors are not honest with their patients about available treatments. Has the writer ever heard of informed consents? Before starting any treatments, virtually all doctors discuss the medical plan along with alternatives. We physicians have not dictated to patients their health plans for at least the last twenty years.

Then we get to the laughably ridiculous line "In exchange, patients should signal that they don't necessarily want to act on all the possibilities." Are you kidding me? How many times have I seen patients or their family say "I want everything possible done." I've seen 95 year old demented patients get gastrostomy tubes placed because the family wants everything done. I've seen the whole blood bank transfused into exsanguinating cirrhotic Child-Pugh C patients because the family wants everything done. Walk into the ICU in any hospital and you'll find patients on multiple pressors, ventilated, with feeding tubes and on dialysis long past what is medically indicated because the family wants everything done.

The problem of course is that patients don't know or don't care about the costs of these treatments because somebody else is paying for it. The article states "patients may welcome these developments as they watch their wallets" but that is precisely the problem, the patients and families don't. Most people have insurance through their employer or the government so somebody else is paying for all this. If they had to pay for the real cost of medical treatment, like in Britain where dialysis is out of pocket after age fifty and transplants after age 55, we wouldn't have so much needlessly aggressive care. But of course that would be cruel to the "most vulnerable" people in society.

The article ends by saying it is the doctors who need to upgrade their communication skills to better inform their naive easily impressionable patients. And the patients should have bias free information to make an informed decision. Hello. Patients already have that. But medical care is a very emotional decision. If you read the entire text of Harrison's to these patients, they would still want what they want, regardless of the logic and price of the treatment. No wonder doctors are leaving the AMA in droves. If they can't educate the public about what's really going on, the public will just keep squeezing the doctors until we are all just slave labor for the government. But we doctors are not supposed to say the truth. We're supposed to be all about compassion, treating each and every patient regardless of the physical, emotional, and fiscal tolls on ourselves. Otherwise we're bad greedy doctors who only care about money.

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