With due respect to those patient souls among us, America is, in general, an impatient nation. That includes how we think about our healthcare.
This is why I read with some interest, and some amusement, stories like “A real ‘doc fix,’” published this week in the New York Times. Basically it says we need to pay docs for quality and in the end that will generate lower costs for the system. It says we need more primary care doctors, we need to stop doing high priced procedures and expensive diagnostic tests and change the incentive from fee for service to pay for performance.
I agree with all of this logic. Medicine must move to a value proposition of lower cost per utilization, higher measured quality and higher patient satisfaction. There’s only one thing wrong with this equation: we are Americans.
Unlike our friends to the north in Canada or in Europe there is no social compact when it comes to your personal (or your family’s) healthcare. In America, We want it, we want it now, we are not willing to wait for it and we don’t want to miss anything on the first visit – sort of like the drive-through lane at your local fast food joint. Let me provide some context and a specific example.
You come to the ER with lower abdominal pain, some diarrhea and vomiting. A board certified emergency physician with four years of medical school, three to four years of residency training and several more years of practice experience does a standard history and physical examination and determines your ‘chance’ of having a surgical condition, most commonly appendicitis, is less than 5 percent. A CAT scan will likely be negative, give you a significant amount of radiation, but will also move that chance to less than 1 percent (no test is perfect). Are you, as a patient, or family member, willing to accept a less than 5 percent risk of a missed appendicitis and forgo the CAT scan?
Think hard, because that is in essence the thought process that goes through every doctor’s mind in every ER (and many private practices), every day in the US. Extrapolate that to every orthopedic surgeon having to contemplate ordering an MRI for that knee pain or neurologist for that headache and you get the picture.
Am I, as a physician, willing to bet that patient will understand that there is a small but real chance of missing something? In most cases it doesn’t mean much. You come back to the ER the next day and the scan shows the appendicitis and you do the surgery. No harm no foul except another day of pain. What if five out of 100 misses results in a ruptured appendicitis? You then have to undergo IV antibiotics for several days and may have a prolonged hospitalization (not to mention possible fertility issues down the line if a woman).
Still willing to assume that risk as a doctor? How about as a patient? Are you willing to wait and assume some risk that there is a small but real chance that something bad is going on? In most European countries and Canada with universal health care people understand that is the part they play to uphold the social compact. In order to get the greater good, some things get delayed in diagnosing and some things get missed. Some things don’t even get covered. I’m not criticizing these systems. In fact the statistics tell us that they do better than ours in terms of cost and life expectancy.
Until we, as Americans, accept the fact that health care is not McDonalds or Burger King – you can’t always get exactly what you want, exactly the same, right when you want it – the debates will continue. The next time your Doctor says you do not need that test realize he is not only advocating for you in saving that radiation dose, he is advocating for the system. The part you play will define whether we can do the best for all. It really is up to each of us to decide.