Monday, September 15, 2014

BREAKING: Patients Are Not Stupid

In a new Forbes article, David Shaywitz ponders whether patients are the best judges of physician quality. This is a very interesting question, not because the answer is elusive, but because the question itself is rather unusual, and may prove to be the harbinger of a new way of thinking about health care. The question raised by Dr. Shaywitz is not whether patients have enough damning information to select their doctors, which is the common drivel in the media right now. The question is whether regular people are mentally competent to make that decision. Responding in the negative to this question implies that someone, or something, other than the patient should be empowered to judge physician quality, and pick your doctor for you. 

It seems that Dr. Shaywitz was inspired to write this article in the wake of an opinion piece in the Wall Street Journal, where a practicing physician, Dr. Mark Sklar, is railing against the oppressive bureaucracy engulfing his medical practice today. Dr. Sklar offers several opinions, one of which is that “the patient should be the arbiter of the physician's quality of care”. Unfortunately for Dr. Sklar, his other prescriptions seem to be in opposition to some Obamacare tenets, and this is guaranteed to elicit kneejerk responses from Affordable Care Act supporting journalists, who have long ago ceased to even pretend to be impartial in matters of politics.

What I find exceptional about this Forbes piece is that Dr. Shaywitz’s first instinct is to solicit a response to Dr. Sklar’s complaint not from a famous Obamacare supporting physician (of which there are many), and not from the purveyors of rules and regulations at CMS, but from none other than Mr. Vinod Khosla, the billionaire venture capitalist who insists that 80% of doctors are middling and should be replaced with his computer driven algorithms. Of course, once Mr. Khosla gets his wish (and he will), Dr. Shaywitz’s question will become moot, and we will be relieved of another mental burden on our way to perfection, or perdition, depending on your point of view.

Perhaps, we shouldn’t be surprised by the appeal to Mr. Khosla’s informed opinion, since Dr. Shaywitz admits to sharing the modern disdain for physicians in general: “doctors don’t know what they don’t know, they often provide manifestly suboptimal care, and can get away with it so long as they sweet-talk the patient”. Sweet-talk? I thought we were going for the abrupt, dismissive, inconsiderate, aloof image, but either way they can get away with it, because we are all too dumb to know the difference (present company excluded, of course). Among some random thoughts about data collection, Dr. Shaywitz poses another quintessential question which never fails to materialize in this context: “Why should I know more about my mechanic than my doctor?” Note that as always this is a rhetorical question and an answer (other than duh…) is not deemed necessary.

I don’t really know what your car mechanic experiences are, but I can tell you that I know nothing about any of the various people who worked on my cars over the years. I don’t even know if they were mechanics. I don’t know if and where they went to mechanic school, and I have no idea how long they have been practicing mechanics (I assume that older ones have been in the business longer), I have no data regarding how many Jeep carburetors they fixed well and how many they broke, I don’t know how many times people had to come back for the same problem, and I have no idea if it takes six hours to replace ball joints, or maybe just two. Heck, most of the time I don’t even know their last name, and I certainly have no idea if they worked on my car themselves or delegated the work to some trainee on his first day on the job.

And yet, I would insist that I am the best judge of mechanic quality for my car, and I use information to render my judgment. I ask people I know for recommendations, and I ask the grease covered guy at my favorite gas station about the best body shop that’s not too far from my house, and then I pick one, go over and talk to the “guy”, and if I get a good feeling that the “guy” knows his stuff and is trustworthy, I let him fix my car. I have yet to make a truly horrific mistake. The tools and data I use to make my decisions were invented hundreds of thousands of years ago and honed to perfection by every human interaction over the millennia. I use similar tools all day every day, and I like that sometimes they are fuzzy, and I like that they are my tools to shape and alter as I please.

I use my tools to pick my lawyers, my accountants, my hairdresser, my plumber, my air-condition guy, painters, fence-builders, the tree guys, dry-cleaners, the lady that that does alterations, the fresh fish store, the stands at the farmer market, and a gazillion other products and services. Sometimes, I use customer reviews on the Internet in lieu of asking friends, but not very often, and never for personal services. I make lots of mistakes and sometimes I learn from them, and once or twice I rushed into some serious blunders, or procrastinated my way into disaster. It’s called life, and I insist on my right to make bad decisions, because it’s the only way for me to make the right decisions.

The Constitution of the United States of America gives us the right and the duty to judge the quality of the most powerful person on this planet, and we have to do that without any prior performance data and without ever meeting the candidate. We also have to judge the quality of the future executives of our respective States and towns, and from time to time we are called to actually judge the guilt or innocence of one of our peers. These are difficult decisions to make, and in spite of the seemingly egregious errors we are now making, I am not too terribly inclined to delegate these rights and responsibilities to Mr. Khosla’s computers, or the supreme intellect of the ProPublica editorial team.

We may be down and out. We may be disenfranchised right now, and plagued by broad daylight robberies, which we can’t fend off just yet, but we are not stupid. We know that the $2.8 trillion in our health care purse is enough to blind the righteous, and more than enough to attract the wicked. As a group, doctors are taking home a large chunk of that money, because we allowed them to do that in return for an ancient commitment, that means nothing to purveyors of machine ethics, but means a lot to us. We know that there are thieves and murderers among doctors, and some of us fall prey to those disturbed individuals, but as a group, physicians have proven worthy of our trust, and certainly more so than the corporate organized crime consortium and the sensationalist media outlets that serve them.

We don’t seem to be the best judges for picking our occupations, our food, our sports, our houses, our financial investments, how we educate our children, how we speak, and now how we pick our doctors and medicines. It would be so much more convenient and so much easier for all involved, if we just quit squirming and allowed the billionaires, with their computerized and biological overseers, to help us make all these complex decisions. For our own good, of course, so we can all lead happy and productive lives.

Tempting to be sure, and a merciful way to dispose of western civilization, but I’m afraid that the Reverend Dr. Martin Luther King's famous long arc of the moral universe is still bending towards justice, and away from slavery by any other name.

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