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Sunday, June 27, 2010

The end of information asymmetry as we know it

It has been almost 50 year since Kenneth Arrow published his work entitled "Uncertainty and the welfare economics of medical care". The concept of information asymmetry and its impact on health care was introduced. This concept has fundamentally shaped our view of doctor patient relationships and our obligations as professionals. However, the world is changing and so must our views on how information asymmetry affects doctor-patient interactions.

When Arrow wrote his essay, medical information was a scarce commodity and difficult to acquire and vet. Physicians, through their extended training, experience, and professional networks had virtual monopoly control over the information required to make medical decisions.  As I see it, this environment of asymmetric distribution of information fostered a paternalistic relationship between doctor and patient. Since patients could not realistically be viewed as getting access to nor synthesizing the information required to make informed decision regarding their health, physicians were entrusted to make such calls. Until recently, this process was not widely questioned.

My practice has changed dramatically in the past five years in terms of what information I can and do access and how I use that information. Where I used to go to the medical library to pull articles, I simply go on line. Furthermore, more often than not, I access non-proprietary information. This means I am reading the same information that my patients have access to. I refer to this phenomena as the first medical reformation, likening it to when the printing press allowed greater access to the Bible by non-clergy.

While some view this as a threat, I see opportunity. When discussing options with patients, I often defer implementation of treatment for non-urgent problems, instead directing them to well moderated internet sites with vetted information regarding their specific ailments. They often find elements of information which fail to register with me as important. For certain patients with certain chronic diseases, they may link into disease communities which hold vast stores of information crucial to coping with chronic disease, something that is essentially missing from our training as physicians.  I fully understand that over time, many of my patients who are singularly focused on a single disease may become more of an expert on that given disease than I am. I treat some very smart, motivated,  and insightful patients.

Perhaps one of the most important areas where the disappearance of information asymmetry may have a profound impact is the development of  guidelines of care.  This is an arena which has taken on substantial importance for a number of reasons, not the least of which is they are being linked to quality metrics which then linked to payments for services. Guidelines are all about data and interpretation of data. The data used is ideally controlled trials for whatever intervention (diagnostic or therapeutic) is being considered. If high quality data already existed, the development of guidelines would not be so problematic. However that is simply not  the case.

We are left with the situation that we are being called upon to measure something important but we are not really sure what is important. Furthermore, we have not really decided who should decide what is important. In the previous era where information was scarce and could realistically be interpreted by highly trained professionals, it made sense that they be the primary agents involved in the development of guidelines. However, that is almost certainly not the case now.  In a world where physicians and other health professionals no longer have exclusive access to the vast majority of information required to make clinical judgments, what set of skills and attributes can justify their continued control of this process?

There is a paradox (no pun intended). Guideline development heavily focuses on Grade A evidence; hard data, controlled trials, and not anecdote. What physicians have, that the public does not, is experience and from this experience, intuition. Within the world of evidenced based medicine and guideline development, this doesn't count for much. It makes me wonder what the future holds for the medical profession. What will we do in the future which will bring value to patients?

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