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Saturday, February 26, 2011

Sound Bite Medicine

Peggy Noonan wrote an interesting column in the WSJ this morning (http://online.wsj.com/article/SB10001424052748703408604576164763798782124.html?mod=WSJ_Opinion_BelowLEFTSecond) entitled "The internet helps us get serious". The basic premise of this piece is the internet has again changed how information is presented and appears to be capable of rescuing us from the sound bite mentality.  As she summarizes:
In the past quarter-century or so, the speech as a vehicle of sustained political argument was killed by television and radio. Rhetoric was reduced to the TV producer's 10-second soundbite, the correspondent's eight-second insert. The makers of speeches (even the ones capable of sustained argument) saw what was happening and promptly gave up. Why give your brain and soul to a serious, substantive statement when it will all be reduced to a snip of sound? They turned their speeches into soundbite after soundbite, applause line after applause line, and a great political tradition was traduced. 
But the Internet is changing all that. It is restoring rhetoric as a force. When Gov. Mitch Daniels made his big speech—a serious, substantive one—two weeks ago, Drudge had the transcript and video up in a few hours. Gov. Chris Christie's big speech was quickly on the net in its entirety. All the CPAC speeches were up. TED conference speeches are all over the net, as are people making speeches at town-hall meetings. I get links to full speeches every day in my inbox and you probably do too. 
The reason that TV moved to the sound bite was time pressure. The time real estate associated with news  programming became so precious that no one could devote sufficient time to fully explore an idea or point of view. What the internet is doing is moving information exchange from one way to two way and while there are time constraints, they are simply less constraining. People are abandoning broadcast in droves.

So, what does this have to do with medicine? Reading this article made me realize that we practice sound bite medicine for many of the same reasons that conventional news organizations practice sound bite news. Our information exchanges with patients occur in remarkably time constrained circumstances and the results are predictable. We simplify the messages so that they can be conveyed in the few moments we have with patients and are framed to virtually guarantee what decision will be made. Here, get this blood test to screen for prostate cancer. We will discuss the results later. You need to get your mammogram and if something is identified as worrisome by the radiologist, we will send you to the surgeon or radiologist to have something else done. You need to be on this statin to prevent heart attacks.

Who is going to question these recommendations presented as they are? Who wants to have cancer or heart attacks?  However, the usefulness to any given patient is not so overwhelmingly certain. How many patients are in a position to ask questions such as ..Do I really want this test or drug? How likely will it be that I actually benefit from this? What is the likelihood of harm? No many given how fast the throughput that is needed to feed the machine. Can there actually be any discussion?  Not really since the waiting room is full of patients waiting to get their sound bites.

Granted there are many people who are the equivalent of politically agnostic. They do not really appear to care even though they have a dog in the hunt. However, there are many who will be willing partners in shared decision making but the architecture of present encounters allows them only time sufficient to exchange sound bites with their caring physicians.  These patients have great value since they are the ones who force health care providers to reflect upon what they are doing and make sure we do not simply default to believing all of our sound bites.

I often hear my colleagues ridiculing the health information posted on the net but I would argue that the those who seek information there are infinitely better informed than those who rely on their physicians. This is true not because their physicians are generally uninformed but because they are unwilling or more  likely unable to devote the time required to go beyond simply sound bites.

The internet has the potential to create really valuable  tools which can both provide much enhanced educational and disease management tools for patients that go beyond platitudes and sound bites. There is risk involved but the risk is probably greatest to the relative monopoly of the conventional health care industry. The internet has disrupted the print and broadcast journalism industry and while those displaced lament the changes, the public now has access to information which they could have only dreamed up a generation ago. Journalism is alive and well. Similarly, changes in information flow in health care are almost certainly going to disrupt the historical doctor-patient relationship. As the decisions get more complicated and the goals for individual patients more nuanced, the sound bite approach won't cut it. Patients deserve and will demand better and if we do not deliver it, they will get want they want from other quarters.

1 comment:

  1. Excellent post, however as a fellow disciple of Richard Epstein I would take issue with the concluding sentence. That patients "deserve" better is a value judgment more based on a deontological perspective than a utilitarian one. That they will "demand" better is good as competitive forces in health care as in any marketplace is welcome. However they will not get what they want from other quarters—they will get what they pay for. Given the present and prospective reimbursement structure, and the constraints legal and financial to circumventing it, patients will be getting soundbites for medical information from their physicians now and increasingly in the future—and probably mini-bites at that. And the quality of information they pay for from alternative sources will follow the fundamental axiom of "you get what you pay for" as well. Unfortunately in the professional realm there is an accelerating tendency of regression toward the mean—or perhaps in this case regression toward mediocrity—for care, especially the educational component of its patient encounters. The extrinsic pressures toward homogenization of care and the unthinking, reflexive practice of medicine that physicians in training learn ("get a PSA or mammogram" "that atypical looking mole there must come off because it is almost certainly a melanoma" as my pathologist will certify) will insure this trend continues until market forces are allowed to operate on economic side, legal and regulatory constraints are reigned in on the political one, and academic institutions reassert their primary mission of training practitioners to think critically.

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