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Sunday, September 8, 2013

Never say die

The Saturday WSJ published a piece "The ultimate end-of-life plan" by Katie Butler. She has authored a book "Knocking on Heaven's Door" (which I have not read). The Journal piece outlined her mother's story (Valerie Bulter) and her refusal to embark on "heroic" measures to prolong her life.(End of Life) The story is not new or unique. Her mother decided against invasive measures to improve cardiac function based upon her previous experience caring for her husband whose life was extended but only at the cost of severe debilitation and dementia.

There is a bigger story here which is much more generalizable beyond end of life decisions. As I have previously written about there is a bias for action which has developed within American health care . Its sources are multiple. There are financial incentives, no doubt but it goes way beyond finances. They reinforce tendencies which are preexisting and those biases are two fold. First, we worship the persistent and those who say never say die. Second, we tend to overestimate the likelihood that action will provide benefit and underestimate the tendency for interventions to cause mischief. Daniel Kahneman refers to these biases where we irrationally underestimate the risks of what is familiar and overestimate the risks of what is outside our common experience. In this case intervention is familiar and deferral of intervention is uncommon.

Ultimately the payment system has has evolved to reinforce these biases, providing handsome rewards for those whose default mode is to act much and think little. Communications to patients billed as educational outreach blend seamlessly into marketing efforts, exaggerating potential benefits and discounting harms. When faced with someone like Valerie Butler, who failed to be sucked into the action first mantra, there is disbelief followed by repeated efforts to sway her decision. Virtually everyone has come to hold the same belief system.

Take a look at almost any medical practice and where action is taken, it may bring little value to those they serve. Yet most actions have CPT codes which pay substantially more than E&M codes associated with cognitive work. Deep thinking will more often result in finding reasons not to act which pays less that thinking and acting fast.  The payment system reinforces biases which then go on to reinforce the payment system. The public wants everything done. They are part of the problem. Physicians are biased toward action and payment for action. They are part of the problem. Health systems are paid for volume. They are part of the problem. Insurers have made money by being middle men. They are part of the problem. We have met the enemy and he is us.

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