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Sunday, August 29, 2010

Time pressures and medical decisions

I was doing my usual scan of the blogosphere and national papers this morning and I came upon an interesting quote from John Oxendine, who is the Insurance Commissioner for the state of Georgia. He was commenting on the problems associated with various forms of add on insurance (such as insurance on modest retail purchases) and stated:

 “This is the bottom line key with any kind of insurance,” Oxendine said. “You should never make a decision when you’ve got pressure and time constraints. That’s when people get ripped off and make a mistake.”

This is basically good advice for anyone under virtually any circumstances. Making rash decisions without taking time to weight the options is never a good idea. The irony here is within the realm of health care we make virtually all our decisions under the influence of pressure and time constraints. I understand that there are some circumstances where there are real time constraints where decisions need to be made quickly because lives are a stake. However, most encounters that patients have with physicians and their surrogates occur under circumstances where time pressures are artificially inserted, mostly to promote patient throughput.

Earlier this year I had by annual visit to my internist, dealing with the usual over 50 year old male issues. As some of you who have followed my blog for a while realize, I am skeptical of the mindless application of screening tools for prostate cancer. After much thought, I elected not to have a PSA drawn. However, the default mode is to opt in for PSA screening and I was the one who had to take the initiative to opt out. I cannot help but think of all the men who had their PSAs drawn with little or no discussion regarding the implications of what this test meant and the potential cascade of events which it might trigger.

I am the first to recognize that a full discussion regarding the upsides and downsides of PSA screening would be difficult to impossible undertake within the confines of the usual outpatient appointment. There is simply not enough time. However, what happens to patients as a consequence of this is even worse than the circumstances described at the checkout counter and add on insurance. At least there the default mode is to not purchase the item and you are asked to opt in with little time to think and little information to work with. In the doctor's office various add ons are added on as a default with virtually no discussion as to their risks and benefits.

Part of the issue is most of the broader medical community has actually given little thought to the actual value which these add ons provide to patients and they hold firm beliefs that indiscriminate application of these add ons is an unquestionable plus. The actual numbers may be much less impressive. Just how many people do you need to treat with a statin for one to benefit?  If one screens 100,000 women with mammography over 20 years, how many lives will be saved and how much will this impact those without disease? How many people need to be treated with bone sparing agents to prevent one hip or compression fracture?  How many patients with mild hypertension need to be treated to avert one vascular event and how many will be harmed by their medications?

One thing these interventions have in common is the decision to intervene and the selection of the specific intervention generally occur within the time frame of a basic office visit. The virtually guarantees that there is not sufficient time to actually discuss options. The implications are that absent this discussion, stuff happens. The default mode is to intervene. Tests are ordered and medications are started and given the time constraints and pressures are not likely to improve on subsequent visits, it is not likely that any meaningful discussion will happen in the future. Inertia will take over and cascade of intervention and treatment will continue indefinitely.

I see countless patients on long lists of expensive medications prescribed to prevent conditions which may never happen and they really have no clue as to why they are taking them.  I do not mean to point the finger of blame at their primary care physicians. They are victims of the same faulty decision making architecture. No one has had the time to explain the odds and taking the time to do so is simply not valued by anyone.

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