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Saturday, June 14, 2014

Telling people "You should not want that"

We are increasingly steeped in the evidenced based medicine culture. In a nutshell, this culture promotes interventions which we can demonstrate objectively that patients benefit from. Interventions which fail to demonstrate positive benefits are viewed with skepticism. I am very much a data driven person and I embrace the idea that if I am to push something as adding value to patients lives, I want to have a substantial degree of confidence that it really does accomplish this.

However, throughout the health care delivery system we are grappling with a very difficult problem. Patients frequently desire interventions which evidenced based enthusiasts believe provide them little or no value. We find ourselves taking time to convince patients that "You should not want this".

Our measurements and assessments are based upon the rational patient and doctor model. Measuring what we measure to assess value, we conclude that no rational person presented this evidence should want to have particular interventions or tests done. However, human needs are not always based upon rational desires and the value provided by a host of medical interventions and tests may not be what we think them to be. The actual value which patient derive may be based upon fears and wants which are emotionally based and have little or no basis in what we view as solid evidence of benefit.

As an example I can point out the entire industry based upon screening for early disease. Companies send mobile vans with testing equipment into a host of environments. The idea is there is the potential to reach patients who might benefit but because of accessibility issues, are not normally reached. However, those reached also who are already undergoing care who seek out these additional interventions because they provide some additional level of reassurance which they derive from the believe this action provides some additional protection from bad outcomes. Patients under the care of dermatologists go to skin cancer screenings, patients under the care of their internists get free PSA or lipid panels at the mall, and patients under the care of cardiologists pay additional sums to get a scan to look for calcium in their cardiac vessels from the van cruising their streets.

Another example is the recent decision of Medicare to cover gender reassignment surgery. This is the quintessential example of where human needs and wants are confused and confusing. There is absolutely no objective measure which can be used to justify this specific human desire, to change one's sex. If it is acceptable to say that there is a medical indication for this particular intervention  based upon this unique set of human desires, I am hard pressed to find any other human emotional desire which cannot be justified similarly. Whether one medical professional or another believes it unwise for a particular patient to desire a particular intervention based upon some sort of objective criteria becomes completely irrelevant, no matter what the data might show.

Based upon everything we know, patients should not want particular things but some (many?) do, because at an emotional level, these actions provide something which makes them feel better. This type of behavior is not unique to customers buying products in the health care arena. We purchase many products where either the product provides little or no objective benefit or we move to a higher end of the market to purchase higher priced variants which provide no greater objective value than the more basic products that can be obtained at steeply lowered costs.

We humans have desires which cannot be explained by the objective outcomes which can be measured. That we believe that the mechanisms to meet health care needs and wants can be segmented from the mechanisms we use to meet rest of human wants and needs is simply folly. We end up telling people that they shouldn't want things that they want, not really understanding their motivations and denying human nature.


  1. In contemplating both of the recent posts on individuals' irrational wants and the growing availability of telehealth consultation, I wonder if we will not indulge the former with implementation of the latter to the detriment to the overall health of the population. When a patient can get a quick consultation on that spot on their skin they've always wondered about and a dermatologist can get paid for that brief remote encounter without the overhead cost of physical plant and staff, there is a natural incentive for both parties to do more of the same with prospectively reduced availability of the clinician to those who truly need a physical encounter for treatment. Insurers, whether governmental or private, operate on an optimization model to maximize their client's satisfaction and minimize their own cost—an individual's health is a secondary consideration, protestations to the contrary notwithstanding. Insurers would have an incentive to pay a premium for such services as long as that amount is less than the aggregate cost of care for that individual. What's more is that any overall delay in the availability of providers—who are busy doing telehealth consults—to actually provide needed face to face evaluation and management is in their interest by deferring more expensive interventional care. Circumventing the one market check on over utilization of such services, perversely, insurers would have an incentive to offer patients a full or partial waiver of their deductible for such services and pay providers a premium for not seeing patients avoiding more expensive evaluative procedures such as a biopsy that might be contemplated in an office encounter. The worried well, their doctors and their insurers, may be well off at the expense of the truly sick.

  2. And how do we determine if someone "truly needs" something? What is the outcome we can ultimately measure which will allow us to actually discern if the decision to deal with something using remote tools was a good or bad decision? This is not at all simple. However, there is an additional danger if we assume that the current state is so ideal that in the absence of the ability to measure something meaningful that we should freeze the current state in place and avoid innovations.

    I have confidence that remote health tools can save patients time and money. There is data that such approaches are not inferior to face to face encounters and if this is the case, the time and money savings associated with this should spur further adoption. The structured nature of the data collection with these encounters will also facilitate outcomes measurement. Let it happen on a small scale, avoiding top down mandates and we will be able to view impact in pilot programs.