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.