As we savor the fading days of summer and begin to gear up for a busy autumn, it seems like to good time for another edition of “Three Tensions In Healthcare.” (My usual disclosure/reminder: I work at a cloud genomics company in Mountain View, CA.)
Tension 1: Guideline Fatigue
The delivery of care is said to suffer from excessive variability, which can result in some patients receiving a higher quality of care than others.
To improve performance, there has been the widespread adoption of guidelines, standards and checklists, which have often been critiqued for their imperfections – the level of evidence can be remarkably weak, the motivations behind the guidelines may be questionable and their implementation can reflect excessive generalization.
But even if these guidelines, individually, are flawless, it turns out that the sheer number of guidelines can create a problem of its own, as Bill Gardner, citing recent papers by Leonard Wong and by Blumenthal and McGinnis, has discussed with characteristic elegance.
Clinicians, Gardner writes,
have to optimize their time by prioritizing from an indefinitely long list of tasks that could potentially benefit patients. Therefore any requirement that constrains clinician choice has an opportunity cost in terms of the other things that she might do for her patient. Ideally, before setting a standard we should compare the benefit that can be achieved by implementing the standard against that opportunity cost.
There are two issues here. First, we tend to promote adoption of a particular guideline based on a narrow definition of effectiveness – how it performs at improving the specific task at hand. We often fail to consider the collateral harm adopting the guideline might be doing by distracting providers from potentially more important tasks. Second, adherence to guidelines is often used as a measure of physician quality; I’ve even seen it invoked to support the efficacy of standardized tests, as some exam scores may correlate with the degree of adherence.
But given the explosion of guidelines, the very best clinicians may not be the ones who meticulously and indiscriminately plow through each one, determined to document completion, but rather those who intelligently prioritize, and try to determine on a patient-by-patient basis, where best to spend their limited time.
Tension 2: Patient Power
On the one hand, we seem to live in the age of the empowered patient; there are books like Eric Topol’s The Patient Will See You Now (my WSJ review here), and laudable populist movements like GetMyHealthData, championed by Farzad Mostashari and others. The general thesis is that as more patients demand data, it will inevitably start flowing more freely.
I passionately endorse this ambition. In fact, my own contribution to this discussion, a vision for the “Data Inhaling Clinic Of The Future,” is predicated on the idea that clinical centers offering improved data sharing would have a competitive advantage, since patients would preferentially choose to receive care in such an institution.
Lately, however, I’ve been having some doubts. Not about whether we as patients deserve improved access to our own data – we absolutely do – nor about whether we as patients deserve far more liberty in our ability to order laboratory testing – we absolutely shouldn’t need to go to Arizona (thank you, Theranos) to get this done easily and legally. We also should be able to obtain access to our raw DNA sequence without requiring either a physician’s prescription or an IRB’s stamp of approval.
My concern is whether there are really enough activated consumers to drive the change required. Without question, seriously ill patients, and families of these patients, clamor for improved access. So do a relatively small number of quantified-self folks.
But the reality is that although all of us are potential patients (as Susan Love, a strong advocate of the idea that everyone is a patient, phrased it, you are either post-op or pre-op), we rarely see it that way. Most people are not seriously ill most of the time, and tend to avoid thinking about the possibility of being sick. Most might even support improved data access in theory, but it’s unlikely to be a top-of-mind issue; most people are blissfully unaware. Consequently, the patient “call to arms” evokes the image of John Belushi charging out of Delta House (the first time), followed by no one. Hopefully this will change – as it did for the Deltas.
If there was any sense at all the improved data access and better sharing would encourage consumers to select care from that particular hospital, I suspect that more clinics would jump at the opportunity to provide it. Instead, and rather perversely, sticky data likely represents a business advantage for most hospitals, and unfortunately, one they seem reluctant to give up any time soon.
Tension 3: End Of Life Dollars
There are two major contemporary issues around how care is provided at the end of life. First, there is the very real sense that patients often receive more care and more intensive care than they would actually want, if anyone had bothered to ask. Instead, horror stories – all too real – abound. Improved dialog (many would add: any dialog) should lead to end-of-life care far more aligned with the patient’s wishes.
At the same time, end-of-life care is also frequently associated with a consistent economic message: a disproportionate amount of money is spent for care at the very end of life, care that is often said to be futile. Reduce this spending, we are told, and you could save the system a lot of money.
It’s not hard to see where the tension is, especially as more care delivery organizations begin to own a sizable share of the financial risk (such as in ACO models). An at-risk organization (and its physicians, who generally share in any cost-savings) generally does better, financially, if very sick patients select hospice rather than pursue aggressive treatments.
The key question – as Lisa Rosenbaum insightfully suggested on Twitter – is how to ensure that thoughtful conversations with patients (through the process of “shared decision-making") do not become a mechanism for consistently nudging patients towards less care.
Will physicians who work in at-risk organizations feel pressure to goose patients towards hospice? Will there be a tendency for physicians in these organizations to convince themselves nudging towards hospice is generally the right thing to do? Conversely, will patients worry their doctors are de-emphasizing potentially beneficial treatments in an effort to save money?
Arguably, the larger concern is not that a particular physician will nudge an individual patient towards hospice, motivated by the tiny financial gain that might accrue, but rather that the underlying economics will result in a subtle shift in the culture and ethos of the healthcare system, in a fashion that favors less care rather than more.
Providing less care to the extremely ill would be a very positive development if driven by the thoughtful evaluation of patient preference. However, such a bias becomes a much more concerning development if driven by providers who are either looking out for their own financial interests, or are motivated by their high-minded perception of what’s in the best interest of the healthcare system as a whole, rather than exclusively considering the individual patient.
A patient must be able to trust that his physician is focused exclusively on discerning and delivering the best care for the individual patient before her.
