It is a capital mistake to theorize before one has data. Insensibly one begins to twist facts to suit theories, instead of theories to suit facts.

Sherlock Holmes, in Scandal in Bohemia

I’ve been reading Jack Wennberg’s new book Tracking Medicine, which is about his lifetime of work in understanding the reality of how medicine is practiced, as a route to helping us achieve the best care possible for each of us. My first post about this was three months ago, en route to a seminar on SDM (shared decision making); my first post after the seminar was shortly after. The whole subject has bent my thinking about healthcare so severely that it’s taken me this long to decide what to say next.

Key findings:

  • Your doctors, with the best of intentions and the best of training, may unwittingly be prescribing treatments that aren’t necessary for you, or not prescribing things that are. (“You” includes anyone you’re caring for.)
  • This realization was developed not through people’s opinions but by looking at cold hard numbers. After controlling for all variables, the odds of a given patient getting a given treatment vary by hundreds of percent from region to region.
  • For whatever reason, decades of efforts to change this have been fruitless, so the risks from unnecessary treatments continue and inappropriate care continues.
  • Part of the reason is that we’re in denial (patients and providers alike), and part of the reason for that seems to be that the causes are unconscious. (See below.)
  • This doesn’t mean your doctors are incompetent – the forces at play seem to be universal. The problem is that virtually nobody realizes it’s happening – neither we as consumer/patients nor the physicians.
  • E-patient takeaway: If you want the best care for yourself and your family, do what you can to understand these issues and have empowered, engaged, participatory conversations with your providers.

Wennberg’s method was to crawl through databases. From the start of his book:

Early in my career, I was hired as director of a federally sponsored program whose goal was to ensure that all Vermonters had access to recent advances in the treatment of heart disease, cancer, and stroke.… As the results came in, however, rather than evidence for underuse… we found extensive and seemingly inexplicable variation in the way health care was delivered from one Vermont community to another.

This “practice variation” is described in my previous post. Today’s post presents a  top-level introduction to what has taken thirty years of analysis and testing to confirm. It’s hard to imagine this is true; read the book. In short, Wennberg and his colleagues have established that healthcare decisions in reality can be categorized in three groups:

  • Effective care: situations where there’s no debate – all eligible patients should get this. Example: if you have a broken hip, you should have a hip replacement.
    • This is about 15% of Medicare spending.
    • As a separate cause for concern (not cited in this book), other studies have found that doctors only recommend “the standard of care” about half the time. (Isn’t that amazing and eye-opening?)
    • Note: this is only 15%. 85% of the time, the decision is open to consideration, and you should be presented with options.
  • Elective or “preference-sensitive” care: there’s more than one option, and outcomes vary depending on which option you choose.
    • This is about 25% of Medicare spending.
    • Includes decisions about some surgery, and some screening tests.
    • These decisions are preference sensitive – they have different quality of life (QOL) implications, so the “right”decision for proper care cannot be made without knowing the patient’s preference. You should be asked.
    • Example: if you have an enlarged prostate, one option is to just keep an eye on it (“watchful waiting” or “active surveillance”). The surgical option has significant risk of side effects: impotence, leakage, other issues. Years of research has shown that the importance of each side effect varies widely by patient. The correct decision can’t be made by the doctor alone.
    • But many (perhaps most?) clinicians don’t present us with the range of options – they make the choice for us (perhaps with the best of intentions) and then ask our consent. (This is the “informed consent” form we’re asked to sign.)
    • Most patients don’t know about this, so they don’t ask and they don’t get involved with decisions. But when the options and trade-offs are presented, people often opt not to have surgery. That’s informed choice, vs informed consent.
    • Here’s something to think about: some people at the Foundation for Informed Medical Decision Making (FIMDM) propose that operating on a patient without knowing their preference can be as much of a medical error as operating on the wrong limb! (In both cases you may be cutting something that shouldn’t be cut – a clear mistake.)
  • Supply-sensitive care: 60% of Medicare spending (sixty percent!)
    • As described in the previous post, in a majority of cases your likelihood of having a treatment recommended is proportional to how available it is in your area not related to your need. Even the chance that your death will occur in an ICU is proportional to the supply of ICU beds in your area.
    • Yes, there is vast historical evidence for this. (See Sherlock Holmes above.)

“Supply-sensitive care” smacks of Parkinson’s Law (“Work expands so as to fill the time available for its completion,”), or, according to Wikipedia, a generalization: “The demand upon a resource tends to expand to match the supply of the resource.” Indeed, a similar law, Roemer’s Law, is widely accepted by people I’ve talked to: “A bed built is a bed filled.” (No matter how much hospital capacity you build, it’ll get used up.)

And the doctors who recommend that we be hospitalized to the gills generally don’t realize they’re doing it.

Think this is a complaint about American healthcare? It’s not. For instance, in 1992 it was noted in the Netherlands:

e-Patient take-aways – Things for engaged / activated patients to realize:

I can’t overstate the importance of realizing this as we approach any decision about a treatment, especially surgery. It’s especially important to realize that your own physician, with the best of intentions, may not be aware of the invisible influences driving the treatment recommendations of his or her peers in the local community.

It seems clear to me that we must, must, must create discussion tools – an index card, a flyer, a website – from a respected source to help clinicians listen when we ask, “Is this treatment necessary?” and ask for help in researching the rationale for the decision, including researching the relative frequency of recommending it locally compared to other hospital referral regions.

We need to educate clinicians, patient advocates, insurance companies and health plans, and each other about this issue. What’s at stake is patient safety: every hospitalization and treatment carries a risk of harm as well as the possibility of improvement. I’ve heard from many people that their physicians are sometimes offended when patients ask. (Of course, many other physicians aren’t.)

Our society’s definition of participatory medicine talks about patients becoming “responsible drivers” of their care. Clearly, shared decision making is essential: we need to stand up for our right to be responsible for what happens to our bodies.