Sunday, October 9, 2016

Private Health: American Individualism and the Tyranny of Evidence

I've criticized the two main sides in the vaccine "debate"  previously. One of the things I made clear concerned the personal nature of health care decisions in American culture. Not that other cultures don't share some similar values, such as avoiding harm, doing good, and confidentiality. They do. But many state-run or "single payer" systems are operated on the premises that health care is a right of the citizenry and that therefore all citizens must contribute to the general welfare.

This basically means that the people as a society make sure that everyone has health care. In the US, this has often been interpreted as everyone has terrible health care, which is rationed and miserable. However, most Britons and Canadians like their systems. You get sick. You go to the doctor. You get treated, and you leave better. Simple.

There are problems, but they aren't as bad as they're made out to be. Yes, sometimes people wait for elective procedures. The systems can be overburdened. Like any public enterprise, these things go through good times and bad. Political neglect can lead to actual neglect and poor service or shortages or mismanagement. These systems may be closed (Canada) or open (Britain), meaning there may or may not be a legal cash system outside of the national health service. I'm really simplifying this a bit, so bear with me. But this does describe the essentials, and many countries operate this way.

We here in America have criticized ourselves soundly for our failure to pick up these habits of advanced societies. Of course, by a lot of metrics we do have some pretty bad stats--higher infant mortality, lower life expectancy, much higher costs, and so on. But still, are we that bad?

America is "the land of opportunity." We value the frontier. Although that frontier has become less physical and more metaphorical: we pursue the edge of things, space, medicine, technology. It makes sense that ours is a "free market medicine" opening the doors to creativity and innovation.

These other societies that have centralized their health care delivery and payment streams have managed to achieve remarkable gains in health and longevity. That is true. But perhaps ours is a different metric. Perhaps we measure health as much by our perceptions as we do by our statistics.

I hear a lot of complaints about doctors, medicine, hospitals--but that happens everywhere. Sick people aren't at their best, and to the sick the world can seem a sour place. And mistakes and misadventures happen in all systems of health care delivery, regardless of who's paying the bills. So it also makes sense that our system, despite its obvious faults, "works" in that it imbues us with a sense that the impossible is possible.

I support single payer health care. It's parsimonious and efficient, and it can be humane and expeditious, if supported properly. But I do begin to understand why it's so hard for many in our culture to accept that communitarian health care is to be rejected as a policy change. It robs us of our power, although arguably there's no evidence that Britons feel "robbed" of anything. It is possible here to pay for anything. It is harder in Britain--they make choices that to Americans feel like a defeat. If everything can be done it should be done, regardless of the cost, although held in check somewhat when the "everything" is painful, tortuous, and causes it's own suffering when the benefit really is small.

Recently I helped a family member navigate a new health problem that had all the earmarks of "going bad"--and by this I mean an ever-growing list of tests that obscure more than they reveal, and would expose this family member to an ever-growing list of potential side effects, medical misadventures, and puzzling-but-likely-inconsequential findings that would require "further investigation" but lead to nothing.

This, I have seen before.

The thing that brought me into the picture was the cost of a special type of MRI that the insurance wouldn't cover. This was not because the insurance company is mean, but because experts there know that risks would exceed the benefits at moment in the diagnostic process, and they would pay for a different kind of test--one I might add that is a bit painful for the patient!--but one that would yield more useful diagnostic data in the process. My relative didn't want to pay for her daughter's uncovered special MRI if there was no good reason to do so, but she was a bit peeved at the insurance company.

This is how people experience the "tyranny" of evidence: the evidence pointed to not pursuing the testing that my relative intuitively felt would be more useful to sorting out her daughter's problem. This is understandable, and in my view it's also the reason why Americans instinctively turn away from the possibility of single-payer health care.

In short, we don't want a system that uses evidence to guide health care decision-making because we fear we won't get the care we think we need. We are willing to suffer the inefficiencies and excess costs of our current system because each of us wants what we feel is the "very best."

There's a wrinkle in this argument, and it's similar to the wrinkle in my family member's health care adventure.

If the original operators who evaluated her had done a careful history and thorough physical exam perhaps they'd have found what I did, that the "problem" which seemed on its face so dire was really a less serious problem, nothing that would require extensive, expensive, and painful testing, and nothing that would require the specialists to whom she had been referred.

So, it's not the means of delivery, but the means of execution of our health care that perhaps we ought to be concerned with. I'm not proposing that every clinician needs the clinical acumen of TV's Dr. Gregory House. But heck, I'm just a nurse practitioner and I figured it out!

I propose that the problem is not how we pay for health care, nor who controls the delivery, whether it's insurance companies or a government agency. The problem is that clinicians have become mentally lazy. Listening with empathy, hearing the patient's story while mentally framing that story with basic principles from anatomy, physiology, and pathology, and doing a careful, attentive examination would save more money, deliver more effective care, and produce more healthy, satisfied patients, than anything else we could do with system organization.

I started this blog entry over a week ago. The event I described happened just a week ago--so it closes out the theme in the title in a way I didn't initially expect. It's not about who will pay for health care, nor how it will be paid for. Ultimately, we as a society have to figure out how much waste and inefficiency we will tolerate, and how much control we will cede to others (whether it's an insurance company or a government is merely a matter of aesthetics!).

If I sound a bit sour toward my colleagues in health care, it's on this deeper point concerning the actual clinical encounter. My family member's health concern was treated by decent people, I'm sure. But those same people (one, a specialist) got all tied up in fruitless speculation and punted to exotic tests without good cause. I realize the pressure to order tests that clinicians are under. But I have universally found that simply explaining one's reasoning process and the potential hazards and inconveniences of excess testing soothes people. It's not that you're being stingy, you're acting in their interest.

And by the way, my family member's doing fine. It seems all will be well at this point. It just took a bit of thought and kind, non-technical explanation.

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