Your comments on “The Ticking Clock” (below) raise some questions about consumer-driven healthcare that I decided deserve a separate post.
One reader wrote: “We have all been fretting for decades over how to get patients more involved in understanding and buying-in to their health care needs. Consumer-Driven Health Care (CDHC) is the most effective means to that end that has ever come along.”
He added: “Certainly you are right that very often the optimal treatment is unknown or ambiguous. But isn’t that precisely when the patient should be making the final decision? Who else should do it? That does not mean the patient is playing doctor, only that patients will consult with physicians they respect for the best recommendation and will decide on what course of treatment they are most comfortable with. It is, after all, the patient’s life and health that is at stake.”
Another reader responded to my comment that when the patient begins to think of himself as a “consumer” and of the doctor as a “retailer,” this can undermine the trust needed in a doctor-patient relationship. He replied: “As a physician I have to disagree with your comment that ‘Even then, many physicians feel that the consumer vs. seller model undermines the patient doctor relationship.’ If anything it enhances the relationship as only the consumer truly understands their needs and therefore it is best for the consumer to have a good deal of control. Some physicians tend towards protectionism. I also think your opinions regarding the ability of a patient to make [his or her] own decisions [are] a trifle paternalistic, though I can understand how you might have come to that conclusion.”
Let me say first, that I agree with both readers. But I think that what they are describing is not “consumer-driven medicine.” It’s “patient-centered medicine.” There is an enormous difference.
Begin with what “consumer-driven medicine” really means. Here, I’ll
defer to Harvard Business School professor Regina Herzlinger who is
probably the best-known advocate of the consumer-driven model. (Money magazine has called her the “godmother” of consumer-driven medicine. On her website, she takes credit for inventing the term.)
In her book Market-Driven Medicine Herzlinger defines “smart consumers”
as people who wants “top quality, fast delivery, and excellent
service—all of the time. They do not want to play games. A furniture
retailer notes that American shoppers say, ‘I want it the way I want it
and when I want it—and I want it instantly.’”
This might be a useful (if somewhat obnoxious) stance to take when
purchasing a sofa, but healthcare cannot always be delivered quickly. A
good diagnosis may take time.
Herlzinger believes that health care consumers should demand “convenience, control and choice."
Convenience, she argues, is extremely important. Thus, she believes
that doctors should have office hours on evenings and week-ends. And a
patient never should have to wait in a doctors’ office.
This ignores a few realities: Doctors who get up early to do surgeries
are too tired to work evenings. Those with families would like to see
them on the week-ends—just like everyone else.
As for waiting in a doctor’s office, medicine is unpredictable. I
expect my hairdresser to keep to his schedule because he knows how long
it takes to cut a person’s hair. A physician, on the other hand, has
no way of knowing which patient will come in complaining of headaches
–and then break down and confess that she has a drinking problem. She
needs counseling and attention that will take more than 20 minutes.
Another patient who suffers from congestive heart failure seems much
more forgetful than he was the last time the doctor saw him. He also
appears to be very nervous. A little careful questioning may reveal
that the patient is aware that he is becoming more forgetful, and that
he is afraid that he has Alzheimer’s. As the conversation continues,
it becomes apparent that he has finally come face to face with the fact
that his congestive heart failure will ultimately prove fatal. He
probably does not have long to live.
Complicating his schedule further, earlier in the morning, this family
doctor “worked in” a 5-year-old who did not have an appointment—but who
did have a terribly painful ear-ache. The doctor had to explain to the
mother that, no, the child did not need antibiotics, but she did need a
pain-killer. That put him 20 minutes behind schedule at 10 a.m.
Meanwhile, in the waiting room, Regina Herzlinger is tapping her foot.
Control or “mastery” places second on Herzlinger’s list of priorities.
Here she praises “health care activists” such as Janine Jacinto
Sharkey, who told Town and Country magazine how she
custom-designed the types of incisions that her surgeon used to remover
her breast cancer tumor, faxed questions that arose from her research
about breast cancer to her surgeons, and even selected the classical
music to be played in the operating room. Notes Sharkey: “I’m not the
kind of person to sit there and allow someone else to dictate to me. I
question. I’m involved.”
Uncertainty and Trust
The consumer-driven model assumes that healthcare is a product to be
bought and sold, just like an automobile or a refrigerator. This just
isn’t the case. First, health care is a service, not a product, and
providing the service is as much an art as a science. This often makes
it very difficult to measure the “value” of health care. And this is
why there is no Consumer Reports for medicine (or for art).
While Consumer Reports can rate the benefits of various mid-priced
refrigerators, briskly and clearly, in a way that makes comparisons
easy, it is often all but impossible, even for a physician, to be
positive of the relative benefits of a great many medical treatments.
Of course, in certain cases there is little ambiguity. If I break my
arm, my doctor and I both know what needs to be done. “But only about
25 percent to 30 percent of the decisions that doctors make are backed
up by really good medical evidence,” Dr. James Strickler, former dean
of the Dartmouth Medical School once told me. He went on to define “the
art” of being a good physician: “Learning how to make adequate
decisions in the face of inadequate evidence.
Consider the very first step in any treatment—diagnosis. “It is rarely
the case that signs and symptoms are markers of specific diseases,”
observes Carl Schneider in The Practice of Autonomy: Patients, Doctors and Medical Decisions.
“Signs and symptoms often do not appear exactly as described in
textbooks and the full constellation that describes the ‘classic’
presentation of a disease is often not seen.”
Schneider, who is a professor of Law and Internal Medicine at the
University of Michigan, quotes Dr. Eric Cassell who describes Medicine
as a craft “engulfed and infiltrated by uncertainty and practiced in a
sea of doubt.’ As a result,” says Schneider, often “judgments must be
made on the doctor’s personal experience of past cases; the comparison
of the present size, sound or feel of something with what is
remembered; and on what a clinician believes to be the problem, based
sometimes on very scanty evidence.”
In other words, diagnosis is often driven by intuitions that are not easily articulated. Gary Klein, author of Sources of Power: How People Make Decisions
explains: “Intuition depends on the use of experience to recognize key
patterns that indicate the dynamics of the situation.” He gives the
example of nurses in a neonatal intensive care unit who could simply
look at a baby and tell that it was becoming septic, sometimes even
before tests could detect the development. Klein suggests that these
nurses “reacted to a pattern of cues, each one subtle,” that experience
had taught them to associate with a septic infant.
This is medical information that cannot be codified or passed on to a
consumer who does not share the nurses’ experience: “The problem is
that people who work ‘intuitively’ may not know and thus cannot
accurately explain how they think,” says Schneider. “Because patterns
can be subtle, people often cannot describe what they noticed, or how
they judged a situation as typical or atypical.” In other words, this is medical information that you are not going to find online.
In an Age of Information we often try to pretend that anyone can become
an “expert.” But Schneider explains the difference between how a novice
“sees” a situation and how an expert takes it in. “People trained in
skilled work learn to reason in ways that elide many steps and that
they themselves do not fully realize or understand. . . .Their
experience lets them “see a situation, even a non-routine one, as an
example of a prototype.” He quotes another study of decision-making by
Ranann Lipshitz: “This happens with little ‘conscious awareness, rapid
rate of data processing, high confidence in answer and low confidence in the method that produced it.’”
“Novices lack this experience. Thus they lack those prototypes,”
Schneider concludes. “They must work out step by step what experts
see at a glance. The classic illustration of this difference in
reasoning comes from chess. Chess masters look at a board and see
patterns of force and possibility. Beginners see discrete pieces and
ask how many spaces a pawn can move.”
Yet, despite the difference the expert and the rest of us, somehow,
consumers with high-deductible health plans are supposed to be able to
make wise decisions about what is “necessary” care and what isn’t.
Consider the dilemma for parents who are trying to decide whether or
not to take their feverish infant to the ER in the middle of the night.
They have a $4,000 deductible. They know that once they set foot in the
ER the bill will begin to add up: blood tests, a urine sample,
examining the baby, perhaps keeping her over-night for observation. Yet
of course, they would happily spend $4,000—or more—if she really is
seriously ill. But maybe they should wait and call their pediatrician
in the morning. They are smart enough to know that just taking the
baby’s temperature is not a clear marker as to whether she needs help
immediately. What nags at them is the knowledge that they haven’t seen
hundreds of feverish babies and just don’t have the experience to make
a reasonable judgment.
This is why they shouldn’t have a $4,000 deductible. Their
“consumer-driven plan” is shifting the responsibility for making
medical decisions from the doctor to the patient.
The uncertainty doesn’t end there. Even if they go to the hospital, and
it is obvious to the doctor that the child is very sick, it may not be
at all obvious as to what would be the best treatment. There are just
too many variables, too many unknowns. Every human body is unique. What
worked well with one young patient might be too stressful for another.
This is why “Uncertainty” is, as Dr. Atul Gawande puts it, “the core predicament of medicine. . ." In Complications: A Surgeon’s Notes on an Imperfect Profession,
Gawande underlines the ambiguity of modern medicine: “Uncertainty is
the thing that makes being a patient so wrenching, being a doctor so
difficult, and being part of the society that pays the bills so vexing
. . .”
I have quoted Gawande before and I quote him again here because I think
his insight is crucial to understanding that medicine is still an art.
Many doctors confide they are certain of what they are doing, that it will work, and why and how
it will work only perhaps one-third of the time. Often, there is no
“right answer.” A doctor may try one treatment, then another, just to
make a diagnosis. In the past, physicians who presented themselves as
all-knowing hid their doubts. Today, doctors who trust their patients
are honest with them.
This, as Gawande rightly says, is what makes being a patient so
distressing, being a doctor so stressful, and being part of the society
that pays the bills so frustrating. In many cases, there is no way to
measure whether we are getting the best value for our health care
dollars, even in retrospect. The patient might have recovered even if
he or she wasn’t treated. A different treatment might have had fewer
side effects. Over-treatment may have created needless complications.
As Americans, we want to believe that science and technology can
provide “right answers.” Thus we resist the notion that the best
answer to a great many medical questions is: “it depends.” Yet,
despite the enormous progress made in the 20th century, medicine is
still a young science. We have barely begun to understand how mind and
body interact. “With all that we know today about people and diseases
and how to diagnose and treat them, it can be hard to grasp,” Gawande
writes, “how deeply the uncertainty runs.”
This is why the relationship between doctor and patient must be based
on trust. The healthcare market is different from any other market
because it is so much harder for the purchaser to evaluate what he is
buying. Adding to his dilemma, unlike other shoppers the patient knows
that he can’t rely on a friend’s experience with the product. While two
consumers may derive pretty much the same value from the same
mid-priced refrigerator, a particular course of treatment can have a
drastically different effect on two people.
Nor can the consumer rely on his own past experience. Three-quarters of
health care dollars are spent on products and services that the patient
has never purchased before and most likely hopes never to purchase
To make the patient’s dilemma even more wickedly difficult, he knows
that there are no warrantees, no guarantees, no returns. As a consumer
he is in a uniquely vulnerable position: there is a very real
possibility that it could do him more harm than good. This is how the
purchase of healthcare is different from any transaction that takes
place in the commercial marketplace. How could the patient possibly go
forward if he didn’t trust the seller? This is a market where caveat
emptor cannot apply.
I believe that this goes to the heart of the difference between “the
consumer” and “the patient.” When advocates of consumer-driven medicine
talk about the patient as a consumer, the relationship between patient
and doctor often begins to sound adversarial. It’s up to the consumer
to take responsibility for making sure she gets the “best care
possible” –as if the physician will cut corners unless the patient is
vigilant. In truth, in most markets “caveat emptor” is a good warning.
The buyer cannot trust the seller to put the buyer’s interests first.
So the buyer must demand the best product at the best price.
By contrast, the physician is a professional who has pledged to put his
patient’s interests ahead of his own. The patient must trust in his
doctor’s knowledge and professionalism. Otherwise, the health care
market couldn’t function. Who would submit to a painful, invasive
procedure if he didn’t trust the doctor?
Healthcare economist Victor Fuchs sums up the situation: “The
patient-physician relationship is very different from the one that we
accept in commercial marketplaces because it requires patients and
health professionals to work cooperatively (rather than as adversarial
buyers and sellers). Mutual trust contributes to the efficiency of
Regina Herzlinger believes that what the health care consumer wants
most is “convenience,” “control” and “choice.” This may be true when
you’re buying eye-glass frames. But the lion’s share of our healthcare
dollars is spent when we are seriously ill. And then, I believe, what
we most yearn for is “competence” and “kindness.” We want choices, but
most of us do not want complete autonomy. We do not want to feel that
our physicians are abandoning us.
But what about the uncertainty of medicine? Does all of this mean that
the patient must simply trust (or hope) that his doctor has the “right
Not at all. As Fuchs points out, patient and doctor must collaborate,
with the doctor bringing his knowledge and experience to the table,
while the patient contributes her knowledge of herself—what she hopes,
what she fears, what she is willing to wager, and what she is not
willing to risk.
This brings me to “shared decision-making” a formal process that has
been developed at a number of hospitals around the country.
Dartmouth-Hitchcock in Lebanon, New Hampshire led the way in 1999 when
it opened a Center for Shared Decision-Making where doctors and
decision-making coaches learned to use various decision-making aids”
to help patients weigh their options. (See their website here).
These aids include pamphlets that spell out the risks and benefits of
various elective tests and procedures as well as videos featuring
patients who describe how they went about making the decision—and
whether they are happy with the outcome.
In August, I wrote
about how this process can help men who have been diagnosed with
early-stage prostate cancer decide whether they want to be treated—or
pursue a strategy called “watchful waiting.”
The videos and booklets stress that patients have a choice: this
is why we call knee implants, hip implants, most angioplasties,
by-passes, spinal surgery, treatments for early-stage prostate cancer
and a wide variety of tests “elective.” As the doctors at
Dartmouth emphasize, the patient who decides to undergo one of these
procedures is making a “wager” that the benefits will outweigh the
risks and possible side effects. Some patients are willing to take a
bigger gamble than others.
Patients take these pamphlets and videos home, and often view the
videos more than once, with their families. When they go back to the
doctor, he or she asks questions to test whether the patient fully
understands the benefits and risks. If the patient seems confused, the
doctor explains further until, as one doctor puts it—“Suddenly, the
patient’s face clears—and you know they understand.”
At that point, the doctor begins to ask the patient questions about his
own preferences, fears and priorities. Are there certain side effects
the patient fears more than others? Is he a risk-taker? How does he
feel about uncertainty? Is the breast cancer patient’s first priority
to try to preserve her breast or would she prefer to “get it over with”
by having a mastectomy? The treatment that might be “right” for one
patient will not be right for another.
Here the patient becomes an active participant in the decision-making
process. In the past, we talked about patients giving “informed
consent” before any elective procedure. At the decision-making center,
patients make an “informed choice” that takes their own values and
temperament into account.
This is not consumer-driven medicine, but it is patient-centered
medicine. Those who prefer the “consumer” model believe that if
patients have “skin in the game” (i.e. a high-deductible) this
will somehow lead them to make shrewder decisions. Those who advocate
for “shared decision-making” believe that if patients have more knowledge
they will make wiser decisions. This is not about providing
“transparent information.” This is about leveling with patients and
telling them that much of medicine is not transparent —it’s ambiguous.
This is also about giving patients time to absorb this knowledge, mull
over the pros and cons of treatment and, with the help of a
decision-making coach, decide what they want.
“Shared Decision-Making” takes time, and today, physicians are not well
paid for spending time with their patients. We expect them to be “doing
something” to them. But health policy experts are becoming more aware
that we need to compensate doctors more when they practice “thinking
medicine.” If we do that, we may not have to pay as much for more
Research reveals that if patients share in making the decision, some 20
percent to 40 percent of patients decide not to go ahead with the
elective treatment. Thus many are spared treatments that they didn’t
entirely want, didn’t entirely understand, and might well regret.
Meanwhile, satisfaction among patients who go ahead with the treatment
is higher. The state of Washington already has recognized that “shared
decision-making” could be one answer to malpractice suits. In
Washington, new legislation makes it much, much harder for a patient to
sue if the doctor took him through the formal decision-making process.