The Mind Body Connection: Could Psychosomatic Disorders Account for 30% of Chronic Symptoms?

Below, a guest-post by Dr. Clifton K. Meador, the author of well-known satirical writings on the excesses in our medical system, including “The Art and Science of Non Disease,” (the New England Journal of Medicine, 1965) and  “The Last Well Person,” an essay he published as an “Occasional Note” in NEJM  in 1994. HealthBeat readers may remember past guest-posts by Meador including “The Art of Diagnosis” drawn from his book True Medical Detective Stories, and “The Unheard Heart: A Metaphor,” 

In this guest-post Meador writes about the importance of listening to patients—something that often doesn’t happen in a 15 minute office visit. I’m hopeful that under reform, more and more doctors will be able practice medicine full-time, leaving billing, hiring and firing of support personnel ,and all of the  other time-consuming details of running a business to others. Telemedicine also should open up some time: rather than coming in for a 15 minute appointment, patients who don’t have questions could ask for refills of routine prescriptions on the phone or via e-mail.

Eventually Health IT will be good enough that doctors will no longer spend hours tracking down lost Faxes. Finally, more physicians will be dividing their work with nurse-practitioners. In some cases, the nurse-practitioner might be especially effective when dealing with chronically ill elderly patients; in other cases he or she might excel in treating adolescents.

Ideally, restructuring how care is delivered will lead to longer appointments with some patients, giving the doctor the opportunity to truly listen—particularly when the cause of physical symptoms remains a mystery.

If a doctor had more time, what would he discover? Here, Meador offers what some may consider a radical thesis: 55 years of experience as a  primary care physician, combined with studying the medical literature, has convinced him that “between 30 and 40 percent of first contact  primary care visits are stress- related or are psychological in nature.”

I’m particularly intrigued by his description of “psychosomatic disorders” as described by Dr. John E. Sorno in The Divided Mind.

I haven’t yet read the book, but look forward to doing so. The reviews are impressive. As Meador makes clear, to say that an ailment is “psychosomatic” does not mean that “it’s all in your mind.”

Finally, Meador mentions that at this time, the medical profession denies the existence of psychosomatic illnesses. I’m baffled.  Both life experience and years of reading have convinced me that mind and body cannot be separated. I’d be interested in hearing from other physicians on this point. — MM

                                  The High Cost of Not Listening to Patients

by Clifton K. Meador, M.D.

www.cliftonkmeador.com   

www.doctorswholisten.net

             Author: True Medical Detective Stories and Symptoms of Unknown Origin  

Before we can understand the high cost of not listening, we need to examine in detail the diagnostic process. I am limiting my discussion to patients with chronic or recurring symptoms lasting several months. I am not discussing acute illnesses. They fall into completely different category.

 

At the front line of medical care, at the first contact between a patient and a doctor, the patient describes physical symptom. Whatever the real underlying cause, a physical symptom is the required ticket to see a physician. (Michael Balint, Lancet. Pp 683-88, 1955).

The physician, on first contact, has no idea what the underlying nature of the patient’s chronic complaint really is.  At the risk of oversimplifying, there are five broad categories of the causes for complaints. These are:

1. There is a definable medical disease in one or more organs.

2. There is no definable medical disease but the patient is in contact with an unknown toxic substance causing the symptom (inhaled, ingested, or from skin contact).

3. The patient is in a stressful or toxic relationship at home or work producing physical symptoms or even a definable medical disease. (“What the mind cannot process is relegated to the body.” Dr. William Mundy, psychiatrist, personal communication. )

4. The patient or a companion is inflicting harm. Here, there are several categories:

–    Factitial disease (in these cases the patient or someone else creates physical symptoms)

–  Malingering to gain money or drugs,

– Munchausen syndrome—a serious mental disorder in which someone with a deep need for attention pretends to be sick or gets sick or injured on purpose. People with Munchausen syndrome may make up symptoms, push for risky operations, or try to rig laboratory test results to try to win sympathy and concern.

–  Munchausen by proxy — a parent or another caretaker exaggerates  symptoms that a child is suffering. (For both forms of this disease see Marc Feldman, “Playing Sick”, Brunner-Rutledge, NYC, 2004. )

5. There is no definable medical disease but the patient has assumed a chronic illness role in life with multiple symptoms (i.e.hypochondriasis).

                                 Psychosomatic Illness 

6. There is a sixth category; patients with psychosomatic disorders. Time and space does not permit a full discussion of this important and very common set of disorders. I suspect they represent more than fifty percent of patients seeking primary medical care. The book “The Divided Mind” explains and defines these disorders and the successful treatment applied to thousands of patients at NYU by Dr. Sorno and his colleagues. At present the medical profession denies the existence of this category. The epidemic emergence of pain clinics comes from lack of knowledge about psychosomatic disorders and their proper treatment.

Of course, the patient can have any of these, and also be suffering from a definable medical disease.

But my experience in primary care over the past 55 years –combined with studies in the medical literature–suggest that between 30 and 40 percent of first contact  primary care visits are stress related or are psychological in nature (#3 and #6  in above list).

It should be obvious that the only way to sort out these causes of symptoms requires very careful listening to the narrative of the patient’s life. Some of these causes can be determined only by listening.

Let’s now trace a hypothetical patient and a hypothetical physician, who does not have the time or inclination to listen carefully.

The hypothetical patient is 48 years old, married, and the mother of two teenage daughters. The husband is a severe alcoholic and often physically beats up the patient.

The sixteen year old daughter just told her mother that she is pregnant.  The patient’s mother, with Alzheimer’s, wanders in and out of the house at night, often getting lost. None of this story is revealed to or explored by the doctor.

The patient complains of abdominal pains, headaches, fatigue, insomnia, and constipation. The doctor, in the first 15 minute appointment, focuses in on the abdominal pain and orders an endoscopy of the upper GI tract and a full battery of blood chemistry screens.

The endoscopy is normal. Chemistries reveal a slightly elevated alkaline phosphatase, suggesting liver or gall bladder disease (later found to be a false positive).  The physician then orders as abdominal ultrasound, suspecting gall bladder disease. The gall bladder exam is normal, but there is a suspicious looking mass in the left upper quadrant. The physician then orders a CT scan of the abdomen. And the work up continues over several weeks, including a colonoscopy.

The cost of the workup exceeds $5000 and reveals no abnormality.

The physician tells the patient “it is all in your head” and prescribes Xanax and a sedative at bedtime.

This story is only slightly exaggerated.  With the increasing shortage of primary care physicians, this tale will become more common as more patients are fed into the high technological workup prematurely, without the sorting process and without being heard.    Though if , under health care reform, we make greater use of nurse practitioners—who are trained to spend time with patients, and listen to what they have to say-- we may find that more diagnoses are based on the patient’s oral history.

                                   Feeding the Patient Into the Specialist System

But today, too often, the primary level is by- passed. The patient is fed directly into the specialist system. The job of the specialist is not to sort out the real causes of the symptoms. The job of the specialist is to discover if the patient does or does not have a disease related to  his specialized organ.

Does the patient have (for examples) heart disease or GI disease or chest disease or joint disease or blood disease or the disease of whatever specialist is being seen? The chance to sort out the influences of the lived life of the patient has been lost in this process.

There is one other element leading to the high cost of not listening to the patient.  It is the false positive problem.  Here I must digress a bit into some details of the diagnostic process.

The accuracy of any test (i.e. true positive or false positive test result) depends on how common or how rare the tested disease is. If the probability of the disease being tested is low (rare), there will be a large number of false positive results.

The physician who listens carefully can be selective in ordering tests. This step of being selective actually increases the accuracy of the test. If this step is bypassed, there is a high chance of getting a false positive test result.

This is the case when patients are seen directly by specialists who automatically order the definitive test of their specialty.  The false positive test result must then be chased down by another test, and on and on, creating large unnecessary costs and anxiety for the patient or even a false diagnosis of a nonexistent disease.

In the end, not listening to patients generates higher costs on two levels:

1. At the primary care level, failures to hear the life stresses and explore them leads to premature testing and high rates of false- positive test results.  This, in turn,  leads to unnecessary costs and even false diagnoses of nonexistent diseases.

2. At the specialty referral level (by- passing primary care) the automatic unfiltered testing creates high costs and the increased chance of false positive test results. In the worst case scenario, this leads to false diagnoses of nonexistent disease.

The magnitude of the costs of “not listening” is unstudied and unknown.  The  medical literature that we all rely on does not attempt to measure the number of false diagnoses.

But given the large numbers of patients suffering from stress or psychologically determined symptoms, it is likely that a large percentage of the national high cost of healthcare comes from the fact that too many doctors are not listening to their patients.

Let me suggest that there are two questions that any physician should ask of each patient, no matter what the complaint:

–Are you happy with your life?

– Do you like your work?

 

 

 

 

 

21 thoughts on “The Mind Body Connection: Could Psychosomatic Disorders Account for 30% of Chronic Symptoms?

  1. It certainly makes intuitive sense to me that a significant percentage of PCP encounters may be for psychosomatic or stress related complaints. However, I’m skeptical that even if the doctors had more time to spend with patients to solidify that conclusion in their own minds that patients would readily accept an answer that boils down to it’s all in your mind or it’s stress related. While there are numerous conditions that are uncommon and not so easy to diagnose, my main issue is with the culture of patient expectations in the U.S. which, I think, differs materially, from patient expectations in other developed countries. My perception of the U.S. patient culture, at least for many of us, can be summarized as follows:

    1. More care is better care and more expensive care is better care as well. Doctors who try to practice cost-effective care by ordering fewer tests are not sufficiently “thorough.”

    2. If I have a negative outcome or if my disease, especially cancer, could have been diagnosed earlier than it was, my first instinct is to consider whether I should try to sue or not regardless of whether doctors or the hospital actually did anything wrong.

    3. There is a general attitude among way too many of us that can be summarized as: I want what I want when I want it and I expect someone else (insurers or taxpayers) to pay for it.

    Layer this culture on top of a general culture of litigiousness across the society and it’s no accident that defensive medicine pervades the U.S. medical culture even as liberals insist that it accounts for only a tiny percentage of healthcare costs. Yes, it’s impossible to quantify the impact of defensive medicine with any precision, but the mindset of avoiding lawsuits and their associated stress and uncertainty at all costs impacts practice patterns in a significant way. It doesn’t even matter how much is ultimately paid out as that is largely covered by insurance anyway. It’s the uncertainty, the stress, the lengthy time period needed to bring a case to a resolution and the lack of consistency and objectivity in how similar cases are decided both within and across jurisdictions that drive practice patterns. This, of course, varies regionally, even within a state, depending on how plaintiff friendly local jurisdictions are perceived to be. Without significant tort reform, more time for each PCP patient encounter won’t make much difference in reducing healthcare utilization in my opinion.

  2. Barry–

    As Clifton makes clear, “stress-related” does not mean “It’s all in your mind.”

    A good primary care doctor will ask the patient questions to try to get at the source of the stress.
    Home and work are the two most likely sources.

    If the problem is at work (a bullying boss, feeling that you’re in over your head, hating the work or the environment and dreading going to work every day) a good primary care doc would talk to you about whether you might change jobs–even if it means taking a pay cut. He might recommend that you talk to a psychologist who
    specializes in career counseling, or that you begin networking–letting people know that you’re thinking about making a move.

    If the problem is at home, a primary care doc might suggest that you go for marital counseling. If you’re being physically abused, he would recommend counseling for abused women.

    None of this has anything to do with malpractice

    I actually Googled psychsomatic and malpractice– virtually nothing came up.

    Btw, I think the Obama administration may well recommend “safe harbor” laws that protect doctors who follow the guidelines for evidence-based medicine. (Unfortunately, today less than half of all physicians follow those guidelines, though if they work together in large groups (like Kaiser ) where the organization stresses evidence-based medicine and other doctors are looking over their shoulder, they are more likely to.
    We probably need guidelines for treating patients who appear to be suffering from stress-related illnesses.

  3. Maggie –

    From 1986 to 1993, I had a high pressure / high stress / high pay job at a money management firm. After seven years, it was starting to adversely affect my health and I knew I needed to try to find a less stressful position before I wound up as one of the richest guys in the graveyard. It was pretty obvious without needing to hear it from a PCP. The next job paid 40% less but still more than enough to support my family. It was one of the best decisions I ever made.

    I still think we have a culture in the U.S. of unreasonable patient expectations vs. what is typical in other developed countries. This has its biggest impact in hospitals, especially ER’s, where the doctor usually doesn’t know the patient. The fact that the doctors and hospitals often get paid more to do more, at least until they determine a specific DRG, compounds the problem of excessive utilization of services.

    I think we know how to make the medical tort system more objective and consistent for doctors and we know that safe harbor protection from failure to diagnose lawsuits if they follow evidence guidelines will be helpful, at least over time.

    By contrast, the patient expectations issue will be more challenging. In other countries, an implicit part of the social contract is that you don’t impose unreasonable expectations and their associated costs on your fellow citizens.

  4. Barry–
    It sounds as if you made a very wise decision. But
    a great many patients need someone else to point out that
    stress is killing them. In our culture, men in particular are
    reluctant to admit to what they might see as “weakness” or
    a “character flaw” rather than a normal response to excessive stress. (Very likely, they wouldn’t listen to a wife, though they might listen to a doctor.) And when it comes to introspection, not everyone is equally intelligent.

    Under reform, I’m convinced that we really will be moving away from fee-for-service. A new CAP report that the Obama administration is paying attention to suggests accelerating the table table. (It’s called “The Senior Protection Plan” and it’s very good on targeting places where there is waste in the system.

    I also do think we’ll see safe harbor protection, and that it will be useful. I would love to see “shared decision-making”–(which involves making sure the patient is aware of the possible risks as well as benefits from treatment)part of safe harbor protection. The state of Washington has already done this. We know that when the shared-decision-making protocols are followed, a substantial number of patients decide not to go ahead with the treatment.

    On the difference between the U.S. and other countries.
    I do think we are more optimistic that anything can be cured (some call this “American optimism”).We also seem to be more fearful of death.

    But when it comes to paying for medical care for your fellow citizens, as you know wealthy Europeans (and upper-middle class European) pay significantly higher taxes (when you put all of the taxes together: income, VAT, sales, etc.) than we do, and much of that money goes to
    support a “safety net system” that is far more generous than ours. Only the UK rations healthcare by looking at cost-effectiveness.
    European doctors are less aggressive than American doctors when it comes to doing everything possible, but this has to do with how they were trained: In U.,S. medical schools heroic measures are considered heroic. Sometimes the push comes from patients–or patients’ families– but our doctors are also taught to encourage patients to “fight” & “don’t give up.”
    And our doctors are not trained to tell patients: “You are going to die. There is nothing we can do.”
    Finally, of course, our fee-for-service system rewards docs for doing everything possible. And I should add that I think the majority believe that this is the “right thing” to do.
    By contrast,when my husband’s best friend (an Italian who lived in Rome) was diagnosed with liver cancer, his doctor told him–at the time of the diagnosis– I’m very sorry. but there is nothing we can do.”
    He was not hospitalized. Instead his doctor sent him home (a beautiful home where he would be very comfortable) with morphine, showed his wife (a very smart woman) how to administer the morphine. Whenever his wife called, the doctor called her back, and visited her husband at home a number of times. He was kind, and caring– and didn’t pretend he could do more.
    In this country, I don’t know what would happen to a doctor who didn’t hospitalize such a patient, and sent him home with morphine, but if the hospital where he had privileges got wind of it, I suspect he would be punished.

  5. Seeing how many people I know who go to the doctor incessantly and usually seem worse if not even maimed and/or killed by the process got me to wondering. If you compiled a list of medical condition that had predictable treatments with success rates of 90% or higher and you took a population and removed these diagnoses from consideration. Then look at the remaining population and separate out those with good exercise and diet from those without. I wonder if the ones with good exercise and diet only could be looked at, would going to the doctor increase like span and quality or decrease it for the majority of these. Now wouldn’t that be an interesting stat for our overly treatment oriented and dependent-creating medical system!!

  6. NG-

    I agree that patients who seek what you describe as “incessant medical attention” can easily become victims of over treatment. But of course some patients (such as diabetics) need to see doctors frequently to help them manage their disease.

    And you may be putting too much faith in “good diet and exercise.” While bad diet and lack of exercise hurts us,
    good diet and exercise does not assure good health.
    We all die eventually, and a great many people who ran, worked out, and ate their vegetables will be diagnosed with cancer, Alzheimer’s, heart disease caused primarily by stress, etc.

  7. Maggie,

    Remember I started my above comment with the statement that what works in medicine at the 90% (or whatever) success rate be excluded from the calculations! So those in real need of predictable treatments should indeed get those treatments. However, the profession and its research counterpart must be responsible going forward for only suggesting and providing treatments that have a very high level of successful effectiveness, and they must come clean with our society about the making money on junk and dangerous treatments allowed because of a desperation/miracle/trust oriented atmosphere that has been fostered that allows that!

  8. It’s quite difficult to care for these patients. They are often convinced they have something physically wrong with them. (if they were thinking it was “all in their head” they would be less likely to come in to the office in the first place). Statistically, some will indeed have something wrong with them. If the doctor doesn’t do “due diligence” and investigate the symptoms, he/she risks a bad outcome in a patient who knew something was wrong. This could lead to a lawsuit.

    The trick is to decide when to stop looking for things, but it’s a classic “boy who cried wolf” phenomenon. No one wants to get burned, and it’s hard to know what to attribute to stress/somatic conditions, and what to take seriously. You can get a sense in some patients, but it’s harder in others.

    The idea that we could solve this issue if we were only more aware of this issue, more educated, compassionate, better listeners, etc, sounds nice in theory, not so simple in practice.
    I do think cultural expectations in the US are a large issue. We’re really not allowed to “miss” anything, for the most part, in the minds of many patients. This leads to lots of tests and consultations. “Better safe than sorry” is an expensive way of doing things.

  9. PCB-

    I’m sure that many patients are convinced that there is something physically wrong with them when stress is the primary cause of their symptoms. .
    But I would think that talking to a patient about how stress may well be “aggravating ” his condition could provide an opening for discussing stress factors. Moreover, I think many patients would be open to understanding that mind and body are hard to separate, especially if you emphasize “This does NOT mean that it’s all in your head.”
    I agree that expecting that a doctor “won’t miss anything” is setting the bar too high.
    Physicians themselves can help by explaining to a patient: “Frankly, I’m not able to find a physical cause for your symptoms. I think reducing some of the stress in your life would help, but I would also urge you to consult with another doctor. He might think of something that I didn’t—the human body is so complex and none of us have all the answers.”
    I would then make a note that you said that.
    One reason patients have such high (and unreasonable) expectations is because in the past, the medical profession tended to put doctors up on a pedestal– patients shouldn’t question them; going for a second opinion was insulting, etc.
    Finally, I’m a big believer in the placebo effect–another way of treating the mind. Many of us
    suffer from some vitamin deficiency, and that can make us tired, while contributing to depression and anxiety. If you know of good vitamin (or package of vitamins) that isn’t too expensive and that you think might help . . .you might suggest it to the patient.

  10. Dr. Meador’s excellent essay captures a very important ‘node’ from which many errant ventures are propagated. The initial cognitive error/oversight can cause huge ripples in the pond, generating enormous waste and hardship for ‘consumers’.
    While ‘defensive medicine’ is oft-quoted as an excuse for overdoing it on the testing side, it is mostly a cop-out, imho.
    It does not address the inadequacy of patient encounter. Sometimes it may seem easier to order 20 tests than ask a few good questions and then actually perform a physical examination…followed by an intelligent selection of tests, based on probability and grounded in reality.
    How many doctors code for level 5 visits, but hardly interrogate and examine the patients properly?
    Patients are more of a substrate for profit than a target for true health care, imo. The companies that control health care have one mission: shareholder value.
    Regards,
    Ruth

  11. NG & Ruth–

    NG:- You wrote “the profession and its research counterpart must be responsible going forward for only suggesting and providing treatments that have a very high level of successful effectiveness, and they must come clean with our society about the making money on junk and dangerous treatments allowed because of a desperation/miracle/trust oriented atmosphere that has been fostered that allows that!”

    I totally agreed that a “desperation/miracle/trust oriented
    atmosphere” encourages futle treatment and overtreatment., Not everythign can be cured.

    Nevertheless, I think your proposal needs to be fine tuned.
    There are treatments that don’t work 90% of the time for most people, but do work 90% of of the time for people who fit a particular medical profile . ..

    Ruth–
    Insofar as U.S. health care has become a corproate for-profit enterprise (and in many ways it has) you are right that “the companeis that control health care have one mission: shareholder value.”

    But U.S. law for-profit corporations must put the interests of their investors first–ahead of their customers. (They cannot lie to their customers, or knowlingly put defective products on the market, but their customers cannot trust them not to over-charge, whenever they can — even if they are drug-makers and device-makers selling essential life-saving products–even if they are for-profit hospitals. This is why
    I believe that, in the health care industry, we need govt’
    regulation of prices, just as we have govt regulation of
    pricing in the industries that sell us heat and light.
    Healthcare, like health and light, are necessities and for that reason, everyone should have affordable access to these products and services.

  12. Maggie –

    Electric, gas and private water utilities are not price regulated because they provide necessities. They are regulated because they are extremely capital intensive natural monopolies. It wouldn’t make any economic sense to have more than one set of power lines or gas lines or water pipes to serve a particular territory. So, as natural monopolies, government regulates how much these companies can charge customers but affords them a reasonable return on their “rate base” within what’s called a zone of reasonableness.

    While hospitals are capital intensive as well, they are not natural monopolies in the same sense. Multiple hospitals usually serve a given region though hospital consolidation is increasing market concentration which is a bad thing, in my opinion. Also, patients can go outside of their immediate area for hospital based care if they can get comparable or better quality care at considerably lower cost by doing so.

    I’ve suggested for years, however, that what we need in healthcare is price and quality transparency tools available to both patients and referring doctors to make it much easier to identify the most cost-effective high quality providers. Price transparency in this context means disclosure of insurer contract reimbursement rates, not list prices. Medicare rates are already ascertainable but it could probably be made easier.

    Finally, I also think there needs to be special rules around how much can be charged by hospitals for care that must be delivered under emergency conditions. Charges for such care should probably be limited to some modest percentage above Medicare rates.

    • Barry–

      It wouldn’t make sense to have more than one cable company running lines through a neighborhood either, but the government does not regulate how much your cable company charges for premium channels (HBO etc) because premium channels are not a necessity. (Thus the cost of premium cable has skyrocketed over the years.)

      Utilities are regulated not because they don’t have competitors but because they are providing necessities. Ratemaking is allowed because the product is determined to be “a social necessity and rates must be fair across different classes of consumers.” See Principle of Public Utility
      Rates, a classic Econ textboook.

      On hospital consolidation: much reserach shows that when there are more freestanding hospitals in an area, prices are HIGHER. (Search Health Affairs for good articles on this subject, or see my book, Money-Driven Medicine.) Miami and NYC are just two examples.
      For many reasons, market competition does not work for hospitals. For one, they all buy the same very expensive equipment, creating costly redundacies in their “arms race” to attract high-profile docs with wealthy patients. We have too many hospitals in many parts of this country, and this over-supply creates demand for unnecessary hospitalizations. We also have too many, small, often surburban hospitals doing complicated procedures that they don’t do often enough to do well. (Organ transplants, etc.)

      As Atul Gawande explains in a recent New Yorker article, we will have higher quality, less expensive care if we have “centers of excellence” providing care. As he explains in “Big Business”–under reform medicine is becoming a big business that will provide higher quality care while following
      evidence-based guidelines.

  13. Maggie,

    You wrote in response to me:

    “There are treatments that don’t work 90% of the time for most people, but do work 90% of of the time for people who fit a particular medical profile”

    What I write below is critical to the evolution of this overtx/overspending/miracle-desperation system we have now, especially in the third party payment era! There must be a process to find out which group fits the 90% success rate because it was the “shot in the dark, spend the money and pray hopes” that has led to the useless and often dangerous treatments with their resultant huge expense. No accountability for results coupled with this prayer that this or that treatment may work at the 90% level but just for you IS THE PROBLEM along with outright fraud. Accountable Evidenced-based medicine in the future must not allow shot in the dark treatments at group expense unless the groups that will clearly benefit are able to be identified before costly and/or dangerous treatment!

    • Ng–

      I’m glad you repllied.

      You write: “Evidenced-based medicine in the future must not allow shot in the dark treatments at group expense unless the groups that will clearly benefit are able to be identified before costly and/or dangerous treatment!”

      Consider the case of a newborn who is having problems breathing. There is a treatment that has shown a 40% success rate for all new borns and a 55% success rate for newborns who fit her
      medical profile. Do you and I want to share in the cost for her treatment?

      Of course we do. She could be our child. (“There but for fortune . . “)

      It would be great if all important treatments showed a 90% success rate. But that’s rare.
      Medicine is shot through with uncertainties and ambiguities. Rarely can doctors approach a
      serious problem with 90% confidence. (Treating a broken arm comes to mind as one of the few
      cases where we’re confident that we know how to do it.)

      In most cases, neither hip replacements nor knee replacements enjoy a 90% success rate. Patients should be aware of this going in–informed of the risks, of how hard recovery can be (depending on your age, weight, other conditoins contributing to your problems…)

      I believe that we should keep registries of these operations, showing what device was used, the medical profile of the patient and the outcome. (This is what other countries do.We don’t because device manufacturers don’t like the idea of
      head-to-head comparisons,and some people cite “privacy violations” if public records are kept.)

      But if we did this we could determine which devices have,say,an 80% success rate for women
      over 70 suffering from a variety of problems–including arthritis. Then we could use those devices.

      By setting the bar so high (at 90%) you pretend that medicine is as simple, as say, repairing
      plumbing. It isn’t. I’d urge you to read Dr. Atul Gawande’s wonderful book “Complications: A Surgeon’s Notes on an Imperfect Science. .” I think you’d like it.

  14. Don’t get hung up on 90%. I think a systematic % for predictable success needs to be determined maybe per procedure, but surely there is a low % side number/chance where we cannot allow group payments to throw money at and bankrupt the system for no benefit! Value as you say above must be determined FOR GROUP PAYMENTS, and a system effort made to enforce such value before we just bankrupt the system for nothing. There may well come a time when all worthwhile treatments cannot be done for all because of a lack of system funding for every worthwhile treatment that may be needed, but before we get to that unhappy point, at least let’s discipline the system to not throw money away on processes of low value that are wasteful and even dangerous!

  15. NG–

    I certainly agree with you about over treatment. and you make a good your point that the number doesn’t have to be 90%.

    But keep in mind that the bulk of our health care dollars are not spent on futile/heroic end-of-life treatment where the odds of saving the person are 20% or less.

    75% of our spending goes to treating chronic diseases (diabetes, congestive heart failure,etc.)—diseases that don’t kill the patient (at least not rapidly) but require treatment over many years. We aren’t as good at this as other countries because we don’t put enough emphasis on preventive care and continuous care–and so the chronic disease becomes more serious and the patient lands in the hospital. (In other words, we spend so much treating chronic diseases precisely because we don’t do it well. High quality care is less expensive than low quality.)

    Under reform, nearly everyone will have insurance, and so we should be able to do a better job of providing that continuous care.

  16. Maggie,
    As you point out in your book (Money-Driven Medicine), preventive care is sometimes not considered a ‘worthwhile investment’ for many insurers who have a relatively high turnover (versus Kaiser, for example). I have rarely seen patients who are literally warned (by their insurers) to follow up on prevention (e.g., mammography), otherwise there will be consequences.

    I’d hate to think what trouble I’d go through if I ignored a notice to get my car tested for smog emission.

    Ruth

    • Ruth–

      Good to hear from you.

      Under the Accountable Care Act insurers have to cover preventive care, without co-pays and
      without applying the cost to the deductible. This means that more patients will go to doctors for preventive care.
      (Meanwhile, under Medicare, physicians who provide primary care will be paid 10% more.)

      Also, under reform legislation, health care providers will be paid more if they manage to
      to keep patients out of the hospital. This gives them an incentive to focus on preventive care.

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