Saturday, March 5, 2011

A New Dartmouth Health Reform Twist- Geographic Practice Variation "Unethical"

Insensibly one begins to twist facts to suit theories, instead of theories to suit facts.

Arthur Conan Doyle, Sr. quotes (Scottish writer, creator of the detective Sherlock Holmes, 1859-1930

We have to make sure patients are really fully informed about their options, and that they get to choose the elective procedure that's the right one for them. At its very heart, it's an ethical issue.

Shannon Brownlee. MD, lead author, “Improving Patient Decision-Making in Health Care,” 2011, Dartmouth Atlas Report

I see the Dartmouth Atlas crowd, who use Medicare data to blame the “quality chasm” on regional variations among doctor practices, are at it again. They have just issued a 43 page report “Improving Patient-Decision Making in Health Care.”

In essence, the report says if doctors do not "fully inform" patients on the outcomes of invasive procedures vs. conservative approaches and do not give patients the “choice” between the two, the doctors are somehow unethical.

The Dartmouth sages, have chosen 8 clinical situations to make their case.

1. Early stage breast cancer

2. Stable angina

3. Low back pain

4. Osteoarthritis of knee and hips

5. Carotid artery disease

6. Gallstones

7. Prostatic hyperplasia

8. Early stage prostate cancer

Surely, the Dartmouth authors say, if patients were fully informed about the risks and outcomes or surgical intervention vs. conservative therapy, surgical interventions would plunge, care variations would be reduced, 20% of patients would choose conservative approaches, with the savings of millions of dollars and lives.

One of the authors, Michael Barry, MD, explains the “ethical issue” this way.

"The patient safety movement in the last decade has worked very hard to make sure that the wrong patient doesn't get surgery, that Mr. Jones doesn't get taken down to operating room for surgery that was scheduled for Mr. Smith, and that's really important.”

"But if Mr. Smith were fully informed, and would then decide he would neither need nor want this surgery, then taking him to the operating room is like operating on the wrong patient as well."

Doctors, Barry claims, are not "correctly" informing patients of their alternatives.

Richard Wexler, MD, a director at the Foundation for Informed Medical Decision Making, collaborated with the Dartmouth Atlas on this report, says doctors are making decisions without considering the patient's point of view. Medical practice is “doctor-centered” rather than “patient-centered.”

The implication is that most patients never really fully informed of reasonable and effective options that don’t involve surgery. Doctors, it seems, are deliberately withholding information for their own convenience and profit without consulting with patients about alternatives.

This speculative argument is the latest twist in the Dartmouth argument that if somehow, someway, we could standardize and make uniform care in every section of the country based on Medicare data, we could simultaneously save money and improve quality. If every patient were “fully informed,” and “fully understood” risks and outcomes they would make different choices.

This assumes policy-makers in their ivory towers know best what should transpire on the ground, and doctors are acting unethically by putting their interests ahead of interests, outcomes, and safety of patients.

This is an unverified opinion and assumes the Dartmouth gurus know what goes on the in the minds of doctors and patients. Therefore, it makes little sense to call the theoretical and hypothetical unethical.


HaynesBE said...

The hubris of the central planners never ends.

Richard L. Reece, MD said...

The hubris of central planners never ends,
They claim they can reduce what government spends.
They can give those cost curves the downward bends.
They can reverse those negative health care trends.
The hubris of central planners never ends.
But they have never been there and done that,
So all of their theories end up going splat!

HaynesBE said...

Truth in poetry! Thank you for all your writing, poetry and prose.