Monday, March 19, 2007

Doctor patient relationships - Who Should Health Care Consumer Trust?

Friedrich Hayek, 1974 Nobel Laureate in economics, won his prize by arguing self-organizing free-market capitalism is the best system for governing.

Centralized government agencies like Medicare, Hayek believed, simply didn’t and couldn’t know enough about patient-doctor relationships to regulate on the ground transactions. Attractive as centralized planning sounds on paper, and as seductive as it is for providing financial security, Hayek maintained government simply wouldn’t and couldn’t work in health care marketplaces. Hayek concluded a policy for freedom of individual patients and physicians “is the only truly progressive policy.”

Wall Street Journal OP-ED Article

Which brings me to Wall Street Journal OP-ED piece by Scott Gottlieb, MD, deputy commissioner of the FDA from 2005 to 2007, now a resident fellow at the American Enterprise Institute.

Gottlieb asserts government health agencies don’t trust doctors to choose the right drugs for their patients, or for that matter, for patients to decide what drugs are right for them (“Prescription for Trouble,” The Wall Street Journal, March 6, 2007).

Here are Gottlieb’s words:

Inside the federal agencies that oversee parts of the health-care system, there is a palpable view that doctors can no longer be trusted to do the right thing.

The Food and Drug Administration, Medicare and even the Justice Department all believe they cannot rely on many doctors to heed safety warnings, wisely weigh new medical information, or follow therapeutic approaches that maximize health benefits or lower health benefits.

Reflecting this pervasive distrust of medical practitioners, Medicare is increasingly tying payments to choices doctors make, compensating doctors more to follow certain cookie-cutter treatments or practice guidelines that are promoted by the agency because they are believed by government experts to maximize benefits and reduce health-care costs.

Who to Trust?

So who can you trust, your government or your doctor?

Here are your choices,

• Government experts holding forth in bureaucratic cathedrals in Washington, D.C., issuing position papers and perusing data output sheets, far removed from clinical medicine.
• Local medical practitioners seeing patients every day in the clinical trenches at ground zero.
• Some outside source, which can increasingly be found on the Internet
• Yourself.

Gottlieb’s Answer

Gottlieb’s answer is that Medicare treatment guidelines, issued from on high inside the Beltway, are not the right answer for everyone “because there is a need for judgment that attunes treatments to individual variations and preferences.”

Direct regulation will not, Gottlieb says, fix anything but will sacrifice medical autonomy and patient choices, a medical stew with so many permutations and combinations that no one, least of all government “experts,” know what’s going on or foresee consequences of regulating health consumer/doctor interactions. Gottlieb favors physician organizations, working in concert with government, to develop guidelines.

What to Do?

So what’s a health consumer to do?

In the first place, don’t dismiss government out of hand. Trust the government’s judgment on certain drugs with huge databases covering hundreds of thousands of patients. Government is more likely to pick up evidence of untoward effects of a few recently released drugs than a single doctor, seeing a mere handful of patients. Vioxx-induced heart attacks are an example. Another may be the latest FDA warning that erythropoietin, or Procrit, may cause heart attacks if given in too high a dose.

Still government can’t regulate every transaction or predict every complication in every patient, even if it issues thousands of regulations and guidelines in hundreds of manuals.

Personally I trust my doctor in most situations. I know him. He knows me. And he is doing the best he can under sometimes difficult circumstances, including government interventions into clinical situations for which it knows nothing but statistics. People may not be reflected in overall statistics; people are variable individuals. The live and die as individuals, not as statistics.

Go Directly to

Or you can proceed directly to Steve Case, who founded American Online, has moved on to found another company, the Revolution Health Group. He and his management team has assembled a group of expert specialists to answer your questions. Go to, and its home page will come up. On the left hand side of that page, you will see a green box with the heading, ”How can we help you?” The box contains this list.

• Compare and rate doctors and hospitals
• Learn about a condition
• Discover tips to lead a healthier life
• Find drugs and treatment options
• Check a symptom
• Get support and exchange insights
• Learn about our membership programs

Click on “Get support and exchange insights,” and you can read blogs of specialists, or you can post a topic or question that personally concerns you. You can pick from 45 topics or questions arranged alphabetically, and, depending on which one you choose, you will be directed towards a specialist whose opinion you can trust.

In The End, Trust Yourself

In the end, trust may come down to trusting your own judgment. There are no easy answers. In other words, sometimes you must trust yourself rather than the government or your doctor.

• You can ask your doctor if you really need this drug, e.g. antibiotics for “bronchitis” or a viral disease.
• You can go to a website like to check the credentials of your doctor (It will cost you $7.50).
• You can check around the community to see what neighbors and others think of your doctor.
• You can go to a respected health facility, or a group practice, within your community, which generally plays by the regulatory rules.
• You can go to to see what the side effects of a drug are.
• You can take a list of your current medications to your local pharmacist to see if any potential drug interactions might be.

My Bias

My bias is towards a trusting personal relationship with your doctor. He or she is more likely to know your history, your condition, and your family than any faceless bureaucrat in Washington, even with the best of intentions and the best of statistics.

My bias is towards a open-ended partnership with your doctor, who is willing to answer your questions candidly and to direct you towards reliable Internet sources. My bias is towards autonomous physicians, rather than physician automatons blindly following Medicare guidelines.

In free-market capitalistic system like the United States, trust holds us all together. Trust makes a market-based system work. This trust is important in health care. For better or worse, we’re all in this together.

In the story of the hedgehog and the fox, the fox knows many things and hedgehog knows one thing. I’m a hedgehog. I believe in a free-market capitalistic society, trust lifts all boats. With the help of savvy consumers, leaks will be plugged. Government may pug some leaks, but not many, and it can’t plug all leaks. It’s too far removed from care sites and can’t foresee, much less manage, all variables.


Dr. Val said...

I totally agree with your stand – government can plug some holes, but patients are individuals, not statistics – and ultimately the doctor still knows best.

We must offload medical practices with IT solutions so that the physician has more time to spend with her patients. Pressuring docs to see 30+ patients a day undermines the very best chance that we have of getting good care to people, because as doctors become more removed (how much can you really understand/know about a patient if you only see them for 5 minutes?) they become no better at doing the right thing than a distant bureaucratic entity.

We must fight to save the medical home. Outcomes depend upon it. Personalized healthcare depends on it. Patient satisfaction depends on it. Lives depend on it.

My 2 cents.

Steven M Hacker,MD , Dermatologist said...

I also agree.. the health care consumer must take control , to some reasonable degree, of his medical care. I do not think Governmental control is the correct entity to intervene in an individual's health care or a doctor's treatment, diagnosis, etc.. the first step in consumer control is a personal health record.
As a physician and founder of PassportMD, Inc. ( ) , I remain committed to creating a free site and service so that people of any age and any economic status can participate. The free service helps people through the often-tedious process of creating a very valuable, and potentially life saving tool, the personal health record. We are committed to simplifying this process, giving people, seniors, adults, children, particularly with a history of at least one chronic medical disease, on multiple medications, or with a history of allergies access to a system that can help save their lives. Doctors need to have access to reliable information that is legible and accessible and PassportMD provides this needed function.
Medical Mistakes are common, hospital errors are responsible for over 100,000 deaths per year and these could be preventable. Information about drug interactions and cross reactivity combined with allergy alerts lead the way in being critical to every healthcare provider before initiating care. At we have created a very easy way to solicit this information from individuals and host it so that they may access it or print it off in times of need at no charge and as often as they would like.

Scenarios where this type of service makes the most sense is baby boomers that are responsible for managing their elderly parents’ medical care and doctors’ visits, or seniors that live alone or are responsible for managing their own care and visits to their doctors. Or, “snowbirds” that share many doctors between more than one state would benefit from Alternatively, children, before they go to summer camp, if they have an allergy or take chronic medications for chronic problems. Anyone with any chronic disease, diabetes, hypertension, heart disease, for example would benefit from the free service. Additionally, active, healthy individuals that are pro-active with their health in preparation for unexpected and unpredictable medical problems would benefit from People that travel frequently, cruise to the islands, or boat, would be especially susceptible to medical emergencies without their accurate medical history.
The doctors are very slowly adopting electronic health records. This adoption is way too slow and is very complicated. It has many factors in play as it relates to the economics of medicine. Although privacy is considered an issue, the true issue is cost, implementation and maintanence costs to the physician practice are too burdensome in light of decreasing reimbursement. Thus, only 7.5 % of physician practices are currently adopting electronic health records. Though, if you poll the remaining 92.5% of physicians, probably all would agree that electronic health records are better for medicine and for the patient. Adoption is inevitable but the pace and time period for adoption is dependent upon many factors.