A few years ago, back when I was still an employee at a large corporate practice, a middle aged woman who I knew well came to see me complaining of abdominal pain. I took a history from her, examined her carefully, and reviewed her recent labs. After doing so, I was reassured that she had nothing serious going on and needed no further workup for the moment.
So I did exactly the sort of “irrational” thing that makes no sense to an insurance company but all the sense in the world to a doctor: I ordered an abdominal ultrasound.
Before getting back to this case let me digress for a moment. Over a century ago, Sir William Osler – one of the famed pioneers of modern medicine – stated that “it is much more important to know what sort of a patient has a disease than what sort of a disease a patient has.” This bit of wisdom, handed down through generations of physicians since, aptly captures just the sort of human touch that the practice of medicine should have. It acknowledges that each patient is unique, with their own biological, psychological, and spiritual responses to their given situation, and that medicine is as much an art as a science. No reasonable person could argue with this. And yet our currently formulated healthcare system subverts the wisdom contained in this maxim at every turn. For evidence of this claim, I return now to my opening anecdote.
Even though I didn’t think my patient needed anything medically, I knew this patient well. I knew that she was someone who tended to get anxious easily. I knew that she had recently lost a close friend to pancreatic cancer. I knew, in other words, that her symptoms were most likely driven by worry, and that what she really needed was reassurance. And I knew that if I didn’t order some kind of test, she would not be able to sleep for the next few weeks, and that she would come back to me again and again until she got one.
The standard test to look for pancreatic cancer is a CT scan, and had I been as worried as the patient, I would have ordered one. But a CT scan is expensive and exposes the patient to radiation. An ultrasound is a decent test for pancreatic cancer, but not as good as a CT. However, an ultrasound is cheap and harmless. So I made the calculation that we could order the cheap, safe, decent test, and that when she got a normal result her symptoms would probably get better, obviating the need for anything further. (And if they didn’t, then of course, we would do the CT scan).
But the insurance company didn’t see it this way. They refused to pay for the ultrasound based on the fact that the risk for any serious disease seemed low. So the patient was sent home to suffer.
And suffer she did. Then, after a few days of suffering, she couldn’t take it anymore. She went to the emergency room at the local hospital. There she had a full workup including a CT scan. Thankfully all was, as expected, normal, and when I saw her about a week later her abdominal pain had mysteriously vanished. A happy ending.
Except that my patient was exposed to some unneeded radiation. And the insurance company, by getting out of paying $100 for an ultrasound, ended up paying several thousand dollars for an ER visit and a CT scan.
If you want to know why our healthcare system is so broken, this anecdote offers more than a few clues.
The attempt to run our healthcare system as a large bureaucracy is inherently inhumane. The insurers, the pharmaceutical companies, the government regulators, and the big corporations who run most of the healthcare delivery in this country have no choice but to be focused on things like efficiency, cost-savings, and adhering to “evidence based guidelines.” And in theory, those are all good things in and of themselves.
But trying to run a healthcare system by the same logic that one would run an automobile manufacturer or a telecommunications company simply doesn’t work. In healthcare, human nature is the coin of the realm, and the complexities of each individual patient can never be accommodated by the sort of standardization that has brought efficiency to other industries.
What the bean counters can never grasp is that human beings are inherently complex psychological and spiritual creatures who need from their doctor things like reassurance, motivation, and the warmth of a personal relationship in at least equal measure to the scientific insights that modern medicine can provide.
In the mainstream health system, reassuring a patient and putting their mind at ease is not a good enough reason to order a test. The patient has to first have symptoms or findings to suggest that the test might actually pick up a disease.
Nor is feedback and motivation a sufficient reason to order a test. If, for example, a certain study might confirm the need to lose some weight and get into better shape, it will not be approved, since the advice to lose weight and get into better shape is pretty much always correct and can be given without first obtaining the test. The psychological factor – the fact that a patient might finally find the motivation to change after being presented with evidence of a looming health concern later in life – is simply not something that can be considered by the insurers.
Decisions are ultimately driven by cost-benefit algorithms, and can never account for the fact that doctors – most of whom are keen students of human nature and develop with experience a good feel for what each individual patient really needs – have to make all sorts of judgment calls that don’t fit neatly into algorithmic thinking.
I will get back to writing about health topics soon, but I was inspired to write this rant today after talking with a colleague of mine with whom I used to practice. He’s still stuck in the corporate insurance driven system, and is slowly being driven to burnout from it. Listening to him talk about his job frustrations made me again grateful that I “dropped out” of that system and went into Direct Primary Care (DPC).
To summarize my thoughts in this post another way (by way of paraphrasing a popular book from the ‘90s): doctors and patients are from Earth, and insurance companies are from Mars. And direct primary care brings the doctor-patient relationship back down to Earth.
