The Secrets of Medical Decision Making: How to Avoid Becoming a Victim of the Health Care Machine

Health care is becoming increasingly complex, with multiple factors affecting decision making. You may have heard about or experienced some of the shortcomings of this system first hand. People of all ages and all degrees of health are affected by the current way of medical practice. It starts with infants, who are put through a variety of tests by overzealous physicians responding to their own or their parent's fears. Young women become unnecessarily worried from their Pap smear screening, prenatal testing, and encountering a wall of defensive medicine during childbirth. Middle aged men are enticed into a highly questionable practice of prostate cancer screening and ending up with surgeries that, instead of prolonging their life, leave them deprived of their basic human capacities. There are a slew of breast biopsies and mastectomies as a result of screening mammography in women, without concomitant prolongation of life but with an enormous mental and physical toll. Finally, the elderly are put through testing and procedures in the last six months of life—the evidence now clearly shows that this actually slightly shorten their lives when compared with those who did not have the option of utilizing health care system to the same extent (due to living in regions of the US with lower Health Care funding).

When we enter the system as patients, we are simply hoping that a physician will take good care of us. We also sometimes hope that health care will prevent us from getting sick, discover and diagnose any hidden illness, cure or treat it, and possibly make us live longer. The physician of course tries to live up to some of these expectations.

I am a doctor, but this doesn't protect me from health problems. Recently, I had a kidney stone, and became a patient. The physician taking care of me in the emergency room accurately diagnosed and treated the problem. At the discharge, the physician told me that I needed to follow up with a urologist. Now that I have a kidney stone I should have a urologist. Those two go together in her mind. She was the usual overworked senior resident in the emergency room of a university hospital. She told me what she tells all the patients discharged after the discovery of a kidney stone. From the point of view of the usual medical training, she was an exemplary physician. She gave her recommendation with the best intentions: she truly believed that she was doing me good by giving that advice. Physicians are systematically taught to give the same advice to everyone; we do not have the time nor the training to pay attention to individual differences.

She was quite surprised when I told her that I wasn't planning to follow her advice, that I simply intended to alter my diet. At that point I opted not to follow her medical advice and not to subject myself to additional testing with the time commitment, inconvenience, and expense that it entails, let alone the risks of false-positive results and unnecessary procedures with their side-effects. That was my personal preference. Whether or not my decisions were wise is not the issue. Rather, it is my hope to empower patients and their family members to recognize the freedom of choice even when none is presented and to know that the information they lack for decision making can be obtained by directly questioning the system. It is also my intention to decrease undue expectations that the medical system itself fosters, and to deflate the balloon of medical omnipotence.

I call this system The Health Care Machine because it has become mechanical. The race for ‘clinical productivity’ is turning health care into another form of an assembly line. There are other factors I'll soon discuss that push us in the same direction. A physician who sees you is no longer an agent who works for you. Rather, he or she is trying to balance a number of conflicting demands. As I watched a TV interview at an advertising agency that created a television ad for one of the frequently used drugs, the spokesperson stated …the medications now are a part of a healthy lifestyle… She truly believed that and wanted the rest of the world to believe it as well. So it is with the physicians and other health care workers who are placed in a position (and I call this position The Medical Box) that pressures them to have only a standard, mechanical response to any given set of problems. Eventually, being in that box makes them believe that those are the only possible answers. I think a patient can navigate through this system much more successfully by being aware of its limitations.

In the body of this book, I present vignettes from my clinical practice, experience in the medical school and residency, and personal research. Mostly they are the accounts of actual patients I have cared for, directly or indirectly. I have altered the details to make them unrecognizable while maintaining the essence of each story intact. They all demonstrate the facets and influences of the rules of the game: the game of health care. It is my hope that from reading these accounts with the accompanying discussions, you will understand the motives influencing your doctor's decisions and will learn how to be more self-reliant.

Throughout the book I placed subheadings: Patient/Family Perspective, Physician's Perspective, Societal Perspective and Spiritual/Philosophical Perspective. Though these subdivisions are somewhat artificial, since to some degree, one perspective contains all of the others, I hope that they will ease the flow and absorption of the material. Patient/Family Perspective deals with the issues that most closely relate to, or would be most helpful for prospective patients and their families. Physician's Perspective reveals physicians perception of the issue. Societal Perspective shows the impact on the society as a whole. Spiritual/Philosophical Perspective addresses spiritual and philosophical aspects of medical care, aspects that cannot truly be separated from any endeavor seeking to understand a human being.

Physician's Perspective

The term ‘Medical Box‘ is my invention to show the boxed-in thinking imposed on physicians; the boundaries they need to overcome in order to do what's in the patient's best interest. I believe it is important for the patient to be aware of them too. Here are what I call the four corners of the Medical Box:

Fear of litigation.

Financial and time pressure.

Guidelines of Health Care authorities.

The current Medical Model—disease oriented thinking.

I think most physicians wish to do good and to be genuinely helpful. This wish is impeded by the Medical Box.

Litigation has a potential of disrupting medical practice and increasing malpractice insurance premiums. Being labeled as high risk physician limits one's employability. According to the Association of American Medical Colleges, an average physician who graduated from medical school in 2004 had $115,000 of educational debts! This debt has been steadily increasing. After spending a minimum of eleven years of intense learning, one tends to want to have some degree of comfort, to be able to repay one's debts, and have a feeling of some financial security in order to support a family. All of that is threatened by a lawsuit. Medical mistakes do happen and it is fair to hold the doctor accountable for them. However, the success of a lawsuit does not always depend on the degree or even presence of a mistake on the doctor's part, but rather, on the gravity of the outcome or on chance alone. One of my obstetrical colleagues was successfully sued after her patient's unborn baby died. Though by the standards of medical practice there was no error, it is hard for the jury not to feel overwhelmed by such a tragedy. Consequently, she was deemed guilty, resulting in stigmatization, raised malpractice insurance premium, and a mark on the record that will be questioned whenever she may want to look for another job, or apply for another malpractice insurance.

This record is permanent. It is not surprising that fear of being sued is one of the major forces driving medical decision making in the US today. I attempt to illustrate some of the implications of this in the vignettes of the subsequent chapters where actual patients are described. I am not the only one to believe that the success of a lawsuit does not depend on the presence of an error. Linda Crawford, who is on the faculty of Harvard Law School, where she teaches trial advocacy and has been consulting people on research and evidence-based effectiveness for malpractice depositions, states that five out of six lawsuits involve good medicine, half the time there isn't even a bad outcome (Tracy, 2003). She further states: Let's talk about brain-damaged children. All of us now go into labor and delivery presuming we will have a perfect outcome. The parents believe it. The family believes it. The community believes it, and frankly the providers believe it; yet, it is still true that we have not made any significant gains since 1965. Five percent of children are born with significant disabilities. There is a gap between what everybody is expecting and the reality. I am all for good relationships with your patients; I think it has a great deal to do with the quality of our professional lives. However, I also look at the specialties and the individual surgeons who are sued, and it often has to do with the expectations of your patients going into whatever the event is. These expectations are not easily changed and are often the result of a well publicized boasting of the medical system about the great advances we've achieved.

Money and time are intimately related in our society and the medical system is no exception. Beginning in medical school, we (medical students) were repeatedly told that medicine is business. I do not share this opinion but it is now held by the vast majority of physicians. More than that, in medical school we were specifically taught that it is not important for us to care about the patients, what is important is to know how to create an impression of caring. We were then taught how to do that, how to fake a caring attitude. A doctor has to say aha, tell me more, to make a pause after a patient says something he finds significant; one needs to make brief remarks indicating compassion and understanding so as not to make an impression of being uncaring. All this is so that the business part of medicine can go more smoothly.

Third party payers also drive some of the important changes in this realm. Health insurance attempts to cover health care needs and make some money off of this process. They have to find some quantifiable way of reimbursing physicians. This quantification (which is difficult to avoid) is one of the problems. My residency training was in a suburban university hospital. From time to time, in addition to the usual lectures by the faculty, we were lectured by the community physicians who were supposed to teach us how to survive in the real world. We were taught that talking to the patient doesn't pay, that in order to survive financially we needed to decrease the amount of talk to the minimum and instead to do as many office procedures as possible. Insurance won't pay for educating a patient, but they pay for throat cultures, wart removals, hearing, vision, blood and urine tests etc. An excerpt from a recent article for the physicians in the Family Practice Management Journal (Martz, 2003) illustrates this