Atul Gawande’s latest article in The New Yorker (gated) is one of his best. It is about attempts to reduce health care costs by focusing on the most expensive patients. A tiny fraction of people produce something like 30% of the total cost. You can save a lot of money, it turns out, if you try hard to help them.
To help them, it turns out, you need to do things that aren’t obvious, such as hire someone whose last job was at Dunkin Donuts (as a “health coach”). It turns out that not everyone is happy with what you’re doing.
[One high-cost patient] had seen a cardiologist for chest pains two decades ago, when she was in her twenties. It was the result of a temporary inflammatory condition but [the cardiologist] continued to have her see him for an examination and electrocardiogram every three months, and a cardiac ultrasound every year. The results were always normal. After the clinic doctors advised her to stop [having the tests], he called her at home to say her health was at risk if she didn’t keep seeing him. She went back.
To me, the most revealing part of the article was about a young woman with persistent migraines. During the last 10 months she had required $52,000 of medical care (“twenty-nine E.R. visits, fifty-one doctor’s office visits, and a hospital admission”). Yes, dealing with a persistent migraine by going to the E.R. over and over isn’t getting anywhere. But here is what Gawande (a doctor at Harvard, who writes for The New Yorker) recommends:
She wasn’t getting what she needed for adequate migraine care–a primary physician taking her in hand, trying different medications in a systematic way, and figuring out how to better keep her migraines at bay.
During those fifty-one doctor’s office visits, the woman wasn’t prescribed all possible medicines? And, if she was, she needs a doctor’s help to figure out if they work — which they obviously don’t? How stupid does Gawande think that she and her doctors are?
I don’t think Gawande thinks they are stupid; I think he is unable to stop thinking like a doctor, which means thinking that every serious problem has a solution that includes prescription drugs or other medical care. (Unless it’s obesity, in which case the solution is the ancient advice to “eat less, move more”.) This woman needs to explore lifestyle solutions to her problem. She doesn’t need a doctor for that. But most doctors, judging by their actions, cannot imagine such a thing.
And if she wants to experiment with different drugs that might help her, why does she have to go through the hassle, expensive, and bureacracy of seeing a doctor??
Vic’s hit something there. The solution to medical problems is to have people treat themselves instead of doctors for most common issues. We used to do this and with the internet it should be easy to fix most common problems.
I filed for a primary care physician during a summer in college.
I was shocked and disturbed by the prevalence of mental health issues with the doctor’s frequent visit patients.
I guess it sort of makes sense. It’s difficult for people suffering depression to make changes in their life and that leads to other medical issues.
I’m not sure what the answer is. But it does seem like mental health drugs do not work as well as we once thought and that cognitive behavioral therapy is fairly effective.
People, especially the elderly, often go to doctors for a bit of human contact when they feel isolated–drugs can’t relieve social isolation on their own. Some researchers are now looking at the placebo effect not only of drugs themselves but of the medical rituals of examining patients, prescribing, etc. For some depression, CBT is effective, and so is psychodynamic therapy–apparently roughly equivalent. The human connection with the therapist is an important factor in healing.
For an interesting take on placebos: https://www.radiolab.org/2007/may/17/
Would you like to comment on the recent Statins story?
https://www.telegraph.co.uk/health/healthnews/8267570/Millions-taking-statins-needlessly.html
John, Jon Stewart commented on Sarah Palin’s talent for turning criticism into victimization. It’s the same with placebo effects. If something that should not have an effect does have an effect, it implies the experimenter doesn’t understand what’s going on. Exactly that, no more, no less. All that talk about placebo effects being due to “expectations” goes beyond the evidence. Yet somehow placebo effects are taken to mean the experimental subject is credulous. Medical researchers, in other words, are showing a talent for turning indications of their ignorance into indications of their sophistication (“we controlled for placebo effects”).
dearieme, thanks for bringing that article to my attention. My interpretation is that the skepticism of doctors (dismissing acupuncture, for example) isn’t really skepticism, it’s self-interest. When being credulous is in their self-interest (e.g., thinking statins are wonder drugs, without serious side effects), they’re credulous.
I heard Gawande on NPR. He said she was using a weak migraine treatment, and nobody had thought to prescribe a better one, e.g. one that would actually work for her.
Nathan, that’s a good point. Apparently thinking like a doctor means not thinking at all.
When you say “(Unless it’s obesity, in which case the solution is the ancient advice to “eat less, move more.”)” you go from criticizing doctor think to thinking like a doctor. What about the ancient advice to “go for a walk and work up an appetite.” In other words, move more, eat more.
Chuck, I have a low opinion of the ancient advice.
Seth, my apologies. I totally miss-read the preceding sentence.