Wendy Lynch
First posted 8/18/11 on the HCMS Blog
A question: Does uncertainty in medicine mean consumers should be more or less involved in choices?
As the country watched wild swings in the stock market these past weeks, every investor faced unfortunate hindsight: if only I had cashed out at 12,500! Combined with the pain of continued uncertainty, many investors decided to remove their (remaining) funds simply to stop the discomfort of an unknown future.
While we all dread the anguish of downward market fluctuations and wonder daily what it is store for our dwindling nest eggs, no one can change the fundamental truths of investing: risk and uncertainty. Yes, experts can advise us and help us assess varying degrees of risk among options, but no one can guarantee the success of our investment decisions, no matter how well informed.
If the world of financial markets is this uncertain, should investors be less involved in the decisions about where they place their money and how much risk they assume? One could easily argue that the average investor is not capable of making good decisions. So, should we all find a seasoned stock broker to make decisions for us, independent of our personal circumstances and preferences? After all, they are the experts—right?
What about letting someone else make decisions about our health?
There is more of a parallel between managing financial assets and health assets than most of us would like to believe. Would it surprise you to know that of more than 1,100 medical studies conducted on new treatments or therapies between 2006 and 2010, 92% were labeled unreliable (1)? Or that 75% of new treatments in the past 20 years provided no clinical improvement (safety, efficacy or compliance) over existing treatment (2)? Or that scientists conducting medical trials admit being pressured or influenced by the sponsors or manufacturers funding the research (3)? Or that the popular press (or researchers themselves) often exaggerates research findings to make the study results more compelling (4)?
And this is just the part of standard medical practice that has been studied; a large part has never been investigated carefully at all. By some estimates, over half of what is accepted as the “right” course of treatment has no scientific basis; rather, they’ve simply became customary based on anecdotes and traditions passed on over time (5). Almost every week we hear of a study that disputes, updates, or flat-out reverses a medical “fact” proving that a standard practice has no proven basis (6).
To be fair, the presence of uncertainty does not imply a failure of medical science, but instead reveals our societal desire to minimize risk and guarantee answers, even when neither is completely possible. It is more comforting to believe that certain treatments and cures are absolute. Like watching stock prices rise and fall, there is anxiety in the unknown.
In a wonderful description of how uncertainty affects doctors and patients, physician Richard Hayward (7) writes that:
“Nowhere is the equation, condition A, if followed by treatment B, will produce result C, less certain than in the practice of clinical medicine.” Yet, “Such uncertainty can be as dispiriting for doctors as it is for patients, often leading to denial (by both parties) that such uncertainty even exists.”
As somewhat of an “insider” to healthcare and knowledgeable about the challenges of rigorous research, I still find myself startled by the degree of uncertainty in clinical treatment. If my reaction is one of mild surprise, I have to assume that scores of “outsiders” have misplaced enormous faith in the credibility and dependability of medical science.
So does inherent uncertainty make patient choice more or less critical?
Back to my earlier question, rephrased: If the world of healthcare and medicine is this uncertain, should patients be less involved in the decisions about their personal health and how much risk they assume? Should we all find seasoned physicians and allow those people to make decisions independent of our personal circumstances and preferences? After all, they are the experts—right?
Because I often write and speak about patient decision-making, I commonly hear concern that medicine is too complex for the average person to understand, suggesting that only physicians are capable of choosing the right course of treatment. I’ve been pulled aside many times to hear someone confide, “All this work to inform consumers is fine, but in the end, few patients will go against their doctor’s advice.” What does this say about our system if we believe doctors and patients are on opposing sides of a treatment decision? More importantly, how can doctors make appropriate decisions without knowing a patient’s preferences?
If patients believe that medicine is much safer and more effective than it actually is, what is healthcare’s responsibility to inform and educate patients and consumers? Does this suggest we should be more or less transparent about uncertainty? And given the degree of risk, should we be more or less inclusive of patient preferences? Doesn’t the person who will experience the consequences deserve to have the final decision about risk versus reward?
For me there is no question. Just as investors need to understand the balance of risk and opportunity, so too do patients require frank, open information about what is and IS NOT known. The higher the risk of loss, the more the investor (or patient) needs to make the decision. In business, leading an investor to believe that a particular return is almost certain—without informing him of potential risk—constitutes fraud. A talented investment manager educates clients in ways that they maximize gains, while minimizing risk to the levels they choose to tolerate. A responsible medical provider must do the same.
Why this matters: Financial and physical health are tightly connected. Protecting our health is vital to a productive work life, and protecting our finances provides us more options for managing our health. Responsibility for neither can be assigned to someone else.
Every time you seek healthcare, remember that more than half of what a doctor suggests is based on opinion and tradition rather than science. Then, ask yourself if you’re better off blindly taking that suggestion, or if you might benefit from additional information about what is known and unknown, and what other options might be available. If you wouldn’t give someone else complete and independent control over your financial assets, don’t your personal health decisions deserve the same level of care?
References
1. Socha, T. Assessing New Medications Using Evidence-Based Value. First Report Managed Care, Nov 19, 2010;http://www.firstreportnow.com/articles/assessing-new-medications-using-evidence-based-value?page=0,0 (accessed Aug 17, 2011).
2. The National Institute for Health Care Management, Research and Educational Foundation. Changing Patterns of Pharmaceutical Innovation. NIHCM Foundation, May, 2002; http://www.nihcm.org/pdf/innovations.pdf (accessed August 17, 2011). (accessed Aug 17, 2011).
3. Fairman KA , Curtiss FR: Rethinking the “Whodunnit” Approach to Assessing the Quality of Health Care Research – A Call to Focus on the Evidence in Evidence-Based Practice. J Managed Care Pharmacy 2008;14:661-74.(accessed August 17, 2011).
4. Fairman KA , Curtiss FR: Making the world safe for evidence-based policy: let’s slay the biases in research on value-based insurance design. J Manag Care Pharm 2008 ;14:198-204.
5. Joelving, F. Medical “best practice” often no more than opinion. Reuters, Jan 10, 2011; (accessed Aug 17, 2011).
6. Krumholz, H. Medicine’s Drip of Uncertainty. Forbes, Mar 2, 2011; (accessed Aug 17, 2011).
7. Hayward R: Balancing certainty and uncertainty in clinical medicine. Dev Med Child Neurol 2006; 48:74-7. (accessed August 17, 2011).
A question: Does uncertainty in medicine mean consumers should be more or less involved in choices?
As the country watched wild swings in the stock market these past weeks, every investor faced unfortunate hindsight: if only I had cashed out at 12,500! Combined with the pain of continued uncertainty, many investors decided to remove their (remaining) funds simply to stop the discomfort of an unknown future.
While we all dread the anguish of downward market fluctuations and wonder daily what it is store for our dwindling nest eggs, no one can change the fundamental truths of investing: risk and uncertainty. Yes, experts can advise us and help us assess varying degrees of risk among options, but no one can guarantee the success of our investment decisions, no matter how well informed.
If the world of financial markets is this uncertain, should investors be less involved in the decisions about where they place their money and how much risk they assume? One could easily argue that the average investor is not capable of making good decisions. So, should we all find a seasoned stock broker to make decisions for us, independent of our personal circumstances and preferences? After all, they are the experts—right?
What about letting someone else make decisions about our health?
There is more of a parallel between managing financial assets and health assets than most of us would like to believe. Would it surprise you to know that of more than 1,100 medical studies conducted on new treatments or therapies between 2006 and 2010, 92% were labeled unreliable (1)? Or that 75% of new treatments in the past 20 years provided no clinical improvement (safety, efficacy or compliance) over existing treatment (2)? Or that scientists conducting medical trials admit being pressured or influenced by the sponsors or manufacturers funding the research (3)? Or that the popular press (or researchers themselves) often exaggerates research findings to make the study results more compelling (4)?
And this is just the part of standard medical practice that has been studied; a large part has never been investigated carefully at all. By some estimates, over half of what is accepted as the “right” course of treatment has no scientific basis; rather, they’ve simply became customary based on anecdotes and traditions passed on over time (5). Almost every week we hear of a study that disputes, updates, or flat-out reverses a medical “fact” proving that a standard practice has no proven basis (6).
To be fair, the presence of uncertainty does not imply a failure of medical science, but instead reveals our societal desire to minimize risk and guarantee answers, even when neither is completely possible. It is more comforting to believe that certain treatments and cures are absolute. Like watching stock prices rise and fall, there is anxiety in the unknown.
In a wonderful description of how uncertainty affects doctors and patients, physician Richard Hayward (7) writes that:
“Nowhere is the equation, condition A, if followed by treatment B, will produce result C, less certain than in the practice of clinical medicine.” Yet, “Such uncertainty can be as dispiriting for doctors as it is for patients, often leading to denial (by both parties) that such uncertainty even exists.”
As somewhat of an “insider” to healthcare and knowledgeable about the challenges of rigorous research, I still find myself startled by the degree of uncertainty in clinical treatment. If my reaction is one of mild surprise, I have to assume that scores of “outsiders” have misplaced enormous faith in the credibility and dependability of medical science.
So does inherent uncertainty make patient choice more or less critical?
Back to my earlier question, rephrased: If the world of healthcare and medicine is this uncertain, should patients be less involved in the decisions about their personal health and how much risk they assume? Should we all find seasoned physicians and allow those people to make decisions independent of our personal circumstances and preferences? After all, they are the experts—right?
Because I often write and speak about patient decision-making, I commonly hear concern that medicine is too complex for the average person to understand, suggesting that only physicians are capable of choosing the right course of treatment. I’ve been pulled aside many times to hear someone confide, “All this work to inform consumers is fine, but in the end, few patients will go against their doctor’s advice.” What does this say about our system if we believe doctors and patients are on opposing sides of a treatment decision? More importantly, how can doctors make appropriate decisions without knowing a patient’s preferences?
If patients believe that medicine is much safer and more effective than it actually is, what is healthcare’s responsibility to inform and educate patients and consumers? Does this suggest we should be more or less transparent about uncertainty? And given the degree of risk, should we be more or less inclusive of patient preferences? Doesn’t the person who will experience the consequences deserve to have the final decision about risk versus reward?
For me there is no question. Just as investors need to understand the balance of risk and opportunity, so too do patients require frank, open information about what is and IS NOT known. The higher the risk of loss, the more the investor (or patient) needs to make the decision. In business, leading an investor to believe that a particular return is almost certain—without informing him of potential risk—constitutes fraud. A talented investment manager educates clients in ways that they maximize gains, while minimizing risk to the levels they choose to tolerate. A responsible medical provider must do the same.
Why this matters: Financial and physical health are tightly connected. Protecting our health is vital to a productive work life, and protecting our finances provides us more options for managing our health. Responsibility for neither can be assigned to someone else.
Every time you seek healthcare, remember that more than half of what a doctor suggests is based on opinion and tradition rather than science. Then, ask yourself if you’re better off blindly taking that suggestion, or if you might benefit from additional information about what is known and unknown, and what other options might be available. If you wouldn’t give someone else complete and independent control over your financial assets, don’t your personal health decisions deserve the same level of care?
References
1. Socha, T. Assessing New Medications Using Evidence-Based Value. First Report Managed Care, Nov 19, 2010;http://www.firstreportnow.com/articles/assessing-new-medications-using-evidence-based-value?page=0,0 (accessed Aug 17, 2011).
2. The National Institute for Health Care Management, Research and Educational Foundation. Changing Patterns of Pharmaceutical Innovation. NIHCM Foundation, May, 2002; http://www.nihcm.org/pdf/innovations.pdf (accessed August 17, 2011). (accessed Aug 17, 2011).
3. Fairman KA , Curtiss FR: Rethinking the “Whodunnit” Approach to Assessing the Quality of Health Care Research – A Call to Focus on the Evidence in Evidence-Based Practice. J Managed Care Pharmacy 2008;14:661-74.(accessed August 17, 2011).
4. Fairman KA , Curtiss FR: Making the world safe for evidence-based policy: let’s slay the biases in research on value-based insurance design. J Manag Care Pharm 2008 ;14:198-204.
5. Joelving, F. Medical “best practice” often no more than opinion. Reuters, Jan 10, 2011; (accessed Aug 17, 2011).
6. Krumholz, H. Medicine’s Drip of Uncertainty. Forbes, Mar 2, 2011; (accessed Aug 17, 2011).
7. Hayward R: Balancing certainty and uncertainty in clinical medicine. Dev Med Child Neurol 2006; 48:74-7. (accessed August 17, 2011).
Care And Cost 
This analogy is dead on-no pun intended. And it can be expanded even further. The complexity of financial markets and medicine allows charlatans to promote products that do not benefit the customer/patient while tremendously increasing the income of the individual promoting the product. The complexity allows old paradigms to remain in place while the old guard pushes back against the adoption of more effective, less expensive treatments. A perfect example is the widespread use of revascularization procedures in stable angina in the face of overwhelming evidence that optimal medical therapy with generic medications and life style instruction produces equal results with less risk and cost. The financial disasters of the dot-com and housing bubble were facilitated by deregulation. We need strong leadership at the level of the government to examine the efficacy of various treatment options and strong regulation to promote reimbursement based on the evidence. The science and systems exist today to prevent most heart attacks. Unfortunately we will not realize that benefit without leadership from those with the power to insist on payment reform, system redesign, and evidence-based protocols consistent with best practice.