As a follow up to the Dr. Kohar Jones’ progress note “Choosing Wisely”, I would like to further stress the ethical imperative to reduce waste and excess in the healthcare system. I had the pleasure to meet Dr. Howard Brody this week and discuss the “Choosing Wisely” initiative, which is his challenge to the various medical societies. We discussed at length the moral necessity for health care reform, but also the need for physicians to take responsibility for their actions. More specifically, physicians must stop using the excuse of “defensive medicine” and ethically assess the care they provide and do what is in the best interest of the patient. Is a specific intervention really needed or helpful? Is it evidence based? Is the patient fully informed about his/her choices? These are the questions that a physician must answer and engage his or her patient in a “shared-decision” making process.
Physicians have an ethical responsibility towards their patient’s well-being, before their own. Healthcare can be a murky business, and when financial benefits are concerned, the stability of ethical decision making is in danger. A code of ethic should be the foundation of all medical institutions idealistically; and I say idealistically, because it has become egregiously complicated. However, the “Choosing Wisely” campaign is a step in the right direction and the fact that certain specialty societies have stepped up to offer their list of five avoidable and non-beneficial interventions is an encouraging sign.
A reference that measures the large potential for preventing medical care futility and curtailing costs is the Dartmouth Atlas. This tool had been tracking Medicare spending and distribution of medical resources for the past two decades about national, regional, and local markets, even to the specificity of a given hospital. Dr. Atul Gawande used the astonishing findings from this database in his article, “The Cost Conundrum”, published in The New Yorker three years ago. The crux of the story compared two neighboring towns in the state of Texas, with similar demographics and health outcomes, but Medicare spending in one was twice as much as the other. This example is not unique, it is the story of our healthcare system. The evidence repeatedly shows that there is little to no correlation between higher cost of healthcare and quality of population health. It is not hard to reason that such variations in use of resources at the government’s expense is due to perverse financial incentives, which healthcare providers should accept most of the responsibility for. The Institute of Medicine estimates that 30% “care” is waste and unnecessary spending in healthcare. Idealistically speaking again, if we recovered all that wasted spending for the next two years, we can meet the Congressional Budget Office estimate for the cost of Obama Care for the next 10 years without any new revenue.
The solution must start with the code of medical ethics. As the stipulations of the health care reform further materialize, physicians need to ignite their capacity of ethical doctoring and help their patients and the failing system.
As far as doctors putting their patients welfare ahead of their own, this used to be commonplace. As I have gotten older, I have noticed that this is no longer the norm. I say this with experience as my teacher, since I am in a situation right now, where I may very well lose my home, because my treating physician missed diagnosing an injury for well over 2 years.