Magical Thinking, Overtreatment, and Neglect of Patient and Family Values

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My friend and college classmate Ted Marmor (see his recent post here) and Jonathan Oberlander have a short but illuminating article in a recent issue of the Journal of General Internal Medicine – “From HMOs to ACOs: The Quest for the Holy Grail in U.S. Health Policy.”  They offer a chastening analysis of our almost theological belief in the existence of a “‘Big Fix,’ a reform that will decisively rein in spending and simultaneously improve the coordination and quality of medical care.”

Marmor and Oberlander identify three drivers of our tenacious search for health policy miracles. First, “because panaceas promise to moderate spending by reducing ineffective care, improving coordination, and keeping people healthy, such policies offer the prospect of painless cost control,” a view that politicians find irresistible. Second, “reform ideas are framed in ways that make rational criticism seem implausible . . . . The language used to describe many health reforms is meant to convince rather than to describe and explain.” Who would oppose the idea of a medical home, of maintaining health, or of giving consumers choices? Finally, they believe that “absence of a coherent national system” makes us powerless to control costs, and in our powerless state we solace ourselves with recurrent bouts of faith in salvation through health maintenance organizations, managed care, health savings accounts, consumer-directed care, pay for performance, and more.

This endless search “for a transcendent solution inevitably produces a cycle of exaggerated expectations, followed by deep disappointment.” Because our need to believe that the policy answer is at hand and that the persuasive labels given to the magic bullet de jour embody reliable truths, we characteristically underestimate the challenges a reform will face, and don’t acknowledge just how hard it will be to scale up a promising innovation and make it generalizable. I was guilty of this in my early days of practicing at the not-for-profit Harvard Community Health Plan HMO. I believed prepaid group practice and salaried physicians was the right way for American medicine to go. I still believe it’s an excellent model and get my own medical care from the system, but I recognize that the model has had limited appeal. As good as it may be, it’s not a panacea.

Marmor and Oberlander conclude with a proposal of their own:

“We believe that the U.S. needs less innovation and more emulation. That is, in order to control costs effectively Americans should focus less on (re)inventing the latest delivery system or payment method, and instead pay more attention to what other countries do to slow health care spending. Global budgets, fee schedules, systemwide payment rules, and concentrated purchasing power may not be modern, exciting or ‘transformational.’ But they have the advantage of working.”

I share their view that universal insurance and a global budget for the health system is the right way to go. But we should heed their warning about irrational exuberance. We’ve had universal insurance for the over 65 population since 1965, but Congress still doesn’t let CMS take cost into account in managing Medicare.

We Americans are consistent in thinking about health care in terms of magic. Our belief in magical health policy bullets that will solve the cost problem is mirrored in our belief that magical clinical bullets will forestall death (almost) forever. The quest for clinical miracles even when they’re not to be had can cause harm at every age, but it has special relevance for the over 65 generation. Over the years the primary care residents I teach have used the term “flogging” for the overly aggressive care they see seniors receiving in the hospital, based on the hope that one more chemotherapy or one more surgery will halt the inevitable.

In the world of health policy, magical thinking leads to the cycle of ineffective reforms and recurrent disappointment that Marmor and Oberlander describe. In the world of clinical care, magical thinking leads to overtreatment and neglect of patient and family values. Our country and the over 65 generation need more realism from policy leaders and clinicians.

James Sabin, M.D., 73, is an organizer of Over 65 and a clinical professor of psychiatry at Harvard Medical School.

6 Responses to “Magical Thinking, Overtreatment, and Neglect of Patient and Family Values”

  1. Leslie Kernisan, MD

    Hi Jim,
    Interesting post. I must say that my experience has been that patients and families often value overtreatment, in part because they don’t perceive the burdens unless a clinician spends time articulating the likely benefits and burdens of each option. Perhaps it would help if at the national level we started doing what some of us do as clinicians: 1) acknowledge that none of the options available will get us what we want (better care, less cost, no painful choices); 2) thoughtfully consider the trade-offs embedded in each feasible option and then move forward with the set of trade-offs that seems to be the best fit for our values.

    • Jim Sabin

      Hi Leslie –
      I agree that dealing with “overtreatment” takes time. Patients and families expect and deserve clear explanations of why we think a treatment they’ve heard about or had in the past is not needed, or even might potentially be harmful. When we are (a) comfortable with our recommendation against a particular intervention, (b) are able to explain our rationale clearly, and (c) ideally, already have a relationship of trust with the patient/family, then(d) not overtreating becomes much easier.
      I believe that it’s possible to provide better care at lower cost, but I agree with you that doing so involves painful choices. Sometimes we as physicians deeply believe in an intervention that experts in our field know to be less effective and more costly than an alternative. Giving up our cherished belief and habitual practices is painful, and we often resist. Likewise for patients and families.
      But even if we wring out all forms of “overtreatment,” with an aging population and expanding treatment possibilities, it will be necessary to make painful trade-offs. That’s an area that societies with an overall budget for health care have started to come to grips with. But we in the U.S. have run away from doing the kind of thoughtful consideration you recommend. In U.S. political discourse, “rationing” is a very dirty word!

  2. Clifford C. Dacso, MD

    I agree with your major points. I am a primary care general internist. I believe, however, that the panacea people are searching for is not a systemic one. Of course there is no one single system that will make everyone happy. Sometimes, a society just has to do what is reasonable in the context of fundamental ethical principles. Personalized medicine has come to mean “I know your genes therefore I know you.” My view is that real personalized medicine means “one size fits one.” Although one cannot quibble with the principle of evidence-based medicine, its use as a weapon to enforce standardization is unfair to both patients and physicians. Personalized medicine is when physician and patient collaborate in the context of science to provide the most effective and humane care for that individual. Alas, this is expensive and very hard to teach.

    • Jim Sabin

      Hi Clifford –
      I love your “one size fits one” aphorism!
      My own intuition is that well-conducted personalized medicine in the manner you envision it is actually cost-reducing overall. Patients – especially in the over 65 population – are often concerned with specific functional capacities, and do not want the high-tech, “full court press” approach that has so much momentum in our culture.
      My hope is that the Accountable Care Organization concept, in which guidelines and limits would be governed by a group of clinical colleagues rather than over an 800 number as was so common in the 1990s, will bring a better balance of flexibility and individualized practice of the kind you’re advocating for with appropriate forms of evidence-based restraint.

  3. Sivam

    Forbes had a good article wtihin the last few months showing how the uninsured statistic is pretty misleading. The vast majority of that uninsured number consisted of young (20-25) people that just don’t get sick too often, people making 75,000+ a year but without the desire to buy health insurance, and illegal immigrants. The true number of people without health insurance and unable to pay for it was something like 10 million, which is 3% of the population. Also, there were many people that were eligible for medicaid and other federal programs that just didn’t register for them due to ignorance or other reasons. Is health care a right? If it is, then I would contend that cars, food, entertainment, housing, and other things are also rights. The declaration of independence does say that we have the right to life, liberty, and the pursuit of happiness

  4. Jim Sabin

    Dear Sivam –
    I’m sorry for the long delay in responding – I’ve been away and I only just now came upon your comment.
    While I agree that a civilized society should treat ensuring adequate food and housing for its citizenry as obligations it must meet, citing cars and entertainment trivializes your argument. The Declaration of Independence refers to the right to pursue happiness as we envision it, not a right to the “goods” that we might desire, whether those “goods” be cars, entertainment, or the “other things” you refer to. Health care, food, and shelter are preconditions for exercising our basic liberties and pursuing our conception of the the good life.