The Book Club

How Doctors Game the System and Trick Patients

Dear Darshak:

We are certainly covering the major issues facing doctors and patients in today’s medicine, with respectful but clearly different points of view.

I am not sure that testing everyone with an eating disorder for celiac disease would be, in current parlance, “cost-effective.” On the other hand, dissecting the story of everyone with an eating disorder is. Automatic testing according to some pre-existing algorithm makes sense only if the prevalence of the error is high. Even then, I suspect an astute clinician will consider using such testing without resorting to it every time, as a recipe for decision-making.

Now, on the dilemma of finding a doctor. I agree this is one of the most difficult challenges. No doctor is perfect, and, as I point out in the book, different doctors may be better or worse “fits” for different patients. But I am very leery of the report-card system you propose. Not because I am afraid of being evaluated but because it is both overly simplistic—measuring care by the lowest common denominators—and because it fails to capture important dimensions of medicine.

Several years ago, I wrote a piece for TheNew Yorker about prostate cancer treatment. I looked at “outcomes data”—data demonstrating how patients do after a surgery.What I discovered was that certain doctors could “game” the outcome, the way clever students know how to game the SATs. Several surgeons cherry-picked their cases so that their outcomes looked far superior than those of colleagues who operated on sicker patients. Although some claim such discrepancies can be corrected by making transparent the characteristics of the patients each doctor sees—how sick they are, etc.—it would be very, very complicated, perhaps impossible, to provide an authentic picture of performance. Marketing tactics have come to shape these report cards, and game-playing surgeons claim that the rates of complications suffered by their patients (complications such as impotence and incontinence) are very low, so they “should be” the ones to wield the scalpel. These doctors avoid patients with diabetes or heart disease or vascular problems, stacking the deck in their favor.

The report cards for internists like me give us grades on controlling blood pressure and the like. In effect, we are penalized for taking care of patients with multisystem diseases where blood pressure control is often complicated by many medications or by severely disordered biology. Internists who care for the confused, indigent, and “noncompliant”—all important populations that are underserved—will come up with bad grades, as Dr. JudyAnn Bigby points out in my book.

So, as we link payment to performance, we will discriminate against the sickest people and the most neglected. Moreover, since these report cards are based on standardized patients, they fail to address the reality that many of us are not “standardized” but quite different, not only in our biology but also in our psychology.

Another flaw in using metrics based on prevailing “wisdom” is the question of what constitutes “correct treatment.” For years, estrogen was given to menopausal and postmenopausal women, prescribed based on guidelines. Open-minded and curious physicians like Karen Delgado—a doctor I write about in How Doctors Think—questioned this simplistic treatment of aging women and questioned blanket claims that hormone-replacement therapy protected the heart and prevented Alzheimer’s. Rather than follow “standardized care,” she tried to customize her care. Of course, we now know that the guidelines were flawed. And we are returning to a more balanced and individual approach to menopause and hormonal prescriptions. Karen Delgado would have gotten a D or an F by refraining from giving her aging women hormones as preventive therapies just a few years ago.

Finally, let’s consider my own field of oncology. I might be able to keep someone alive a few weeks or months longer with intensive treatment, but at great cost to the person and his family. Such decision should be driven by an individual patient’s desires, not by a report card. But my “outcomes” would look better if I pushed extensive toxic therapy, since my patients might have more prolonged survival times than they would if they were seeing a less-aggressive oncologist at another cancer center. So, what metric measures outcomes for the soul, for the emotional well-being of patients and families? Medicine is not working on an assembly line, putting together cars with standard parts. It is a healing art that mixes science with care for the soul. A thinking doctor considers both. Patients feel this in the intimacy of the examining room. “Secret shoppers” are not attuned to this level of interaction, because they are not actually grappling with the tempest and turmoil of illness.

I do believe that certain systems and better practices have their place. Hand-washing and the use of antiseptics on a routine basis can reduce infection rates around catheter insertion and the like. But I won’t choose a doctor for myself or my family based on standardized metrics that are easily manipulated and fail to encompass the existential dimensions of medicine. Rather, I will engage in dialogue and listen to my doctor’s words to hear how he thinks about body and soul.

There is no one “outcome” for everyone, because all of us differ in our biology as well as our needs and beliefs in complex ways. Once you move away from the simplest medical problems, outcome metrics fall apart. What remains should be a thinking and caring doctor who tries his or her best for all of us.

Come by for tea and we can continue. I suspect the conversation is not over.

Warm regards,