frank-cotham-let-s-begin-with-a-philosophical-question-who-am-i-and-why-are-you-here-cartoon1Me, as a first year resident on a healthcare team, developing a treatment plan for a patient with a cancer that will be almost certainly terminal: Why can’t we just stop the treatments and let the disease take its course?

Attending physician: Because that is not why we are here. We give patients hope.

Me: But for this cancer there have been no reported cases of survival

Attending: Then our patient will be the first.

The patient lapsed into a coma and died five days later, after chemotherapy and multiple interventions failed to stave off the inevitable.

Physicians hold all the illness cards. They know what might happen with or without intervention. They are expected to “do the right thing.” In my last post (found here) I pointed out that people tend to make good choices, all things being equal (here is the mathematical treatment of this concept). The problem is. all things can never be equal:

What’s the worst thing that asymmetry of information can lead to? Basically, it’s fraud. Potentially, doctors (and other providers) can induce us to get care we don’t need — even risking our lives in the process. They can claim they have skills they really don’t have. They can bill us for services we never received. And make other “billing mistakes” that line their pockets at our expense.

In the vast majority of cases, physicians are not intent on committing fraud. They are, however, working within a system that offers little opportunity to advocate for the right thing to happen every time. From an essay published in the New York Times this past week about cancer care:

Many cancer patients, after getting a diagnosis of a terrifying disease, pursue any potentially promising therapy, regardless of the price. But the main cost driver is the fee-for-service payment system. The more doctors do for patients, the more reimbursement they receive. Surgeons earn more for every procedure. Oncologists typically make more money if they use newly approved drugs and the latest radiation treatments than if they use cheaper, older alternatives that work just as well. (This is because they get paid back the cost of the drug, in addition to an extra 6 percent of that cost — the more expensive the drug, the higher the compensation.)

20 cancer doctors from nationally known programs asked for the following to happen:

  • Move payments from fee-for-service toward a system of bundled payments, in which doctors are paid one fee for all the treatments involved in caring for a cancer patient. Currently physicians get paid more the more charges they rack up.
  • Require insurers to give physicians information about where the physicians are spending money. They don’t know the consequences of their actions
  • Accompany payment changes with rigorous quality monitoring to ensure that there is neither under- nor over-utilization of care.
  • Create more “high touch” oncology practices.
  • Develop better incentives for research that evaluates care over time after the technology is approved.

In the case of my patient, I had neither the training nor the seasoning to advocate harder for less aggressive care, allowing the inevitable patient death with minimal discomfort, in the face of a patient’s family that “wanted everything done” and an attending who considered no amount of care to be too aggressive. It is still unclear how much the payment structure clouds physicians beliefs regarding needed care, much less how it affects the delivery of the message to the patient. What is clear is that the payment structure has been awfully good to physicians and patients tend to follow their physician’s advice. Since I am paid on salary,  I often find myself being the voice of reason which may be why I stick around.