Monday, October 26, 2009

Confronting the Consequences of "Industrial" Health Care

Last August, when it seemed as if the very concept of a public debate over health care reform was being reduced to one aggressive shout-fest after another, I raised the following question:

Is there any country other than the United States that classifies health care as an industry?

I reflected that this was a classic example of how, through a simple linguistic twist, the United States had perverted a concept that could be traced all the way back to Ancient Greece. I therefore took great comfort this weekend, when I read Jerome Groopman's piece for The New York Review entitled "Diagnosis: What Doctors Are Missing." I wrote about Groopman's insights a couple of times back in 2007 after the appearance of his book, How Doctors Think. This time around I found myself influenced by not only his past insights but also one of the better one-liners from the Nurse Jackie series:

Doctors do not cure; they diagnose.

As the article title suggests, the quality of health care often comes down to the quality of diagnosis; and Groopman's book tried to take on the problem of why recent diagnostic quality has become so poor. In this respect it is worth repeating a passage I cited in 2007 from Richard Horton's review of Groopman's book (which also appeared in The New York Review):

On average, about 15 percent of a doctor's diagnoses are inaccurate. Groopman directs a well-aimed arrow at a system of medical training that more often than not fails to investigate why these diagnoses are misses. Doctors are rarely taught to ask how an error could have taken place, let alone how it could be avoided in the future. Most are unaware of their mistakes. Even if patients remain unwell, no systematic effort is made to find out where doctors may have gone wrong. Doctors are uncertain about their own uncertainties. (Although for some doctors, such as radiologists, Groopman cites alarming research that shows the worse their performance, the more certain they seem to be that they are right!)

Groopman's own New York Review piece involves an analysis of three cognitive errors that "cloud logic" during diagnosis: anchoring (attaching too much value to the first data you encounter), availability (paying too much attention to recent or dramatic cases), and attribution (making conclusions based on stereotypes, rather than observation). When Ellen Goodman read Groopman's book, she wrote her own essay entitled "The Benefits of Slow Journalism," which basically argued that, in the age of "Internet speed," hasty writing was subject to the same kind of distorting biases that Groopman had been investigating in faulty medical diagnoses. As I put it in my own blog post, both doctors and journalists were now practicing in "a world without reflection."

Groopman takes the argument a step further, however. True to the Thinking in Time strategy of Richard Neustadt and Ernest May, his New York Review piece tries to take on what I call the how-did-we-get-into-this-mess question, which is where his conclusions link up with my opening remarks:

But only recently has medical care been recast in our society as if it took place in a factory, with doctors and nurses as shift workers, laboring on an assembly line of the ill. The new people in charge, many with degrees in management economics, believe that care should be configured as a commodity, its contents reduced to equations, all of its dimensions measured and priced, all patient choices formulated as retail purchases. The experience of illness is being stripped of its symbolism and meaning, emptied of feeling and conflict. The new era rightly embraces science but wrongly relinquishes the soul.

One would think that the concluding sentence of this excerpt would be enough to sway any Fundamentalist Conservative to the cause of health care reform; but, apparently, the boogie man of "godless socialism" is far more frightening that "soulless" medical practice. Thus, the future of health care will rest not on either the underlying principles of "how doctors think" or even religious convictions of the faithful over the difference between right and wrong but on the power of the "consciousness industry" to bias prevailing opinions based on both reason and faith. If these biases continue to hold sway, then both doctors and their patients will be the losers in any effort towards health care reform.

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