Comments on GeriPal - Geriatrics and Palliative Care Blog: Gawande, Greed, and You Eat What you Kill

Dan, you're right that the Dartmouth folks are...

2009-07-28T15:27:15.437-07:00

Dan, you're right that the Dartmouth folks are trying to figure out the why, I was being disingenuous. The advantage of the investigative reporting approach is clear. Gawande’s article may well be a lesson on the need for this kind of reporting in a time when newspapers and other periodicals face unprecedented financial pressures.

Ken, I like the framing perspective – that all doctors respond to financial incentives as part of human nature. The defensiveness of many physician bloggers has been remarkable. I just read a post from a physician who said something like, “when will people start to realize I make decisions based not on my pocketbook but on the needs of the patient in front of me!” and several other posts refer to Gawande as the “Ivory tower doctor,” "singing Kumbaya," disconnected from the real world of private practice. The brilliant aspect of Gawande’s article was that he outlined what happens when the financial incentives clearly align with explicit physician goals, at the expense of the healthcare system and potential detriment to the patient (excess testing, procedures, intervention, false positives, etc). The unintended consequence was portraying what is really a systems issue as a moral failing on the part of a group of physicians. To be fair, he did explain his findings in the context of contrasting health care systems that incentivized physician billing on a fee-for-service basis and population level care. Still, I understand how some reacted defensively.

I couldn't agree more. Enough with the holier...

2009-07-23T10:23:20.225-07:00

I couldn't agree more. Enough with the holier than thou attitude that physicians have where we think we have mastery over outside influence. Our mesolimbic system, which plays an integral role in motivation to perform behaviors, is no different than that of Wall Street bankers, or for that matter rats that are trained to press levers to get rewards. It took us decades to come to the conclusion that incentives brought to physicians by Big Pharma (dinners, vacations, research grants) actually are very effective tools in changing our prescribing behaviors. How long will it take for us to act on the fact that financial incentives that focus on procedures impact medical decision making, just as much as that vacation to Hawaii from Big Pharma.

Of note, in studies of rats that have been trained to press a lever in order to obtain a reward, they will continue to press the lever until the reward is received or fatigue sets in. This doesn’t bode well for our current health care system.

It seems there is little question that financial i...

2009-07-23T09:53:51.356-07:00

It seems there is little question that financial incentives influence the practice of medicine. The evidence for this is quite compelling, but the the physician community often seems to have difficulty acknowledging this.

I wonder if part of the issue is framing. Specifically, it seems an implicit suggestion that is often made is that only bad people act in their financial self-interest. Because of this framing, physicians often get defensive when there is a suggestion that financial incentives could be influencing their clinical decision making, and this defensiveness shuts off discussion.

The truth is that good people respond to financial incentives. It is normal human behavior. We do it when we are not even thinking about it. Much of the behavior is subconscious, and we will respond to financial incentives even if we try not to. The reason financial structures have such a big impact on our clinical treatment decisions is because physicians are normal people---even good well intentioned docs respond to financial incentives.

It seems once we acknowledge this, it then becomes easier to have an open discussion about payment structures and financial incentives can be aligned to reform the health system in a way that works best for our patients.

I wouldn’t go as far as agreeing with the infamous...

2009-07-22T22:14:42.145-07:00

I wouldn’t go as far as agreeing with the infamous words of Gordon Gekko that “greed, for a lack of a better word, is good”, but medicine is what it is now a days, a business. Are physicians really “bad” or acting unethically when trying to maximize returns on an investment (in this case the investment is an average student debt of $139,517 after medical school)? Many people I know in the business community would think it is a sign of pathology not to choose the option with the greatest return. The problem then isn’t the physician. It isn’t even the health care industry, as they too have the same requirement to maximize profits. The problem is really the entire health care system and its current basic design that incentivizes this behavior. A system where the most profitable entities are those that are performing the most procedures, the most interventions, and the most “costly” of care.

Great blog Alex. Two comments: 1) Dartmouth has...

2009-07-22T06:36:09.408-07:00

Great blog Alex.

Two comments:
1) Dartmouth has been trying to figure out why. One of the things this McAllen thing has made me think of is what is the value of the IRB. Doing some ethnographic field work as a "researcher" requires significant work to gain acceptance through the IRB. As a "reporter," the rules for things like deception are much more lax. I don't think a researcher could have even published this article. Honestly, I'm not sure what I think of this...obviously we don't want to cause harm with our research and one could easily argue that Dr. Gawande's article did "harm" to the physicians in Texas.

2) In the Dartmouth Atlas, San Francisco is actually one of the lower utilizing regions. This begs the very difficult question: what is the right rate or utilization? There is no question that McAllen is overutilizing, but is San Francisco underutilizing? Honestly, I don't think so but it is worth considering...