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Foreword by Colin P. Kopes-Kerr, MD, JD, MPH, Vice-Chairman of the Department of Family Medicine, and Program Director of the Family Medicine Residency Program, at University Hospital and SUNY Stony Brook School of Medicine, Stony Brook, NY.
"The Secrets of Medical Decision Making should be read by everyone, because all of us are sometimes in need of medical care. It is an eye-opener, a call to arms and a guide."
-Robert Rich, Ph.D., author of Cancer: A Personal Challenge
"Dr. Reznik candidly exposes the conflicting interests inherent in contemporary medical practice. This empowering and insightful book is a must read for healthcare professionals and the patients they treat."
-Beth Maureen Gray, R.N., B.S.
"The Secrets of Medical Decision Making awakens thereader rather quickly with startling revelations about the lack of seriousness the health care industry has towards a society of wellness. If this book at least motivates its readers to become more involved in medical decision making when seeking treatment, it will have succeeded as a critically needed public service."
- James W. Clifton, Ph.D., LCSW
"As a Canadian and a health care provider this book frightens me. This book lays out what our country is headed for if we privatize health care in Canada. A must read for everyone working, or accessing, health care in North America and for anyone who has any doubts that we must take drastic action to preserve Universal Health Care in Canada."
- Ian Landry, MA, MSW, RSW
Health care is becoming increasingly complex, with multiple factors affecting decision making. You may have heard about or experienced some of the shortcomings of this system first hand. People of all ages and all degrees of health are affected by the current way of medical practice. It starts with infants, who are put through a variety of tests by overzealous physicians responding to their own or their parent's fears. Young women become unnecessarily worried from their Pap smear screening, prenatal testing, and encountering a wall of defensive medicine during childbirth. Middle aged men are enticed into a highly questionable practice of prostate cancer screening and ending up with surgeries that, instead of prolonging their life, leave them deprived of their basic human capacities. There are a slew of breast biopsies and mastectomies as a result of screening mammography in women, without concomitant prolongation of life but with an enormous mental and physical toll. Finally, the elderly are put through testing and procedures in the last six months of life-the evidence now clearly shows that this actually slightly shorten their lives when compared with those who did not have the option of utilizing health care system to the same extent (due to living in regionsof the US with lower Health Care funding).
When we enter the system as patients, we are simply hoping that a physician will take good care of us. We also sometimes hope that health care will prevent us from getting sick, discover and diagnose any hidden illness, cure or treat it, and possibly make us live longer. The physician of course tries to live up to some of these expectations.
I am a doctor, but this doesn't protect me from health problems. Recently, I had a kidney stone, and became a patient. The physician taking care of me in the emergency room accurately diagnosed and treated the problem. At the discharge, the physician told me that I "needed" to follow up with a urologist. Now that I have a kidney stone I should have a urologist. Those two go together in her mind. She was the usual overworked senior resident in the emergency room of a university hospital. She told me what she tells all the patients discharged after the discovery of a kidney stone. From the point of view of the usual medical training, she was an exemplary physician. She gave her recommendation with the best intentions: she truly believed that she was doing me good by giving that advice. Physicians are systematically taught to give the same advice to everyone; we do not have the time nor the training to pay attention to individual differences.
She was quite surprised when I told her that I wasn't planning to follow her advice, that I simply intended to alter my diet. At that point I opted not to follow her medical advice and not to subject myself to additional testing with the time commitment, inconvenience, and expense that it entails, let alone the risks of false-positive results and unnecessary procedures with their side-effects. That was my personal preference. Whether or not my decisions were wise is not the issue. Rather, it is my hope to empower patients and their family members to recognize the freedom of choice even when none is presented and to know that the information they lack for decision making can be obtained by directly questioning the system. It is also my intention to decrease undue expectations that the medical system itself fosters, and to deflate the balloon of medical omnipotence.
I call this system The Health Care Machine because it has become mechanical. The race for 'clinical productivity' is turning health care into another form of an assembly line. There are other factors I'll soon discuss that push us in the same direction. A physician who sees you is no longer an agent who works for you. Rather, he or she is trying to balance a number of conflicting demands. As I watched a TV interview at an advertising agency that created a television ad for one of the frequently used drugs, the spokesperson stated "... the medications now are a part of a healthy lifestyle ..." She truly believed that and wanted the rest of the world to believe it as well. So it is with the physicians and other health care workers who are placed in a position (and I call this position The Medical Box) that pressures them to have only a standard, mechanical response to any given set of problems. Eventually, being in that box makes them believe that those are the only possible answers. I think a patient can navigate through this system much more successfully by being aware of its limitations.
In the body of this book, I present vignettes from my clinical practice, experience in the medical school and residency, and personal research. Mostly they are the accounts of actual patients I have cared for, directly or indirectly. I have altered the details to make them unrecognizable while maintaining the essence of each story intact. They all demonstrate the facets and influences of "the rules of the game": the game of health care. It is my hope that from reading these accounts with the accompanying discussions, you will understand the motives influencing your doctor's decisions and will learn how to be more self-reliant.
Throughout the book I placed subheadings: Patient/Family Perspective, Physician's Perspective, Societal Perspective and Spiritual/Philosophical Perspective. Though these subdivisions are somewhat artificial, since to some degree, one perspective contains all of the others, I hope that they will ease the flow and absorption of the material. Patient/Family Perspective deals with the issues that most closely relate to, or would be most helpful for prospective patients and their families. Physician's Perspective reveals physicians perception of the issue. Societal Perspective shows the impact on the society as a whole. Spiritual/Philosophical Perspective addresses spiritual and philosophical aspects of medical care, aspects that cannot truly be separated from any endeavor seeking to understand a human being.
The term 'Medical Box' is my invention to show the boxed-in thinking imposed on physicians; the boundaries they need to overcome in order to do what's in the patient's best interest. I believe it is important for the patient to be aware of them too. Here are what I call the four corners of the Medical Box:
Fear of litigation. Financial and time pressure. Guidelines of Health Care authorities. The current Medical Model-disease oriented thinking.
I think most physicians wish to do good and to be genuinely helpful. This wish is impeded by the Medical Box.
Litigation has a potential of disrupting medical practice and increasing malpractice insurance premiums. Being labeled as high risk physician limits one's employability. According to the Association of American Medical Colleges, an average physician who graduated from medical school in 2004 had $115,000 of educational debts! This debt has been steadily increasing. After spending a minimum of eleven years of intense learning, one tends to want to have some degree of comfort, to be able to repay one's debts, and have a feeling of some financial security in order to support a family. All of that is threatened by a lawsuit. Medical mistakes do happen and it is fair to hold the doctor accountable for them. However, the success of a lawsuit does not always depend on the degree or even presence of a mistake on the doctor's part, but rather, on the gravity of the outcome or on chance alone. One of my obstetrical colleagues was successfully sued after her patient's unborn baby died. Though by the standards of medical practice there was no error, it is hard for the jury not to feel overwhelmed by such a tragedy. Consequently, she was deemed guilty, resulting in stigmatization, raised malpractice insurance premium, and a mark on the record that will be questioned whenever she may want to look for another job, or apply for another malpractice insurance.
This record is permanent. It is not surprising that fear of being sued is one of the major forces driving medical decision making in the US today. I attempt to illustrate some of the implications of this in the vignettes of the subsequent chapters where actual patients are described. I am not the only one to believe that the success of a lawsuit does not depend on the presence of an error. Linda Crawford, who is on the faculty of Harvard Law School, where she teaches trial advocacy and has been consulting people on research and evidence-based effectiveness for malpractice depositions, states that five out of six lawsuits involve good medicine, half the time there isn't even a bad outcome (Tracy, 2003). She further states: "Let's talk about brain-damaged children. All of us now go into labor and delivery presuming we will have a perfect outcome. The parents believe it. The family believes it. The community believes it, and frankly the providers believe it; yet, it is still true that we have not made any significant gains since 1965. Five percent of children are born with significant disabilities. There is a gap between what everybody is expecting and the reality. I am all for good relationships with your patients; I think it has a great deal to do with the quality of our professional lives. However, I also look at the specialties and the individual surgeons who are sued, and it often has to do with the expectations of your patients going into whatever the event is." These expectations are not easily changed and are often the result of a well publicized boasting of the medical system about the great advances we've achieved.
Money and time are intimately related in our society and the medical system is no exception. Beginning in medical school, we (medical students) were repeatedly told that medicine is business. I do not share this opinion but it is now held by the vast majority of physicians. More than that, in medical school we were specifically taught that it is not important for us to care about the patients, what is important is to know how to create an impression of caring. We were then taught how to do that, how to fake a caring attitude. A doctor has to say "aha", " tell me more", to make a pause after a patient says something he finds significant; one needs to make brief remarks indicating compassion and understanding so as not to make an impression of being uncaring. All this is so that the business part of medicine can go more smoothly.
Third party payers also drive some of the important changes in this realm. Health insurance attempts to cover health care needs and make some money off of this process. They have to find some quantifiable way of reimbursing physicians. This quantification (which is difficult to avoid) is one of the problems. My residency training was in a suburban university hospital. From time to time, in addition to the usual lectures by the faculty, we were lectured by the community physicians who were supposed to teach us how to "survive in the real world". We were taught that "talking to the patient doesn't pay", that in order to survive financially we needed to decrease the amount of talk to the minimum and instead to do as many office procedures as possible. Insurance won't pay for educating a patient, but they pay for throat cultures, wart removals, hearing, vision, blood and urine tests etc. An excerpt from a recent article for the physicians in the Family Practice Management Journal (Martz, 2003) illustrates this point:
"As practices' expenses continue to grow at a faster pace than revenues, physicians are under greater pressure to do more with less. While working harder and seeing increasing numbers of patients each day is an option, finding methods to work smarter is becoming an attractive alternative. One viable strategy for your practice is to increase charges per unit of time. Performing more procedures is a simple and successful way to achieve this goal.
As you are probably aware, not all procedures are created equal. Some procedures (e.g., flexible sigmoidoscopy) are reimbursed very poorly considering the time they require. Other procedures (e.g., skin biopsy and excisions, colposcopy/biopsy and exercise treadmill testing), though reimbursed more handsomely, may require significant amounts of physician and nursing time, significant up-front costs to the practice and extensive training. However, there is another category of procedures well worth your time and effort - joint and soft-tissue injections."
I don't think that many patients want to see a physician who is thinking of performing more procedures as a means of increasing his revenue. We want our physician to be impartial keeping in mind only what's in our best interest. The interest in joint and soft tissue injections is so strong that it drives practices that were proven to have no more effect than a placebo. I still see patients who ask me to inject their knees with Synvisc-an expensive product used to treat osteoarthritis and subsequently shown to be no better than injections of salt water (Pedtgrella et al, 2002). Their previous doctor did it and insurance paid for it, so they want more. Things may soon get to the point that when you come to your doctor for a sore throat, he'll offer you a knee injection.
Another necessary way of increasing the revenue is to address one or two problems at a time and to keep bringing patient back for frequent revisits. Insurance will pay for addressing one problem on separate visits, but will question and decrease payment for trying to address multiple problems in one visit. Health insurance usually monitors physicians-this is called physician profiling. Payments are decreased to the physicians who charge more than the average. This causes a disincentive to try to solve more than one problem and a preference for younger and healthier patients with fewer problems. There is also a threat of an audit-when a health insurance such as Medicare may review charts. If during an audit, chart documentation does not reflect the charges, a practice can be fined millions of dollars. This brings several consequences. One is that physicians will 'downcode' (charge insurance less) just to avoid the possibility of an audit, another is the need for careful documentation for insurance purposes (which is not the same as the patient's); the third is less reimbursement. All three cause the physician to accelerate his pace in order to continue making the same amount of money. Naturally, quality suffers. Dealing with insurance leads to an additional loss of time because of other bureaucratic processes involved. Billing, coding, credentialing, and auditing are the tasks that take the time and money. For example, a physician has to hire a biller or a billing service. Different insurance companies use different drug formularies-list of medications that are preferentially covered. The physician has to be able to keep up with all that and have the time to do quite a bit for the patient-what the guidelines demand, and what the patient wants, which are usually two different things.
Most medications and treatments carry some consequences, as does the option of foregoing them. That and the fact that physicians have been required to have the informed consent of a patient, creates tension. On the one hand, the physician has to educate the patient in order to obtain a true informed consent; on the other hand, he has no time/money for doing that, but if something adverse should happen a physician can be successfully sued by the patient if there was no written or verbal informed consent.
I would like to digress a bit to discuss informed consent. Informed consent was created with an intention to help the patient make an independent decision about their health care, to actively participate in their health care and be protected from authoritarian physicians. With time, and under the above mentioned pressures, it has degenerated. Informed consent seems mainly to be the tool to protect the doctor, not the patient, and it can do harm. A physician now obtains informed consent because this protects him from being sued. If an adverse outcome occurs, a doctor says-"we discussed this and the patient consented," thus the doctor is off the hook. There is usually no true education taking place, and often the risks are presented only after the patient was already thoroughly convinced by the doctor and made up his mind to do what the doctor wants him to do. I will discuss why a doctor may want you to do something below. The other harm of an informed consent is a nocebo effect (O'Mathúna, 2003). It is the opposite of the placebo effect, which is a beneficial effect of a neutral substance after a suggestion that it can do good. A nocebo effect is an adverse effect of a neutral substance or treatment after a suggestion that it can do harm. Research has found effects such as drowsiness, headache, fatigue, sensation of heaviness, and nausea after patients took a neutral substance with a suggestion that it is a medication that can cause side-effects.
Excerpted from The Secrets of Medical Decision Making by Oleg I. Reznik Copyright © 2006 by Oleg I. Reznik. Excerpted by permission.
All rights reserved. No part of this excerpt may be reproduced or reprinted without permission in writing from the publisher.
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Posted August 17, 2010
The western medical system is considered to be one of the best in the world. In who's opinion? The doctors? Pharmaceutical companies? What about the patients? Our healthcare has become a "system," a machine driven by costs and profits. Patients suffer needlessly as a result of our economic focus on a service industry. The ethics in healthcare have been replaced with a profit and loss statement. Is it the doctors' fault? The insurance companies? Where did we as a society drop the ball on improving patient outcomes? This book gets into the nitty gritty. While we all have our own opinions of what is wrong with our health care system, Dr. Resnik concisely and simply lays out his thoughts supported by case studies, statistics, and a multitude of interesting facts about how the system works.and where it fails us. As a patient, I found this book to be extraordinary and interesting. It brought out what I had felt for years about my own health are. As a professional health care practitioner, it gave me more facts and information to arm my patients with. So, if you are a patient, or in the health care field, you will find this a fabulous and worthy read. He coins the term "medical box' to describe the compartmentalized thinking and treatment protocols. He addresses many medical diagnostic tests from a patient perspective. Then he layers the societal, physician, and family perspective on top of it. The information is like an ice cream sundae...good right to the bottom of it. His advice is invaluable. Resnik writes about how not to aggravate your doctor with threatening requests. it isn't helpful, especially for the patient. He discusses how the drug company reps sponsor CME programs. to who's advantage?! I enjoyed his discussion on health insurance. It truly is a double edged sword in getting what you want. He points out that you can usually get it, but is it necessary and that often, tests are run needlessly because of good insurance. Contrarily, are tests withheld if you have inadequate insurance? You will have to read it for yourself.
I liked that he teaches patients how to be their own advocate, and to educate themselves more thoroughly about their diagnosis, testing and patient care. The patient should be involved to protect his interest. Leaving the medical decisions to the machine is dangerous.
This book will wake you up to our medical system. It speaks the truth which isn't always easy to hear, but in that light it teaches you how too improve your care and that of your family. Don't pass on this read! He has done a great service for improving patient care by addressing this topic.
I received a complimentary review copy.
Posted June 27, 2006
In this work, Dr. Reznik alerts the consumer to the reality of today¿s medicine and its practices. He presents a medical industry that places the individual physician in a `box¿ that influences his decision-making beyond what is always best for the patient. Dr. Reznik position is that the modern physician is unduly influenced by the fear of litigation, the need to follow untested medical guidelines, the pressure of the pharmacology industry and the demands of the insurance companies. He presents a compelling case for his beliefs. His thesis is presented in short chapters of two or three pages that use interesting case studies to inform the reader about their need to ask questions and take charge of their own medical needs. His writing style is easy to digest and compelling. This work is an effortless read and easy for the layperson to understand. My one complaint is in the displayed copies of medical records, notes and tests results as the printing is blurred and difficult to see. Dr. Reznik¿s concern that many patients allow the medical industry to take over their individual decision-making is unfortunately very accurate ¿ too many patients get caught up in endless consultations and unnecessary tests. My one very strong objection is to Dr. Reznik¿s dismissal of the need for cancer screening. As a cancer survivor myself, I believe the truth gives the patient the power of control. To tell the public that cancer screening, especially mammography, is not necessary is extremely dangerous and endangers lives unnecessarily.Was this review helpful? Yes NoThank you for your feedback. Report this reviewThank you, this review has been flagged.