2009-02-28

Thoughts on doctors not spending much time per patient

"Even as an expert, it takes me over 5 hours to review a typical middle age person’s medical history (plotting test results, comparing to distributions of patients, etc.). To select and optimize the best set of sequential diagnostic tests and treatments takes many hours per patient. No physician spends the time needed. In my review of thousands of cases with chronic conditions, more than 95% provide suboptimal care (excluding minor accidents, simple infections, simple cases).
Conclusion. Today we can spend over $1M per person to improve morbidity and mortality. And tens of hours of professional time. Clearly impossible. Therefore, health care implies rationing and restricting physician’s time, diagnosis and treatment.
Thus, the first priority is to admit that it is impossible to provide the state of the art care to every person. Not even a small proportion of the population. Physicians today allocate less than 10’ per patient, on average. In this time it is impossible to review test results, select optimal sequential testing from a menu of 10K +, order them, review results, and so on.
Once we admit that we can only provide a tiny fraction of what modern medicine provides, then we can optimize the allocation assumming that we can agree on outcomes."
— Eduardo Siguel, MD, PhD
Comment six on The Mounting Price of Health Care’s Status Quo

Here is what I posted in the comments in response:

Thank you Dr. Siguel (Comment 6) for sharing some important insights and providing some validation for something I have been wondering about for years.

For most of my adult life I have been puzzled by how doctors routinely make major decisions with little or no research or analysis. Time after time I saw a doctor make a decision on a complex situation without cracking a book (or a database in this modern age) or reviewing records in detail. I suspected that these decisions were of sub-optimal quality, but hoped (since the health of me and my loved ones was on the line) that somehow these doctors had discovered a way to make complex decisions without doing any work. Dr. Siguel's insider view seems to confirm that that quick medical decisions do tend to be sub-optimal.

However, I have to disagree with Dr. Siguel about the implications of limited time leading to sub-optimal medical decisions. He feels that the solution has to be rationing of doctor's time because providing the time needed for optimal medical decisions would be prohibitively expensive. But what about lowering the cost of doctor's time?

The elephant in the room is that physicians make a lot of money because the supply of physicians is constrained by very high educational and training requirements. Sure we want all our doctors to be genius superstars. But here is the conundrum: what is the use of requiring our physicians to have such high qualifications if the resulting high cost of physician's time means that they mostly shoot from the hip and frequently make sub-optimal decisions? If we are willing to accept sub-optimal decisions, why not at least get them for cheap from less qualified, and therefore less expensive, doctors? If we lower the training requirements for becoming a physician, and open dozens of new medical schools, we could get physician's pay down to say the high 5 figures (as versus the current mid to high 6 figures for specialists), and then it would be affordable to have a physician spend more than 10 minutes per patient.

I personally would jump at the chance to be treated by someone with half, or less, of the qualifications of my current physicians if that person would spend some real time carefully examining my records and doing some research on the options. I don't want a genius, I want a workhorse.

Also, with the advent of computers and data technology, the need for spectacularly trained physicians is declining. In the olden days a physician pretty much had to have a whole library in his head because researching stuff involved, well, going to the library. These days the latest medical research is only a few clicks away, and there is not so much need for a physician to know everything.

1 comment:

  1. Excellent post. My review is - Nice post by good author :
    Lindsay Rosenwald http://www.lindsayrosenwald.info/ Lindsay Rosenwald – complete biography.

    ReplyDelete