Don’t Just Do Something, Stand There: Part Two

(Medical care is expensive, no doubt about it, but the remedies proposed by the usual suspects who hope to leverage the problem into political power don’t address the real factors driving up the cost. Maybe I’m just not an excitable fellow but I like to keep a cool head and not get swept up in the hysteria, especially as it is being lead by people who are themselves part of the problem-PB)

Zero Defect

You get what you pay for.

Consider the space shuttle, a technological marvel conceived in the 1970s to revolutionize space transportation by using a reusable space vehicle to drastically decrease the cost-per-pound of lifting payloads into orbit. First flown in 1981, the fleet of incredibly complex and expensive orbiters have yet to achieve their stated purpose of making launches economical and have instead become something of a boondoggle to NASA, sucking vast amounts of money out of less glamorous but probably more important space endeavors. It turns out that disposable rockets are significantly cheaper on a cost-per-pound-to-orbit basis because they are less complex, unmanned, and do not have to be refurbished between flights. The cost of the shuttle program has been almost $150 billion dollars or a little more than one billion dollars per flight for each of the 117 missions. Unmanned rockets, even big ones, aren’t nearly that expensive.

The shuttle is more expensive than was hoped largely due to a rigid zero-defect mentality on the part of NASA. Even a minor malfunction can result in the complete loss of the crew and a two billion dollar vehicle. Consequently, NASA takes an already legendary obsession with perfection to a new level to ensure the absolute reliability of the orbiter before each launch. This obsession is built into the vehicle through redundant systems and meticulous quality control, carries on to the launch where the smallest anamoly can scrub the mission (leading to costly defueling and reinspection), and finishes with an exhaustive post-flight check where the engines and most major sub-systems are disassembled and inspected.

At every stage of the process a small army of engineers and technicians orchestrate a clumsy bureaucratic exercise to document contractually stipulated compliance with procedures and specification. And yet, despite their best efforts, to date there have been two catastrophic losses of crews and vehicles for a failure rate of about two percent.

It wasn’t supposed to be this way but perfection isn’t cheap. If you adopt a zero-defect mentality, you are going to have to pay for it and you will rapidly reach a point where large amounts of money need to be spent for infinitessimal increments of improvement.

Consider modern American medicine which, because it operates in a predatory legal environment, is also expected to be zero defect. It is hard for some people to believe but a physician can be sued by a patient who he treated many years before for a condition that may of may not have been the presenting complaint but which was not discovered at the time even though a reasonable standard of care was used. The patient may even have been told to return if the symptoms did not resolve but for whatever reason was “lost to follow-up” or whichever creepy, politically correct phrase is selected to divorce the patient from his responsibilities, in this case the responsibility to be concerned enough about his health to be more than a passive observer or some kind of oblivious passenger.

The physican’s records will be scrutinized by a rapacious attorney and any mistake or ommission, no matter how slight, will be used to construct a case which, while perhaps not the multi-million dollar jackpot of which all indigent patients dream, may likely be settled out of court to avoid the expense of a trial. It’s a living for many attorneys.

This zero defect mentality costs money and very little of it improves patient care. Mostly it goes to cover the massive cost of defensive medicine which is what, I would dare say from personal experience, most of American medicine comes down to. We know better of course, but it is a lot easier to obtain the CT or order the test than to defend your perfectly reasonable, evidence-based rationale for not obtaining it. We also probably admit many more people than need to be admitted out of the fear of allowing patients to be responsible for their own outpatient follow-up.

A healthy respect for the possibility of error is part of medicine and cannot be discounted. On the other hand, what we have today is an abject terror of making a mistake. Unfortunately, unlike NASA, we are not working with professionals who have contractual obligations that they must honor, at least none that are enforceable. The trendier hospitals make a big deal about their carefully crafted Statements of Patient Rights and Responsibilities but it’s all just fluff to keep Press Ganey, the insatiable God of the Bureaucracy, happy. In our medical system, patients have no responsibilites and therefore the physicians must play a constant game of chess with opponents who moves their pieces at random and out of turn.

The public has to decided what it wants. They can have a reasonable level of relatively inexpensive medical care that relies as much as possible on the clinical judgement of physicians and their own high level of personal accountability with the understanding that occasionally something is going to be missed or they can have a hugely expensive system of medical care where everybody gets the million-dollar workup on the rare chance that something is caught that would otherwise not have been.

But being zero defect costs money and you pay for what you get.

15 thoughts on “Don’t Just Do Something, Stand There: Part Two

  1. As I heard one MD/JD say, “Instead of asking physicians if they practice defensive medicine, why not ask them if they practice fraud. Ordering a test for any other reason than diagnosing a presenting case will cause an unnecessary—and therefore—fraudulent claim against the insurance company.”

  2. That is, of course, utter bullshit and like telling the victim of a mugging that it’s his fault for walking in a bad part of town.

  3. I don’t know if I’d say it’s “bullshit”. I’d say “retarded” is more accurate. If you’re ordering the CT to pick up a .1% chance that it’s something, that’s probably not economically valid on a macro scale nor is it a good use of resources. But it’s _obviously_ not “fraud” to order a test with a low probability of picking up a condition, especially considering that the Stark law prevents self-referral for imaging. Oh look, a couple thousand physicians committed a felony yesterday by writing “r/o AAA”. What a thoroughly dumb comment.

  4. Right. That’s the problem I’m trying to describe. On one hand the folks advocating nationalizing health care (and spare me the usual “but the government won’t actually be involved”) use a collectivist arguement to justify it, claiming it’s for the greater good but then will expect an individualistic approach to medical care where the statistics don’t matter.

    For example, even though we know that spending fifty thousand bucks on an ICU patient is only going to extend their life by as long as they are in the ICU, there is no way the public, acting through their interest groups such as the AARP, are ever going to allow the simple economy of not throwing money away on futile care no matter what the statistics say.

    While I am a big critic of the Freeloader Kingdoms Across the Water (Europe, I mean), they at least know that you can’t have everything in your health care system and they have decided to eschew some of the costly and frankly, wasteful practices that are routine here. Of course, they get a little too jiggy with it. I don’t particularly think that 65 is too old to start hemodialysis like it is in some of the Kingdoms but I also have a pretty good idea that European hospitals are not full of 15/16th dead zombies waiting for the family to decide either that it’s time to let go or that it’s shameful to keep grandma alive for her social security check (which happens a lot, I assure you).

  5. “or that it’s shameful to keep grandma alive for her social security check (which happens a lot, I assure you).”

    that is shocking

  6. I agree, that happens more than anyone outside of medicine can imagine. I honestestly think the first way to reduce costs is to put an age limit on the ICU no admittance over 75.

  7. I think something like 1% of people utilize 50% of the healthcare dollar and something like 50% of the healthcare dollar is spent in the last 6 months of life.

    I don’t see that anyone with any influence has any guts to address this.

  8. Of course they don’t. The AARP has a lot of political clout and the issue will always come down to, “You want to kill grandma.”

    I don’t advocate an age limit on ICU admission because I have seen a lot of healthy, sharp as a tack, 80 and 90-year-olds who did well after an ICU admsission for something reversible. But I do think that patient (or rather family) autonomy has been carried way, way too far to the point that physician’s hands are tied even if they know the treatment is futile. The only way, at most hospitals, to force families to smell the coffee is to involve the hospital’s ethics bureaucracy, something that most physicians are reluctant to do for reasons of liablity, not to mention the time committement.

  9. I also suspect that people might reconsider the those $10k/day ICU stays if they actually had to pay even a fraction of their cost. Yes sir, we can keep her alive for a few weeks, but there is a 0% chance that she will ever come off of that pump. That’ll be $200k.

  10. I too have seen a few 80 and 90 year olds do well after an ICU stay. I’d say its about 1 out of 10 though. I think the vast majority don’t though. If I get to 75, I think that’s a pretty good life. Make everything out of pocket then after 75, if you want to put grandma in the ICU its 10K a day.

  11. I saw a story a week or two ago about a law in Texas that lets the hospital decide that it’s time to pull the plug in cases where care is futile.

    I think that’s a better way to go than age limits. With age limits people that are 80 who are “sharp as tacks” get hurt. You also have people under the age limit that are completely brain dead that the law won’t apply to.

    Of course, the article had the tone of “how dare they decide, it should be the mom’s choice. The hospital is playing God.” But anyone who knows better (unfortunately the minority) knows better.

  12. “I saw a story a week or two ago about a law in Texas that lets the hospital decide that it’s time to pull the plug in cases where care is futile.”
    Exactly, make a hospital committee. In the past two weeks we’ve saved an 86yo and a 95yo (with excellent baseline quality of life) in the ICU. A committee of health care professionals could make the distinction between salvagable and not. You’d really only need it for the delusional…hospice works with the rest.

  13. well said again dr. bear,

    you know it’s not just defense medicine, it is what people expect. i don’t know how many times i have done the million dollar work up for leg or back “pain” because the family will not take your word that we can find no cause of your “pain”. maybe this is defensive though fearing that .01 percent that it could be a tumor. even though i know “it’s nor a tumor”

  14. Yeah, but the story about the Texas hospital deciding when it’s time to pull the plug is in the news because it’s being challenged. This environment where doctors have absolutely no power to decide what is right/wrong for a patient is getting ridiculous. Any national healthcare problem is DOA if they don’t address these numerous shortcomings (which, of course they won’t, it’s politics).

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