19 de nov. 2016

cowboys doctors or... comforters doctors

David Cutler from Harvard University, et. al in 2015 published a working paper to test whether patient demand-side factors or physician supply-side factors explained regional variations in health care spending. They founded that:
  1. Patient demand was relatively unimportant in explaining variation in spending after accounting for physician beliefs.
  2. Physician organizational factors matter,
  3. The single most important factor is physician beliefs about treatment: 35 percent of end-of-life spending, and 12 percent of U.S. health care spending, are associated with physician beliefs unsupported by clinical evidence.

The authors differentiated two types of doctors.
  • "cowboys": Physicians treating a critically ill patient may decide either to provide intensive care beyond the indications of clinical guidelines (such as implanting a defibrillator to counter severe heart failure),
  • "comforters": Physicians treating a critically ill attempt to make the patient more comfortable by administering palliative care.
The cowboy doctors push the frontier of medicine by going above and beyond clinical evidence showed little or no marginal benefit derived from the extra procedures, resulting in wasteful spending.

The authors say that the healthcare system’s current incentives often do not prompt doctors to ask the right questions, such as whether a proposed treatment truly benefits the patient. “If doctors restrict themselves to performing what is evidence-based, “we can save hundreds of billions of dollars a year.” Doctors tend to follow their own beliefs about the right treatment to use, leaving patients little say in the process. How to treat a patient is often a multiple-choice question without a straightforward, single “correct” answer. Doctors should pay more attention to the patient’s preferences, instead of relying on their own experience.

The research suggests that it’s time for the cowboys to rein themselves in, and learn to listen.

Access to the article (pdf) Physician Beliefs and Patient Preferences (wp 2015)

photo: Leonard McCombe LIFE Magazine