Standard medical practice: ignore exceptions to the rule
There is a governing rule in medical practice these days. I call it the 95% rule. Put simply, if 95% of patients with symptoms X can be accurately diagnosed as having condition Y, then for those patients in the remaining 5%, there is very little likelihood you will readily find a physician who will either take you seriously or pursue the actual diagnosis with any diligence. It stuns me that when I mention this unwritten rule to people, they almost invariably say, "You know, that's just like what happened to my brother/father/friend/etc..." As an example, I have a colleague who has ichthyosis, who was variously diagnosed with amyloidosis, eczema and other skin conditions. (One physician even mildly suggested she be prescribed an antipsychotic medication.) She only knows this for certain now because she so vigorously pursued all clinical literature and experts until she was able to find a definitive match between her symptoms and those of ichthyosis. Moreover, based on this premise, she has been able to apply various treatments specific to ichthyosis and has seen stunning improvements in her condition. By the way, my colleague is an RN, which one might think would lend credibility to her premise.
Her case was exceptional only for the seriousness of the condition. I have just as often seen gross apathy by clinicians in diagnosing celiac disease (intolerance to wheat foods), cancers or suspected cancers at a variety of stages, and other conditions.
Why is this? It wasn't always this way. I won't attribute it all to managed care, but there is an awful lot of weight to the argument. It goes like this. Healthcare costs get out of control (no reasonable person denies this). Health insurance is set up to "capitate" healthcare costs. In capitation's earliest manifestations, the effect is simply to limit the amount of healthcare costs spent on each patient. The principle in the long run is that if a physician is short-sighted and misdiagnoses a set of symptoms as minor (and treatable by low cost methods), then when the symptoms are actually part of a serious condition, the inevitable progression of the symptoms to a more serious stage will result in actually higher costs to manage the serious condition (e.g., a Stage IV cancer) than if it were accurately diagnosed at an earlier stage.
It's a nice idea. Suggests that the long term view will save healthcare insurers, patients, physicians -- everyone -- money. Suggests greater appreciation in the system for sophisticated diagnostics, for more emphasis in the treatment of the disease than symptoms alone. Hasn't quite worked out that way, though. The backlash from patients and even physicians (who, in my opinion. railed less about limitations to patients's treatments than they did about an insurance administrator telling them what they could or could not do), has forced managed care into a recognition that healthcare is more complex, the dynamics of the "product" of healthcare delivery not so simple as to lend itself that healthcare can be run like a business, at least not in the way thus far conceived by managed care.
The result has been that physicians, disillusioned by the governance of their profession, either just toe the line and go with the managed care flow or they leave clinical practice entirely. Intellectual curiosity is not extinct, but very scarce. Physicians are not motivated to pursue diagnoses to their definitive clarity, and corresponding treatments. The consequence is that WE THE PATIENTS are now responsible for ourselves. In some ways, this is as it should be. Even many physicians (not all) innately understand that the patient typically has a better grasp on his/her symptoms than the physician does. Therefore, it is incumbent upon patients to challenge physicians, seek 2nd, 3rd, and 4th opinions.
Ultimately, if the patient does not take this responsibility, and if his/her symptoms fall in that 5% exception, he/she runs the risk of continued pain, frustration, financial ruin, even death.
Her case was exceptional only for the seriousness of the condition. I have just as often seen gross apathy by clinicians in diagnosing celiac disease (intolerance to wheat foods), cancers or suspected cancers at a variety of stages, and other conditions.
Why is this? It wasn't always this way. I won't attribute it all to managed care, but there is an awful lot of weight to the argument. It goes like this. Healthcare costs get out of control (no reasonable person denies this). Health insurance is set up to "capitate" healthcare costs. In capitation's earliest manifestations, the effect is simply to limit the amount of healthcare costs spent on each patient. The principle in the long run is that if a physician is short-sighted and misdiagnoses a set of symptoms as minor (and treatable by low cost methods), then when the symptoms are actually part of a serious condition, the inevitable progression of the symptoms to a more serious stage will result in actually higher costs to manage the serious condition (e.g., a Stage IV cancer) than if it were accurately diagnosed at an earlier stage.
It's a nice idea. Suggests that the long term view will save healthcare insurers, patients, physicians -- everyone -- money. Suggests greater appreciation in the system for sophisticated diagnostics, for more emphasis in the treatment of the disease than symptoms alone. Hasn't quite worked out that way, though. The backlash from patients and even physicians (who, in my opinion. railed less about limitations to patients's treatments than they did about an insurance administrator telling them what they could or could not do), has forced managed care into a recognition that healthcare is more complex, the dynamics of the "product" of healthcare delivery not so simple as to lend itself that healthcare can be run like a business, at least not in the way thus far conceived by managed care.
The result has been that physicians, disillusioned by the governance of their profession, either just toe the line and go with the managed care flow or they leave clinical practice entirely. Intellectual curiosity is not extinct, but very scarce. Physicians are not motivated to pursue diagnoses to their definitive clarity, and corresponding treatments. The consequence is that WE THE PATIENTS are now responsible for ourselves. In some ways, this is as it should be. Even many physicians (not all) innately understand that the patient typically has a better grasp on his/her symptoms than the physician does. Therefore, it is incumbent upon patients to challenge physicians, seek 2nd, 3rd, and 4th opinions.
Ultimately, if the patient does not take this responsibility, and if his/her symptoms fall in that 5% exception, he/she runs the risk of continued pain, frustration, financial ruin, even death.
posted by P. Driscoll at
8:10 AM
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