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    May 05, 2010

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    Peter Laird, MD

    Thank you David for the detailed post on what I have termed the new medical ethics in several of my posts in the last couple of years. Having practiced medicine in the real world since 1990, one aspect of patient leaps out when reading about these cost containment strategies and that is diverse diseases often have common presentations that must be elucidated carefully. The cost effective manner to approach diagnosis is to go for the highest statistical likelihood.

    This approach may work in a high percentage of patients could save a lot of money, but at what cost? Quite simply, the patient who presents with the symptoms of a 75% condition but has another condition that must be treated with a completely different regimen. Many people believe that we can improve medical care and contain costs by going to nurse practitioners or physician assistants, but likewise at what cost?

    The cost will be in the fine details of medicine where years of training, experience and attention to details tell the difference of the correct vs incorrect diagnosis. If as a society, we will accept 90% accuracy to contain costs, we will enter into a new world of American medicine that I personally would not want to have any part of as a doctor. When you talk about cost containment in medicine, much of what we do in testing is to sort out the common from the uncommon. Where shall we set that barrier? The cost of going from 90% accuracy to 95% accuracy will be substantial. What if we strive for 100% accuracy? Well, we won't have any cost savings.

    We are entering a brave new world of medicine that really isn't that new. I have seen what cost containment strategies do for patient care for nearly 15 years and it is my opinion that cost containment works in a statistical manner up to a point but then it breaks down and costs actually increase due to costly complications that may have been prevented with a more diligent search in the first place.

    I believe that it is a failed philosophy of medicine that will greatly diminish our standards when applied across the board for all comers. The art and practice of good medicine does not fit neatly into computer algorhythms. I was involved in a malpractice case where all involved followed the protocols exactly yet the diagnosis was missed by three internists, a cardiologist and a pulmonary/critical care specialist. The test that I wanted to run was cancelled by the specialist after it was ordered at my recommendation by another internist. It would have shown the proper diagnosis. Since the consideration of the test was not high likelihood since the same test had been negative 3 days prior, I was without a leg to stand on. Two days later, the patient died from the condition I had considered. It was a lesson I have never forgotten at the price of a patients life. We should get ready for many more such tragedies if we adopt the policies outlined above.

    On the other hand, preventing complications turns out to be a very feasible philosophy of medicine that has a greater upfront cost with lower total costs from less secondary treatments of disease that could have been caught early. The mammogram that prevents a breast cancer from spreading to the liver will not only save a life, but will be much less costly. The best medical practice is most often the cheapest. Filling a new generation of doctors with a self limited approach instead of a comprehensive approach will have a very negative impact on the minority, but a significant minority. That will be the real cost of cost savings.

    Disease is often the great masquerader and the current limitation of the differential diagnosis to the highest likelihood only will radically change medicine. I do not believe it will be pretty. Many times it is the least likely disease that we are dealing with that will not even be on the list of statistically likely diseases. I guess that will just be the patients bad luck.

    somerville

    A general problem with all cost-benefit analyses in medicine is deciding whose perspective to adopt in making this assessment. The healthy public, the disease community, the government, the medical profession, and the individual patient will all have distinct views of how this balance should be determined, and it can only be a political, not a technical, decision whose judgment prevails.

    When I was first diagnosed with Wegener's Disease and suffered intractable vomiting, the NHS physician treating me decided on a cost-benefit analysis that it was too expensive to give me enough ondansetron to reduce the vomiting to less than five times a day. There is no mathematical formula to say whether that judgment was right or too parsimonious.

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