NYT Kristof's A Possibly Fatal Mistake Shows Future of Health Care. It Isn't Good.

NY Times columnist Nicholas D. Kristof wrote a heartfelt piece "A Possibly Fatal Mistake" about his college roommate Scott Androes, who recently was diagnosed with metastatic prostate cancer. His story illustrates the problem with the current health care system.  It isn't about the lack of health insurance. It's about the obstacles all patients face in making the right decisions and the right treatment.

Something that will increasingly be harder with consumer driven health care.

Kristof lets his 52 year old friend, who is well-educated (graduate of Harvard, financial and pension consultant) and also was uninsured starting in December 2003, tell the story.

In 2011 I began having greater difficulty peeing. I didn’t go see the doctor because that would have been several hundred dollars out of pocket — just enough disincentive to get me to make a bad decision.

 

Early this year, I began seeing blood in my urine, and then I got scared. I Googled “blood in urine” and turned up several possible explanations. I remember sitting at my computer and thinking, “Well, I can afford the cost of an infection, but cancer would probably bust my bank and take everything in my I.R.A. So I’m just going to bet on this being an infection.”

 

I was extremely busy at work since it was peak tax season, so I figured I’d go after April 15. Then I developed a 102-degree fever and went to one of those urgent care clinics in a strip mall. (I didn’t have a regular physician and hadn’t been getting annual physicals.)

 

The doctor there gave me a diagnosis of prostate infection and prescribed antibiotics. 

Androes, after being diagnosed with metastatic prostate cancer, like most of us, would reflect on what went wrong.

I read Nassim Taleb’s book “The Black Swan” and imbibed his idea that you should keep an eye out for low-probability events that have potentially big consequences, both positive and negative. You insure against the potentially negative ones, like prostate cancer.

So why didn’t I get physicals? Why didn’t I get P.S.A. tests? Why didn’t I get examined when I started having trouble urinating? Partly because of the traditional male delinquency about seeing doctors. I had no regular family doctor; typical bachelor guy behavior.

I had plenty of warning signs, and that’s why I feel like a damned fool. I would give anything to have gone to a doctor in, say, October 2011. It fills me with regret. 

What can we learn about his experience and the future of our health care system?

Smart educated patients can make bad decisions

Androes is highly educated. If anyone should understand the cost benefit analysis of money and health, it should be a pension consultant educated at Harvard. He had opportunities to seek care sooner, but chose not to. Understanding this psychology is important as it is the underpinning of consumer driven health care - patients will choose more rationally if they have more financial skin in the game. Yet all I continue to see is evidence to the contrary.

First, Androes had many obstacles and not all related to lack of health insurance. He didn't choose to see a doctor when symptoms started in October 2011 because the cost didn't seem worth it. This is where our common sense and experience falls short. We've all had experiences of an ache, pain, or symptom. Many go away on their own. Androes like many other patients have this "success" and filed it away. Plus, work is too busy or important to put on hold (another major problem with the economic crisis of 2008) and personal health takes a back seat. The problem is our previous success with other symptoms may not necessarily apply to the current symptom.

It isn't clear if at that point he researched his symptoms with the always available Dr. Google. Unfortunately, like many patients he winged it hoping for the best. Had he thought about it some more, he might have realized that he never had urinary complaints prior to this episode. Having urinary problems are quite uncommon in young or middle-aged men.

So, Androes, like many others, he extrapolated his prior experience to his current situation, which may not have been appropriate.

Who has time to be sick? Don't "bet" on the wrong diagnosis with Dr. Google

Second, when he did have blood in the urine, Androes did consult Dr. Google. Dutifully, Dr. Google pulled up two possibilities. Infection or prostate cancer. Androes "bet" that it was infection. This is no different than "winging" it. Unlike the first episode of urinary problems, Androes clearly is informed about the possibility of cancer. Problem is he can't afford a catastrophic illness like cancer either from a financial or time point of view.

Here is the reality. None of us can afford it. There is never a good time to be diagnosed with cancer or any other serious life-altering illness. Yet is behavior is common among many patients I see. Their job or their financial assets are more important than their health. Androes "chose" to go after April 15th, after tax season, when it was most convenient for him. Dr. Oz nearly made a similarly bad decision regarding his colonoscopy and colon cancer screening a few years ago and then again when he failed to follow-up as recommended for colon cancer surveillance. Part of the reason we all fall into this cognitive trap is that for the most part, our body does a good job in running despite what we eat, our sedentary lifestyle, and long hours of work.
 
The most important financial asset is your health. With good health you can always make more money, with more money you can't buy good health.  So certainly, Androes had his less than optimal choices.

Did doctors miss a chance to diagnose prostate cancer earlier?

What about the health care system and doctors? Did we miss an opportunity?

Yes. It is possible there were two, though unclear if it would have made a difference in his case.

When Androes sought care with a doctor in urgent care and a urologist, he noted the former diagnosed him with a prostate infection and the latter did blood work. It isn't clear whether either doctor did a rectal exam to feel the prostate. A patient with metastatic prostate cancer with a PSA of 1,110 (normal range less than 4) should have a very abnormal prostate exam.

Had a prostate exam been done, either doctor had a very good chance in telling him he had prostate cancer prior to any confirmatory blood work. At that point, however, even with this knowledge it would have been too little and too late to alter the outcome or overall prognosis.

The second issue is whether the benefits of physical examinations or lab testing, like PSA, would have made a difference. Neither have been demonstrated to save lives. In other words, as a nation we might feel better that everyone gets an annual check-up or lab testing, but there is no scientific evidence that either help. Also, as noted previously, it isn't clear patients will seek preventive care for the reasons above.

So, how does this one story, which sadly is repeated too often by different writers and involves different protagonists, predict our health care future?

It does in the following ways:

Common sense does NOT apply to health care- four challenges in making good decisions about health

Common sense does not apply to health care. Patients may have symptoms they have never had before and erroneously assume based on prior experience, that this new problem is nothing to worry about. Denial is a powerful emotion and can cause inaction precisely when action is needed.

Second, when patients feel fine they don't protect against low probability but high risk problems. Will people buy health insurance? Will they demand for preventive screening tests that save lives? Will they willingly get vaccinated against preventive illnesses? Increasingly we see more parents choosing not to have their children immunized and then nationally see many preventive illness, like pertussis, return again with significant consequences.

Third, there are many obstacles preventing good decision making. Whether higher deductibles, copays, or simply working too hard to focus on one's health, people ignore their health until they have no choice or have symptoms. If Androes who had the good fortune of being educated at an elite Ivy League school made poor medical decisions, what are the implications for the rest of society? Patients should be more motivated to take charge of their health, yet it is likely the drive to consumer driven health care will make the nation's overall health care worse, not better. A similar experiment was attempted in retirement planning with devastating outcomes for retirees.

Fourth, people are increasingly devaluing the important of expertise and experience with the increasingly ease and availability of information on the internet. That isn't to say that non-experts cannot make a contribution to furthering progress. The challenge is that the availability of data provides many non-experts a false sense of certainty and absolute truth which is not necessarily true in medicine. We do have genomics, but it is in its infancy. We do have personalized testing, but it isn't clear if knowing the results will be medically important.  When dealing with the complexity of the human body, nuance and ambiguity are prevalent.

More patients are emailing me requesting for CT scans or MRIs because the office visit copay is too expensive. They don't feel that seeing a doctor, taking a detailed history or examination is worth it.

Yet, to counter the issues above it is doctors who can convince people to act in getting testing, treatments, and interventions when they don't want to emotionally or are uncertain what to do. It is doctors who can encourage patients to get preventive testing and immunizations when faced with the overwhelming amount of information and clutter from the media, the internet, and friends. It is doctors who can tell patients when they must seek care and when they can safely skip. There is medical science and then there is everything else.

However, this is not where our country is headed. Too many believe that to lower costs and improve health outcomes, patients must make better decisions. Patients will do so if they have more financial responsibility and more cost transparency.

Show me the evidence because I don't see it.
What I do see, unfortunately, is more cases like Scott Androes.

Is the Iron Triangle of Health Care a Law or an Observation?

A recent commentary in the Journal of the American Medical Association titled, "The Iron Triangle of Health Care: Access, Cost, and Quality" reflected that any health care system can only optimize two of the three elements - quality, access, cost.  A health care system which provides the finest quality and best access cannot do so without raising costs to unaffordable levels. An inexpensive health care system available to all cannot do so without sacrificing quality. The iron triangle of health care was introduced to me during my medical school training in the 1990s. Like many others, I simply assumed it was a fact. An immutable law. A fixed certainty that could not be altered any more than gravity.

What if this iron triangle isn't a fundamental truth or law? Why don't other industries have their own iron triangle? Is health care really different than aviation or computing?  Asking this simple yet basic question is something medical students and doctors don't ask. Fortunately, this was not the case for Harvard Business School Professor Clayton Christensen, author of the Innovator's Prescription. His book not only details the theory of distruptive technologies, but also how companies who do "disrupt" the incumbent companies and the status quo are the ones that ultimately provide goods and services which are more affordable, more accessible, and of higher quality. Might there be analogies for health care? Professor Christensen highlights aviation and computing as two examples.

Commercial flight for the masses was not a realistic possibility over a century ago when the Wright Brothers navigated their winged contraption in Kitty Hawk. Even decades later, as epitomized by Pan-Am in the 1960s, air travel was for the affluent and a special event. At that point, air travel was not accessible or affordable for the general public. Yet, in the 1970s, a Texas start-up known as Southwest Airlines provided discounted travel to the general public by offering low fares, no amenities, and a point to point service rather than hub and spoke system.

And traveling by air was never the same again.

Now, more people travel by air than anytime in history with unparalleled safety. More accessible. More affordable. Higher quality.

Computers had a similar beginning evolving from a product where only available to a few due to cost and complexity of the systems to now where computers are affordable, ubiquitous, easy to use and of even better quality than the past. One of the first computers in the 1940s, was Eniac, a huge and expensive mainframe computer which was not reliable, extremely complicated, and accessible only to academics. Years later, the general public typically accessed these mainframe computers at work via technicians. Access was limited. It wasn't until the late 1970s that desktop computers appeared. Hobbyists and others, like Steve Jobs, built computers which were less expensive and underpowered compared to the mainframe computers, but they were more accessible to the general public. It wasn't until many years later that subsequent computers became more affordable, more powerful, and more accessible in the form of laptops, netbooks, and now smartphones and tablets. More people had access to computing because the products were more affordable and of even higher quality.


And computing was never the same again.

Based on Christensen's model, we can predict that health care will indeed break the iron triangle and demonstrate it is not a law but an observation. The question is who will lead these changes? Insurers? Doctors? Patients? Entrepreneurs?


Our next generation of doctors must be trained in other disciplines outside of health care. We must collaborate and accept other ways of looking at the same challenges through the lens of other disciplines including business school. Yet, there is a loathing for this. There is the belief that health care is different. Yes, we can continue to talk about the iron triangle of health care and accept that as a reality.

We can also say no. The iron triangle is not a law but an observation. We choose a different path.

The truth is that this is the most exciting time in health care with the intersection of better medical understanding, the availability of technology, and the best and brightest minds working on the issues of better quality, better access, and lower costs. As doctors and educators, it is our job to make sure the next generation is equipped with the right mindset to team with others. If not, others will define the future of health care.

This is what worries me the most.