4 ms·

I think the author is correct in the acedemic sense, but ignorant of the reality of healthcare. If a doctor receives a test result that shows a suspicious mass

I think the author is correct in the acedemic sense, but ignorant of the reality of healthcare. If a doctor receives a test result that shows a suspicious mass, then neglects to order a biopsy to investigate further, there are 2 rough outcomes. 1. It was nothing 2. It was cancer If it turns out to be (2), the doctor and the practice/hospital/whatever gets sued for malpractice. On a more ranty note, why does everyone think they are better at other people's jobs than those people are? Where is the basic trust in the other? You think a doctor in the United States after ~15 years of school doesn't know that most biopsies turn out to be more harmful that useful? Come on. Restore some basic trust in other's competence.

axg11 4y ago
This is the reality. In fact, the situation is getting even more complicated as direct-to-consumer screening becomes more popular (e.g. full body MRI scans). Companies that are selling the health screenings are only incentivized to sell as many screenings as possible. Scans inevitably result in benign incidental findings far more often than they identify real health problems. Then the patient is directed to a specialist who is uninvolved with the screening company. The specialist is incentivized to aggressively investigate the finding out of fear of malpractice and due to pressure from the patient. Nobody has ever thanked their doctor for inaction. The end result far too often is a series of expensive and painful procedures with a large dose of anxiety. Of course screenings also save lives, but nobody is responsible for ensuring the benefits outweigh the harms at the macro level. I don't think any actor in that chain is malicious, it's just an example of poorly aligned incentives. Screening companies, doctors and patients all believe they are making the most optimal choice.
peteradio 4y ago
Presumably the patient can decline the biopsy? What happens to liability in that case? Does the doctor then have to decline to work with that patient further? What happens to liability if the doctor doesn't fire the patient? I agree there needs to be trust somehow, yet it seems practitioners hands are tied from a level above to toe the line for liability reasons rather than patient outcome. Is a doctor able to take into account all extenuating circumstances of a patient or only those predefined on a checklist passed on by a murky review process? What happens to patients who do research and find alternative (maybe better) opinions, well are they in network? Can a network have differing opinions among its practitioners?
- nradov 4y ago
  Generally there would be no potential medical malpractice liability if a patient declines a medical procedure. That happens all the time. Physicians can fire patients, although they seldom do so because of declining a medical procedure. Professional ethics and state laws generally require the physician to first hand off the patient to another physician first; they can't just drop someone with zero notice. There is generally no mandated checklist, at least not from a legal standpoint. Some healthcare provider organizations do require their employees to follow certain written standards of care. Medical societies also publish evidence-based care guidelines. Compliance is voluntary but gross deviations could be factor in liability cases or in actions by state medical boards. Insurance reimbursement is an entirely separate issue. Every insurance plan has a different network of providers and different rules about which services are covered under various circumstances.
CogitoCogito 4y ago
Also the author seems to entirely ignore patient psychology. Sure in some parallel universe where patients can be told "so we found something weird on your lung don't know what it is and don't really care" and just accept it, then maybe doing the unnecessary tests doesn't matter (ignoring extra costs of course which _do_ matter). But we don't live in that universe. Ignoring how patients actually behave and pretending they are just perfectly logical is basically malpractice in my opinion.
- lupire 4y ago
  "Watch and wait" is a very common course of treatment.
  - CogitoCogito 4y ago
    I'm confused why you're replying that to me, because I never said it wasn't a common treatment. Regardless, I do agree with you.

axg11 4y ago

This is the reality. In fact, the situation is getting even more complicated as direct-to-consumer screening becomes more popular (e.g. full body MRI scans). Companies that are selling the health screenings are only incentivized to sell as many screenings as possible. Scans inevitably result in benign incidental findings far more often than they identify real health problems. Then the patient is directed to a specialist who is uninvolved with the screening company. The specialist is incentivized to aggressively investigate the finding out of fear of malpractice and due to pressure from the patient. Nobody has ever thanked their doctor for inaction. The end result far too often is a series of expensive and painful procedures with a large dose of anxiety. Of course screenings also save lives, but nobody is responsible for ensuring the benefits outweigh the harms at the macro level. I don't think any actor in that chain is malicious, it's just an example of poorly aligned incentives. Screening companies, doctors and patients all believe they are making the most optimal choice.

peteradio 4y ago

Presumably the patient can decline the biopsy? What happens to liability in that case? Does the doctor then have to decline to work with that patient further? What happens to liability if the doctor doesn't fire the patient? I agree there needs to be trust somehow, yet it seems practitioners hands are tied from a level above to toe the line for liability reasons rather than patient outcome. Is a doctor able to take into account all extenuating circumstances of a patient or only those predefined on a checklist passed on by a murky review process? What happens to patients who do research and find alternative (maybe better) opinions, well are they in network? Can a network have differing opinions among its practitioners?

nradov 4y ago
Generally there would be no potential medical malpractice liability if a patient declines a medical procedure. That happens all the time. Physicians can fire patients, although they seldom do so because of declining a medical procedure. Professional ethics and state laws generally require the physician to first hand off the patient to another physician first; they can't just drop someone with zero notice. There is generally no mandated checklist, at least not from a legal standpoint. Some healthcare provider organizations do require their employees to follow certain written standards of care. Medical societies also publish evidence-based care guidelines. Compliance is voluntary but gross deviations could be factor in liability cases or in actions by state medical boards. Insurance reimbursement is an entirely separate issue. Every insurance plan has a different network of providers and different rules about which services are covered under various circumstances.

CogitoCogito 4y ago

Also the author seems to entirely ignore patient psychology. Sure in some parallel universe where patients can be told "so we found something weird on your lung don't know what it is and don't really care" and just accept it, then maybe doing the unnecessary tests doesn't matter (ignoring extra costs of course which _do_ matter). But we don't live in that universe. Ignoring how patients actually behave and pretending they are just perfectly logical is basically malpractice in my opinion.

lupire 4y ago
"Watch and wait" is a very common course of treatment.
- CogitoCogito 4y ago
  I'm confused why you're replying that to me, because I never said it wasn't a common treatment. Regardless, I do agree with you.