In his comments about the health legislation the other day, Doc made a very good point: the recent health care bill really doesn’t reform health care, it reforms health insurance. In particular, the bill does very little to directly address the spiraling costs of health care. Obviously that should be the next step in the reform process, although it begs a question: why are health care costs so high?
As far as I can tell, there are really four causes of the high health care costs in this country. I have no idea which one of these is the primary culprit; I’ll let you make up your own minds.
1) Aging population. See, we had this Great Depression thing. Then we had this World War II thing. That was really 17 consecutive years of massive economic turmoil (which included higher death rates and relatively low population growth) and war (when most men of child-bearing years were overseas getting shot at). So what happened after the war? People had saved up money from during the war when the government paid all the men and the women were left behind working; they benefited from a boom in nursing and the medical profession that happened during the war; and they were exceptionally… er, amorous for understandable reasons. The result was a lot of children, many more of whom survived childbirth than previous generations. Fast forward seventy years, and now we have an awful lot of old people. Old people get sick more often, and they cost more to treat when they do get sick. Ergo, health care costs per capita have gone up dramatically.
2) Litigation. See, it turns out that people don’t like it when their doctors kill or injure them. They want to sue when that happens, and rightfully so. But how do you really know when your doctor kills your husband, and when he would have died anyway? Well… in many cases you don’t. Oh, and then other people notice that ambiguity and try to take advantage of it to get rich quick. More litigation means greater insurance costs for all doctors, who buy insurance to pay for those suits, etc. They pass those costs on to the people who pay the bills, which is all of us.
3) Administrative costs. So, it turns out that in the relationship between insurance companies and doctors, the insurance companies have basically all the advantages. As a result, the insurance companies can force doctors to use the forms and billing processes that the insurers want, not the other way around. The result is that every insurance company has it’s own forms, policies, and procedures, which are all different from each other. Then you have a number of different government programs, all of which have different forms, policies, and procedures from each other and from the insurance companies.
Then you have the fact that many doctors and hospitals are stuck with out-dated medical filing procedures and still do the vast majority of their work by writing out things in cursive on sheets of paper, that then get stuck in file folders. And even when those things are computerized, those computerized systems often don’t talk to each other, which means things have to get printed out and stuck in more file folders.
The result is a lot of administrative costs, a lot of paper work that gets lost and duplicated, and lot of excessive tests because no one can find the results from the previous one, a lot of extra time spent in hospitals by patients who are there simply to wait for the hospital to sort through the paperwork, and ultimately a lot of costly and sometimes deadly mistakes (which feeds back into that whole litigation thing).
4) A preference for technology over science in treatment. By science I mean scientific method: experimental research that leads to real knowledge about causes and effects. A new procedure comes along that seems at face value like it should work. So people start using it; it becomes standard procedure, and no one ever tests it. Then it becomes impossible to test, because a real test means denying treatment to some people and that’s suddenly “giving them a death sentence”. Pharmaceutical companies and medical research firms encourage their products into wide usage before they’ve been fully tested; they bribe the politicians to demand that insurance companies and Medicare/Medicaid cover them; patients who are paranoid about insurance companies denying them treatment options also demand access to these new technologies. But no one ever tests these things to make sure that they work.
If you think I’m exaggerating, check out some of the information about the PSA prostate blood exam, heart stents, mammography screening… you get the point. In none of those cases were the procedures and surgeries tested to actually make sure that they prolonged life. They just seemed like good ideas, and so people did them, and only after the fact did someone stop and say “but is this really having the effect we think it’s having?”
I like the health insurance reform bill, relative to the previous status quo. But the health care problem won’t be solved until we can fix at least a couple of the things I mentioned here.
Now, the Obama Administration has pushed some advances in the medical administration front, but a lot more work there needs to be done. Republicans keep pushing on medical litigation reform, although the Bush years demonstrated that most of them weren’t really all that serious about the reform. Probably nothing can be done about the Baby Boomers. And no one in Washington is really talking at all about limiting untested new technologies.
So the chances of something being done about any of these isn’t great. But if you want to know what the next step should be, this is it.
First, thanks for the shout out – it’s nice that every once in a while I make a good point.
I think you understate the cost of litigation – not only does it lead to malpractice insurance, but leads to defensive medicine. Ordering unnecessary tests just to cover your rear end. Unbelievable amounts of unnecessary documentation in case you end up in court so you can protect yourself, etc. All this adds up.
I’d like to add to Administrative costs as well. The government has so many requirements that are so counterproductive from an efficiency standpoint. A patient dies at a hospital because a medicine was switched, and the pharmacist didn’t check the nursing station that night – the patient gets the wrong drug and dies. So, the government passes a law requiring every medicine station to be checked by a pharmacist every night. But then, somebody dies because the medicine is switched during the day. So, the government requires that a pharmacist checks the station every hour… these things keep getting added on. They save 1 life in 100,000 that are hospitalized, but add tremendous expense.
Similarly, if a patient in the hospital uses a single kleenex, the entire box has to be disposed of when the patient checks out of the hospital. This sort of waste adds up. Not to mention the costs of HIPAA, and all the training that the government requires that doesn’t actually do things.
There are at least two causes you missed, that I’d like to add:
1) Insurance insulating the cost from the consumer. Imagine an elective procedure costs $100 – I hurt my elbow playing tennis and I can’t play tennis anymore, although I can still function normally off the court. I may not be willing to pay for that – tennis is fun, but not worth the money. But say I already have insurance to protect me against things that are much worse. Then I only have to pay a $20 co-pay. Now that’s something I might be willing to pay. Costs go up, because there is separation between who is getting the benefit, and who is paying the bill. (The patient pays the bill in the long run through increased premiums, but this is both diffused among others in the insurance pool, delayed, and not obviously connected to the procedure, which lessens how much impact it has psychologically).
2) More treatments are saving more lives. This is a good thing, of course. Old Zeke gets condition X. 20 years ago, it would have killed him. But now, a new drug Wonderfulcillin is on the market and can keep him alive as long as he takes it every day. The pill costs $10 a day, which isn’t much considering the alternative is death. But, that’s $10 a day of additional dollars going to health care. And sometimes, its more like $100 a day – not because of big pharma profits, but because the drug is expensive to produce. Now multiply Old Zeke by the 10,000 other people with condition X. And multiply that by Conditions Y, Z, and omega. And what if its not saving his life, but preventing crippling pain? What about if it reduces his senility? What if it helps with erectile disfunction, or baldness, or passing gas? Its great that more lives are saved, and that lives are being made better. But that does increase the costs of health care. And so long as new drugs keep coming out, new expenses will be added to health care.
Note: When I use the term “doctor” I mean MD’s and not real doctors.
Thanks for posting on this, and I wish there were an easy solution to this problem. I think Doc is right on in his (1) is a real problem.
Maybe I’m splitting hairs but the box of tissues that got thrown out should not fall into “waste.” Perhaps it is wasteful in that the patient did not take it with them when they left. Unfortunately the alternative is really really bad (the spread of germs). This is already something hospitals deal with and is unavoidable.
Mike’s point (3) that addresses paper medical records instead of computers is a time efficiency issue, but I don’t think that is a significant contribution to the overall healthcare cost bloat.
One needs to be careful when trying to regulate of discuss litigation costs. Doc is right in that there are a lot of things that should fit into that bucket. I get scared when I hear politicians trying to limit the payout of malpractice claims. Having explored requirements to successfully win a malpractice suit the bar is set pretty high. So to me, if a suit makes it far enough that a payout is being discussed, chances are the victim probably deserves it. Higher expectations of nurses and doctors is a more effective route to go. Does that mean having doctor’s perform “defensive medicine”? No. I think it means doctor’s spending enough time with patients to really understand their situations and how all their treatments might be interacting. It is my observation that very few doctors do that. Most doctors work in their little bubble of expertise and never bother to look at the big picture. I don’t know how many times I’ve had a doctor tell me that they have read my wife’s “entire chart” and know exactly what to do. By entire chart they mean the short version that is a summary of what I told the triage or scheduling nurse. When I think of entire chart I think medical history, medications, synopses of past hospitalizations or procedures, etc. I think our expectations for workers in the medical industry is way too low, but most people are too ignorant of the problems to say it.
Bah! My blasphemy xml-style tags were removed from my post!
Andy, I have concerns about your point on malpractice. Say it’s true that when a large payout occurs, its usually merited (I’m not sure that’s actually the case, but for the sake of debate I’m willing to grant it). My concern is the effect that has on other doctors. It comes in several flavors:
1) Every doctor has to get malpractice insurance because there are so many suits. And when there are huge payoffs like that, the costs for insurance go up, affecting doctors who did nothing wrong.
2) Doctors will be more afraid of the lawsuits, and will practice defensive medicine. I’m not talking about reading charts, I’m talking about ordering an MRI for the 1 in 100,000 chance that something will show up, because of that lawsuit threat.
As an aside, while the victim may deserve compensation from medical malpractice, the really high rates that politicians are talking about go well beyond what a person deserves just for being unlucky… and a huge chunk of that money goes to lawyers, not victims…
As for reading charts, I actually disagree with you there (and I realize I’m about to open a major can of worms here).
There is good evidence that in many cases people make better decisions when they know less information. A lot of information is more misleading than helpful. The “short summary” chart is designed to contain the information that will maximize the doctor’s chance of diagnostic accuracy given the time spent per patient. Having doctors read entire charts might actually be detrimental to patient well-being. In fact (wincing in anticipation) most of the time we’d be much better off if the doctor just fed the relevant info into a computer and let the bio-informatics software give a diagnosis. Actuarial diagnosis does so much better than human diagnosis – even for expert doctors – that having a doctor involved in diagnosis at all both costs more and leads to worse health outcomes.
What doctors SHOULD be doing isn’t diagnosing patients, its COMMUNICATING with patients. That’s the future of medicine, expert-systems diagnosing and subscribing treatment in ways that massively outperform human doctors, and the human doctor counseling patients. In a sense, though, this actually means I agree with you. To effectively communicate and make a successful medical relationship, the doctor SHOULD know the patient’s entire history. But since we’re not there yet, for now lets stick with actuarial methods that improve accuracy.
Another big health cost increaser is the obesity epidemic. Diabetes is a disease which needs lifelong treatment, and its rates have skyrocketed in the last 20 years. It and other obesity-related diseases are only going to get worse. The First Lady has had a lot of press lately trying to counteract this trend, but it will be very hard because it is so complicated. Sedentary lifestyles play a big role (work at a desk all day, ride in the car home for an hour, watch tv). Also stressed-out people tend to eat poorly, and poor people often can’t find a nearby grocery store or a safe park to play in. Climbing out of this hole is going to take a lot of discussion (and probably a lot more yelling from all directions) until it gets SO bad that something system-wide has to be done. Until then, eat your vegetables and go for a walk.
Man oh man, what a target rich environment.
First, Reb, when referring to “obesity-related diseases” such as diabetes, please be so kinds as to say Type II diabetes. Type I diabetes is an auto-immune disorder and no amount of diet and healthy eating will prevent it.
Next Danny Boy….wow. I’m going to interpret your post in the kindest possible way. First I’ll start off by pointing out common ground.
Doctors need to spend more time communicating. No doubt. I am a huge fan of the “Patch Adams” approach to medicine. If you’ve not seen the movie or are not familiar with the person of of whom the movie was based, his theory is this: if you treat the disease you win some you loose some; if you treat the patient you win every time.
Now to dig into the points where we don’t see eye to eye.
1) For malpractice cases where the mistake results in a truly devastating injury, most payouts do not cover the actual long term costs of the mistake. If you believe, as I inferred from your post that being allowed to file a malpractice suit is like winning the lottery and you were lucky/unlucky enough to win a suit, we can stop this conversation right now as we are clearly living in different worlds.
Actually considering your libertarian leanings, I am surprised that you would support the concept of limiting payouts in lawsuits as a rule. I would think that a libertarian would be of the belief that most situations are unique and each one should be weighed on it’s own merit. To dictate a limit on payouts sounds like a government regulation to me.
As for actual amounts of money, why not change a law to instead of being a concrete dollar amount why not change it to cover additional expenses incurred due to the mistake. Obviously then you get the problem with defining what caused what, but a least then the spirit of the suit is being upheld.
Also if part of your beef with the payout amounts is how much lawyers make, then write legislation limiting how much they make, not the victim. We could make the lawsuit process easier therefore reducing the need for lawyers and their high compensation, but I don’t think that will give you the result you’re looking for. What makes many of these problems difficult is how to put a dollar amount on a loss? How much is it worth for a 31 year old to never be able to live with her husband at home again? I guess you’ve already admitted that love isn’t in the cards for you and are willing to live out your life alone, so I guess you can’t comprehend what that feels like. Lets imagine that you did find the woman of your dreams, and from previous posts on this site that will be quite the accomplishment for you. Now that you’ve got that, now pretend that gets taken away from you. Not through death, no no that’s too easy. Let’s pretend she, say, has a brain injury and at the age of 31 is forced to live in a nursing home for the rest of her life. Can you imagine what that is like for her? For you?
2) The role of doctors
I agree that computers should be used to propose a variety of possible diagnoses, but to allow a computer to come up with the one the doctor should use is just asking for trouble. This is why doctors claim they “practice” medicine. If it were as scientific as you seem to think it is, they would not embrace that term.
You also seem to be under the impression that a doctor’s role is to diagnose and help a patient interpret the diagnosis. Doctor responsibilities also include following through with a recommended treatments. This is the most difficult part of a doctor’s job. Doctors must choose from a variety of treatments, which in most cases none of which will work for all patients. A doctor must decide based on patient history, lifestyle, maturity level (aka attitude), gumption, and overall gut feeling on which of a variety of treatments will most likely work for THIS patient (not MOST patients, but THIS patient). Patients cannot afford a doctor who simply plays the odds, which is what you have proposed by suggesting a computer perform the role of doctor. The other problem with “short summaries” instead of a through review of a chart (AND discussion with the patient) is that at some point someone had to decide what is relevant enough to make it into the “short summary” and if they make a mistake or omit something, then what?
Having lived the past 6 years of my life with someone who is the .01% case, that person is doomed using an actuarial method of diagnoses. Maybe you’re okay with that, but what if you’re that person. This is the real problem I have with libertarianism. They are never “that” person. Most libertarians I know, and I feel safe going out on this limb in describing you this way, are born on 2nd base and think they’ve hit a double.
Danny Boy, there are several more points I could make about your post, but I need to go take a shower now. I feel disgusting.
“If you believe, as I inferred from your post that being allowed to file a malpractice suit is like winning the lottery and you were lucky/unlucky enough to win a suit, we can stop this conversation right now as we are clearly living in different worlds.”
That’s pretty much what I believe. I’ve seen some studies that show that whether one wins, and how much one wins, have basically no relationship to the merits of the case. For an excellent discussion I refer you to Thaler and Sunstein’s book Nudge. But since we come at this from fundamentally different assumptions, perhaps we’ll remain talking past each other.
“Actually considering your libertarian leanings, I am surprised that you would support the concept of limiting payouts in lawsuits as a rule.”
This is actually a really really fascinating point and one that I should think more about. The courts are an arm of government, so limiting the power of the courts isn’t necessarily anti-libertarian. But the question does resonate with me and maybe I’ll write a post on it some day.
“write legislation limiting how much they make”
Mostly practicality prevents this. How would you write such a law, in practice? Is it capping the percent of the settlement that goes to lawyers? In which case, there’s strong incentives for lawyers to just increase the amount they sue for. Or is it a capped amount? In which case lawyers may be unwilling to take cases that will be harder and time consuming (why not just go for easier money instead). So, I’m just not sure how it could be done in ways that don’t make things worse in the long run.
“Let’s pretend she, say, has a brain injury and at the age of 31 is forced to live in a nursing home for the rest of her life. Can you imagine what that is like for her? For you?”
Absolutely awful. But I don’t see why a person who suffers that because of a medical mistake gets compensated for life, while a person who gets that because a mugger shoots her while taking her wallet gets nothing. Bad things happen all the time. Mistakes happen all the time. It sucks. Life’s not fair. But it doesn’t become more fair when we arbitrarily give some people compensation, and others not. This goes back to the lottery point you raised at the beginning – I think we’re talking past each other again.
“A doctor must decide based on patient history, lifestyle, maturity level (aka attitude), gumption, and overall gut feeling on which of a variety of treatments will most likely work for THIS patient”
Here’s the point of your post I most strongly disagree with. Gut feeling is the WORST way a doctor can decide. Using that SHOULD be grounds for malpractice, even if the doctor is lucky enough to get it right. Hundreds have studies have shown that doctors gut instinct is NOT reliable. Consider the Goldman Index. A binary flow chart that a high school student could use does better at determining whether a person should be hospitalized for heart disease than cardiologists with 20 years of experience. It puts fewer people in the hospital that don’t need to be there, and simultaneously misses fewer people who ought to be in the hospital. Bio-informatics that are more complex than a flow chart can do even better than that.
Your wife is the .01% case. My contention is that bio-informatics are more likely to successfully catch the .01% cases than doctors are as well. Because doctors are very unlikely to think about conditions that occur only .01% of the time. And so its much more likely that they’ll miss a telltale symptom than a well calibrated actuarial platform. And as bio-informatics improves as a science, that’s just going to become more and more true.
I agree with you that doctors still need to perform procedures (for now, anyway – robotics advances may make that obsolete in a dozen years too). But I STRONGLY disagree that doctors trusting their gut is a good way to go. I’m not ‘ok’ with people slipping through the cracks because of informatics. But remember that for every 1 person that actuarial methods botch, doctors trusting gut instinct would have botched 3. And to turn your logic back on you, what if you’re one of those three – its three times as likely as being the 1…
“Most libertarians I know, and I feel safe going out on this limb in describing you this way, are born on 2nd base and think they’ve hit a double.”
If we were talking about welfare law, this might make sense. But I’m having trouble understanding what this has to do with anything we’ve been discussing in this post. My arguments here have been much more utilitarian than libertarian in philosophical bent.
Wow. You need to get out of academia and live and work on main street for a while. You have no concept of reality.
As I am sure you have no intention of listening to my prior post, let me refer you to some book, apparently the only thing you know how to relate to (as is proven in this post, this post (http://leftfielder.org/2008/02/14/february-14th/), this post (http://leftfielder.org/2010/02/14/annual-valentines-day-rant/) and many other not worth posting here).
Please look into the excellent book July and July, “Couples Facing Illness.” Or look into other real world organizations of people trying to help themselves like http://www.wellspouse.org/.
Good luck on your next visit into the medical world. I hope you win the lottery like we have.
Andy, I know we don’t see eye to eye on these issues, but there is no call for you to resort to ad hominem arguments or sarcasm. I have tried to maintain a civil tone in this discussion, and I respectfully request that you do as well.
I do not make light of the challenges that you, or others who have loved ones who are ill have gone through. But I took a look at the website that you just put a link to, and I honestly cannot figure out how that relates to either clinical vs. actuarial medical judgment, or how it relates to caps on malpractice suits.
It seems as though you are making arguments that being a caretaker is emotionally devastating. This is something I have never disagreed with. I was the primary caretaker for my grandfather with Alzheimer’s and had to deal with the worry that he would set the house on fire, or electrocute himself by using a fork in the toaster. I had to clean him up and clean up after him. I had to try to help him through his agony when he couldn’t remember the name of his wife of 50 years (who had passed on years prior). I know what its like to suffer because a person that you love is suffering. And I know what its like to live life in the service of another person’s care.
But my arguments above aren’t about that. They’re about the most efficient and effective way of allocating scarce resources and providing care, which is another topic entirely.
Danny,
I had a different post written up last night, but for whatever reason after hitting the submit button and then returning to this site, it did not get posted. Whatever. This will be my last submission and visit to LeftFielder. I don’t see any point in wasting my time on reading the opinions expressed here.
I feel sorry for you. I truly do. It is clear to me that you are a very intelligent person. You are well read and well written. I can see why you and Mike were friends in college. At the same time is crystal clear that you don’t really have any real world experience.
I have a suggestion to you. My hope is that you listen to my advice with a humble heart and follow it. I know you will be a better person for it. For one year, take one afternoon per week, put down your books or skip a lecture being given on campus and block off a few hours. Use that time to do some community service where you work with people who are less fortunate than you. In your case, I would not recommend homeless shelters. I would recommend volunteering at a hospital or group home for the medically complex. Not nursing homes. But try to focus on young people like you and me. Talk to the residents and listen to their stories. Learn about their lives before and after their health deteriorated. I can guarantee you’ll be a better person for it. And I suspect you won’t have to write your annual Feb 14th rant again either. Women generally like guys who have empathy. You’ll also probably meet lots of young professional attractive women who will challenge you intellectually and spiritually who will be really impressed that you’re taking time out of your life to try to help those less fortunate. By spiritually I do not mean religiously, but rather on how you view your fell man and those less fortunate.
Andy
I was really surprised by Andy’s reaction to this conversation. The whole thing was confusing since I couldn’t see how anything I said could be taken as offensive, and because everything he was saying seemed totally irrelevant to the discussion. I re-read the posts several times, and thought about it a lot, and I think I’ve diagnosed the problem.
It comes down to a problematic analogy: “being allowed to file a malpractice suit is like winning the lottery”.
In retrospect, I believe he meant that to be about OUTCOMES. If you win a malpractice suit, is it like winning the lottery, where you’ll be wealthy and set for life?
I, on the other hand, interpretted the analogy to be about LIKELIHOOD. The odds of winning a malpractice suit are about the same as winning the lottery – and whether or not you win is totally due to luck, not the merits of the case.
From that point on, I spent the debate discussing probability, statistics, and odds. While he spent the debate talking about compassion for people who were ill, and why a monetary payout does not make everything ok in terms of outcome.
And he kept getting madder about what he perceived of as me reducing human suffering to numbers, and I kept getting more confused because I wasn’t talking about outcomes at all, but rather about likelihoods. The problem was that “lotteries” have different properties – being “like a lottery” could mean a lot of different things, and we each viewed the analogy in different ways.
Perhaps at some point Andy will decide to start reading Leftfielder again, and realize the entire dispute was a misunderstanding and communication breakdown. Perhaps not. But either way this is a useful lesson, when people seem to be talking past each other, it may be worth going back and looking over the assumptions more closely.
For what it’s worth, DocOpp, I think you did a good job, trying to keep up a level of civil discourse. Your arguments are reasoned and cautious, even when I don’t always agree. That said, sometimes it’s best not to have the discussion at all. When one’s debate partner is escalating towards vitriol, silence is probably the best medicine.
Regarding bioinformatic medicine, it’s plausible to have a decision tree with exit-clauses that fail back to a human expert when it diverges from areas where the model is successful. It’s probably true that these protocols can be developed such that they are better at providing care for people, than can doctors. However, creating these protocols is not trivial, and I doubt they can be well implemented across the spectrum of diseases. Heart disease, type2 diabetes, stroke – probably a computer program can be well crafted; Ehlers-Danlos Syndrome – probably not.
Andy– You clearly have a lot of experience dealing directly with doctors, with the frustrations and failures of our medical system. Your first few posting on this topic are really interesting, and reflect a perspective that I, personally, had not encountered (I’ve spent a little bit of time in healthcare but for the most part I’ve been healthy my whole life, same goes for my family). That said, I hope you have the decency to re-read what you wrote in later posting and appologize. Opp is a kind reader in chalking what you wrote above to a misunderstanding; the way I read what you wrote, it looks to me like you lost patience and your temper and then said some things that you wanted to hurt and and act superior.
I really like your comments in the beginning about malpractice. Doctors hate malpractice, but they hate it like an employee hates his boss — no one wants a boss looking over their shoulder but no one seriously thinks there should be no bosses in the world. Like you say, Andy, its not easy to bring a malpractice claim; some doctors screw up and act irresponsibly, like any other working people… the thing is, when a doctor screws up, its someone’s life at stake. A close friend of mine’s grandfather was a pioneer in developing medical malpractice litigation. He was a doctor who was pretty disgusted by what he saw his collegues doing. Being scared of malpractice leads to a lot of defensive medicine, but it also keeps MDs in line, makes them afraid to go out drinking and show up at work hung over, or rush through seeing someone because of a hot date that night, etc. Not that care is that great now, but when there’s no check on bad performance people perform badly.
I think Opp says something really thought provoking when he asks why does an injury or an accident that a doctor causes get compensated but one that a mugger causes leaves a person with nothing. I find a bit of a puzzle there, same consequence and both have a human cause in both (we can blame both people). Part of it is that the mugger usually doesn’t have money — if a recent lotto winner mugs someone we can go after their lotto assets.
About the entire chart / partial chart issue: I want to add some lawyerly perspective here. If I were advising a hospital about how to protect their doctors from litigation, I would tell them to look at only the information they needed for their niche as a regular practice. To defend the practice I would point out that looking at other information is distracting and leads to bad decisions (Opp’s point). Reading only part of the chart would limit the doctor’s liabilty later. They’re saying I’m only responsible for this chunk. Its classic, boss gets angry (i.e. threat of malpractice litigation) you respond (not my responsibility and point your finger). If I were a patient I would want the doctor to accept full responsibility for my care. I think really good doctors will do this (am I right?), but a good doctor should know what they need to know and don’t need to know.
APB– good point. Lets not forget that someone has to design a decision tree and the tree has to be used. Dealing with expert systems now is a huge pain — i.e. tech support on the phone, customer service people are protocol bound. These are not exactly the kind of procedures that make me jump and say, “hey, you know what would be a great idea: if my healthcare were like tech support on the phone!” Which of several competing decision trees to use is not going to be easy. A bigger issue is following protocol when its a pain. I know security protocols, reimbursement protocols, dealing with protocol beaurocracy is not something capable doctors are likely to enjoy. Also, sometimes the questions that go into a decision tree won’t be well written / easy for a patient to understand and answer precisely / or the patient will provide information relevant to a different point in the decision tree in answering an earlier question.
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