Monday, July 9, 2012

What is "necessary" in health care?

It must be a tough time to be an American astronaut.  

Since the US Space Shuttle program shut down a year ago, their opportunities for spaceflight are limited to hitching a ride with the Russians.  It must be incredibly frustrating.  Consider the years of training, childhood dreams, and self-sacrifice - all for naught.  That is, unless they can convince the American government that space travel is a necessity, and a worthy recipient of public funding.

I imagine that US astronauts must be passionate advocates for funding space flights.  After all, their careers - and self-images - are at stake.

I don't think the astronauts would behave any differently than any of us, should we suffer a similar change in fortune.  A recent on-line conversation has me thinking about how professional self-image (or perhaps self-interest) affects what we consider "necessary" in healthcare.  The discussion started with a post on Healthy Debate (see the comments), then Irfan Dhalla and Mark MacLeod stepped outside.   To Twitter.  The discussion was about fee-for-service and whether it leads to provision of "unnecessary" services.  Dr. MacLeod, an Ontario orthopedic surgeon and OMA past-president, offered this tweet

IrfanDhalla I open my practice completely to anyone who wants to come and tell me the services I provide that are not necessary. Anyone

It's a generous offer from Dr. MacLeod, but I'd rather explore whether or not I'm providing unnecessary service in my own practice.  I took a look at this 2 years ago in this post.  I reviewed 57 new consultations over a 2 week period and tried to judge whether or not they were "appropriate".  (To be fair, "appropriate" and "necessary" may be different classifications.  Read on.)  I judged that 8 (14%)  of the consultations weren't necessary, that is, the condition referred for wasn't serious, was for a false-positive test result, etc.

But, who should decide whether the consultation was necessary or not?  The various interested parties may have differing opinions.  I decided (according to a subjective review) that they weren't necessary.  The referring physician felt they were necessary (by definition, I think, otherwise he wouldn't have referred them...).  In most cases, the patient likely felt the referral was necessary but, for asymptomatic patients (in the case of the false-positive test result), the perception of necessity would have been influenced by the referring physician's appraisal.  How did our provincial health insurance payment agency feel about it?  I don't know, and I kind of hope they didn't read my blog post about it.

The point is that it is easy to make a case that any health service is "necessary", as long as someone wants it.  Patients may want the service to improve their health, relieve symptoms, or just give them reassurance that everything is normal.  Referring physicians may want the service because they have diagnosed a condition that is beyond their expertise to manage, or because they are uncertain of the diagnosis and/or treatment, or to satisfy a patient request to see a specialist.

That bring us to the consultants.  And the astronauts.

Both groups are highly-trained professionals who genuinely believe that their skills are necessary in society.  Naturally, either group would feel threatened if someone suggested that some of their services were not necessary.  Under those circumstances, a natural reaction is to be defensive and rationalize that one's services are, in fact, essential in society.

The debate will just deteriorate from there, with the main point of contention being the definition of "necessary service".

Perhaps we can avoid that divisive debate by rejecting the idea of necessity and instead considering value.  Let patients be the judges of how much value a given service if worth to them.  You might say that substituting "value" for "necessity" is just sophistry.  After all, if something is necessary, it will be considered valuable, and vice versa.  Well, let's go one level deeper to find out what patients are really seeking.

When a patient comes to see me with a kidney tumour, they may ask me to perform surgery to remove their kidney.  But, in truth, they don't want surgery.  After all, surgery is painful, stressful and carries significant risks.  What they really want is to have the kidney tumour treated and trust my advice that surgery is the best treatment.  They then reluctantly submit to surgery.

But, do they really want the kidney tumour treated?  Popular health culture dictates that cancers must be treated.  But, one of the vagaries of kidney tumours is that not all of them - even though they may be cancerous - require treatment.  For elderly patients with small tumours, the risk of surgery may vastly outweigh any benefit, and we often recommend observing the tumour.  This is because the patient's real goal is to preserve quality and quantity of life.  It's not always correct to assume that a kidney tumour will affect either parameter.  Yet, without a full discussion about the patient's desires (the patient is the expert here) and the medical facts (the doctor is the expert here), we can't truly know what course will be most valuable for patients (AKA shared decision-making).

In our practice redesign work, we've tried to think about what value we're providing for patients.  Back to that 2-year-old post.  Many men were being referred to us for "vasectomy reversal".  We found that the men would come for their consultation, listen to us explain the reversal procedure, then tell us they didn't want it done.   Some men were dissuaded by the fact that it is a non-insured procedure and they would have to pay for it.  Others were discouraged by the success rates.  Others were just interested to hear what the surgery involved.  In any case, many of them travelled up to 8 hours round-trip just for a 15-minute discussion.

The men, and their referring physicians, thought they "needed" a face-to-face urologic consultation.  But, when we dug deeper into it, we realized that the value was in the information, not in meeting the urologist.  We created an information pamphlet summarizing the vasectomy reversal information, and began sending men the pamphlet instead of booking a consultation.  We invited men to make an appointment for surgical consultation if they still wanted to go ahead after considering the information.  About 10% of men made those appointments.  They had their need addressed without having to travel.

I told you another (slightly discomfiting) story of poor patient value in this post.  An elderly man and his wife came to see me to get his CT scan results.  A medical student called me on the fact that they could have received the results in a different, more convenient fashion.  The system (my system!) had only provided them with one option - face-to-face with me.  It was a necessary service, but I could have given better value.

I suspect that most medical practices (perhaps even Dr. MacLeod's) would yield similar examples if subjected to scrutiny.  But such attention to other's work would be counterproductive as it would be perceived (correctly) as judgemental, and would lead to defensiveness.  I would rather encourage curiosity about how we can change our own practices to provide better value to our patients.  That also requires scrutiny, but we only need to open our practices completely to ourselves to achieve it.

American astronauts who see their mission solely to be to ride into space must be devastated.  But, those who see their mission to be to use their talent to serve society according to the public's need and desire, and are capable of adapting to fit changing circumstance... they will land on their feet.


  1. Hello Kishore,

    This is post worthy of much debate. But where to start!

    I'll pick a bone with your retrospective review of consults to determine "necessary". Unfortunately the false-positive requires a consultation unless you knew beforehand it was a false-positive. As an extreme example, if there is no other traffic around, was it still "necessary" to stop for the red light?

    Instead, you should review the referral requests and decide again whether or not the patient needed the consult (or surgery). Over the years has your prescribed course of treatment changed?

    As for value, that is a different kettle of fish. With changes in information, technology, expectations, etc. the relative value requires regular review. I know almost nothing about urology, but I suspect that advances in treating kidney stones over the last 20 years has substantially changed the role of the urologist. Brining this back to the astronauts, the question is no longer Is space flight possible (and requiring massive government support to bankroll the technological breathrough) but is space flight (proven to be successful) now a commercially viable activity?

  2. Hi Anon,

    Thanks for commenting. I freely admit that my retrospective review was based solely on subjective criteria. However, I did try to explain the rationale for my decision in each case.

    I hesitate to debate the technical points, but in the case of the false-positive test (elevated PSA after urinary infection), one could identify it ahead of time by understanding the clinical context (patient with urinary infection is a contraindication to measuring PSA). The test could have been repeated after the infection had cleared, thus reassuring the patient (and physician!) and eliminating the need for referral. This would require either education of the referring doc, or feedback to the referring doc from the urologist reviewing the referral letter, or perhaps a reflex testing system where potential false-positive tests (common with PSA) are "double-checked" by the primary care practitioner before specialist referral. Incidentally, we're about to trial such a system in our office with the intent of reducing this particular "unnecessary" referral.

    1. Thanks for the clarification - you've convinced me that there is a better course of action in dealing with this "false-positive".

      If I understand you correctly, the referral was "unnecessary" because the diagnostic test was inappropriately ordered to begin with. (As a child I use to try and skip school by heating the thermometer under the bedside lamp to show my mother I had a fever.)

      I'm interested to hear about the results of your trial.

  3. Once again you have tickled my thought spot! This is a complex twisty kind of topic. Just when you think you might finally have nailed it down, it runs in another direction. This blog is even more pertinent, with the health regions' lean towards LEAN (excuse the pun) which identifies that you must find what adds value to service and what is a defect. Thanks for the thought provoking topic.

  4. Hi Jenn,

    Thanks for the comment. Yes, the lean toward LEAN (in future, please leave puns to the professionals) will challenge us to identify value. Let's resist the temptation to create a circular definition of value (that is, value is what we already offer), and then end up providing the status quo more efficiently!

  5. Hi Kishore,
    Intriguing post. As others have noted it is a complex concept, with a number of dimensions. Since health care is mostly a matter of probabilities - very little is either 100% useful or 100% useless - "necessary" is bound to be an elastic concept. That said, we should distinguish between whether on balance, something ought to be done (a test, an intervention), and how it ought to be done. Communication may be necessary, but it may not require a urologist, or an in-person consultation. We have traditionally organized the system around the most inefficient service modalities: physicians don't get paid unless they see the patients, GPs who refer patients very quickly to specialists will generate more income for both themselves and for the specialists, ordering more tests is an effective way to cut short a consultation, etc.

    Even if/when we resolve these built-in perverse incentives, we still have a dilemma. We know, for instance, that seniors in Miami use 2.5 times as much health care as seniors in Minneapolis, with no difference in outcomes or satisfaction. That would seem to prove that there is a lot of unnecessary utilization in Miami. The Dartmouth researchers have even shown that utilization of services where the evidence is weak accounts for the excess. Yet it is quite possible that the residents of Miami are quite happy with their utilization patterns (they are, after all, as satisfied as their Minneapolis counterparts). In other words they are part of a high-use culture. This creates enormous costs for little tangible benefit, but no one has been willing to bell the cat.

    What this suggests to me is that we, the public/patients, are highly adaptable to whatever care patterns the system offers up. What we submit to is heavily influenced by how you providers frame the circumstances and choices. A GP who says (as mine did), "I really think you should have a PSA screening test" is going to engender higher utilization than one who says "I understand that many promote screening PSA tests, but the science is quite clear - there is no benefit from screening for men like you, who have no family history and are asymptomatic. I'd be happy to go over the science with you if you like." What this means is that variable definitions of necessity come from variable understandings of risks and benefits. If we want to narrow the range of what we understand by "necessity," we have to create more common ground among the suppliers and recipients of care. We will never agree entirely on how much risk is acceptable, how much the likelihood of false positives should influence whether we undergo a test (the mammography dilemma), etc. However, if there is a greater degree of standardization of how risks and benefits are explained and how choices are framed, my hunch is that there will be much less variation in practice among populations.

    And oh yes, we must also realize that all of this is influenced by money: how the system is funded, how people are paid, the relative reimbursement paid for different kinds of services, and how much capacity is out there looking for something to do.

  6. Brilliant! Great talk that was extremely insightful and very entertaining. It's given me loads to think about.