I am a huge fan of Dan Ariely.  A behavioral economist from Duke, his sense of humor and intellectual curiosity make him immediately appealing (watch a video and see).

The rules for the Physician Payments Sunshine Act dropped:

Drug, device and medical supply companies must report all payments over $10 to U.S. physicians and teaching hospitals. The data must include date of payment, a description of the service provided, the amount paid and which of a company’s products the payment involved.

We all know pearls in medicine.  Some withstand the test of time—presumably due to evidence, others not so much.

Read the following contrasting set of paired statements:

• Our thinking is different, and as a result, the company is making a change—and we need to introduce someone in your position who synergizes with corporate goals.
• I am unhappy with your performance and I am not renewing your contract when it expires.

AND

• This relationship is not working out.  I just don’t know what it is—you are so great and all.  This is all me, you are too good, and I do not deserve you.
• I am unhappy in this relationship and I cannot continue dating you.

You can call the above passive or active communication, but at its essence is the reticence of an individual to deliver difficult news.  The top statements are ambiguous and deflect their piercing intent.  Conversely, those below them bare the soul of the speaker—directly and with clarity.  There is a sting just reading them, and the propensity to avoid the conflict that ensues when we use such directness compels us to obscure our thoughts. Those sentiments entered my mind when I read the following:

[…] A fairly common thing I hear doctors say in the first meeting with the family is, “She is really sick, but we have her on the ventilator and we are doing everything we can, and we’ll see how things go.”

[…]  ”Although she is on a ventilator and doing OK right now, I’m concerned because there is a real chance that she won’t survive this. I am hopeful that we will get her through this, but I wanted to share with you the possibility that this may not go well.”

We all must speak these words at some point, and if you are like most physicians, your utterance resembles the first and not the latter statement. Why?

I raise this point because docs and the lay community conger that the confrontation of burdensome and futile care and all its ills are paramount to moving our health system forward.  Yet, we are not solving the problem. The fault line is blurry, and reasons for this veer towards physicians and their reluctance to engage in “tough” conversation (lack of time, remuneration, enlightenment or training), and patients who speak as if they want the truth, but have not prepared for the reality of that truth and its implications.

The stakes are greater in life and death as compared to business dealings and relationships, but the parallel is opaque communication—making statements that have multiple meanings.  The individual’s DNA code will govern the interpretation.

However, the businessperson and the spouse know what their words signify, but cannot convey the message properly.  Conversely, physicians speak the right words, but they do not comprehend, knowingly at least, why their message lacks clarity.

Let me explain.  Estimating the chances of a critically ill individual’s recovery is often difficult and unknowable, and physicians’ ability to prognosticate these cases will vary.  Moreover, the actions a physician takes, and the message they convey to families will differ based on similar approximations.

I might estimate a patient’s chance of survival at 10%, but because of my, a) uncertainty with that figure, and b) discomfort with delivering anything but fully proscribed care at the “10%” level, will behave in a manner unlike my colleague.  Conversely, my colleague may have greater confidence in their calculation, 10% in this case, and will practice differently due to their inherent tolerance for risk.

Beyond the tail ends of the survival curve, our current tools lack precision at foretelling outcomes in acutely ill folks.  When interobserver agreement varies by more than 5%, and I am certain that is a reasonable guess in this case, achieving uniform practice is impossible.

Therefore, when a doctor communicates to a family, “we are doing everything we can, and we’ll see how things go,” do not assume the subtext of the communique is, “I don’t want to have a sophisticated, complex conversation because it’s too time consuming, complex, or poorly reimbursed.”  Rather, the reasoning may resemble this:

–If your loved one had a 5% chance of survival, I would recommend x.

–If you loved one had a 10% chance of survival, I would recommend y.

–If you loved one had a 20% chance of survival, I would recommend z.

–However, I do not know the right figure, so z is the correct path.

Currently, payers may assume physicians have cracked this code.  We have not, and regions within the U.S. that have achieved success in this domain have done so because they comprehend this imprecision and have distributed these silos of uncertainty equally, amongst all parties.

However, this is not the norm and physicians will continue to use opaque language, like that above.  We will bristle at prognosticating with direct, clear data.  And the system will continue to subsume us with expectations far greater than we can fare.  Thus, our internal conflict will persist, with or without self-awareness, and the path to greater clarity will remain blocked.

I also posit, if “having the conversation” was intuitive or close to decipherable, it would have made the ASCO first cut.  It did not, and will not for the near term, for the reasons stated.  Its absence at this juncture of reform speaks volumes and conveys the difficulties ahead.

Without government, hospital administration, or payers explicitly stating, “if a, then b,” we will continue to navigate these waters mostly alone, not because we want to, but because we are stuck.  We cannot quantify what we can only qualify.

Until we break this logjam of estimation and communication, the right words, and possibly intent, will elude us.

I particularly enjoyed this article from the WSJ last weekend.  It is a piece you finish and satisfactorily conclude your time was not wasted.  You have gained a new perspective in reexamining a deed, in this case lying, that we all engage in periodically—that we rationalize, trivialize, or justify—for unwelcome reasons we sidestep to achieve our selfish ends.  This opening paragraph got me hooked:

The press gave the Choosing Wisely initiative, unveiled several weeks ago, a great deal of attention.  Briefly, the ABIM foundation collaborated with Consumer Reports to produce Top 5 lists from nine specialty societies to identify “five tests or procedures commonly used in their field, whose necessity should be questioned and discussed.”  It is a first step to engage patients and physicians in the shapeless “national conversation” on (sensibly) rationing that everyone speaks of, but never hears.  I write about it now, not just because this process is inevitable—which it is, but because the Society of Hospital Medicine is amongst the next group of eight to offer up recommendations.

Here is a twist of irony.

Physicians, and rightfully so, are called hypocrites, when on one hand they decry the payment system for inadequate reimbursements (and threaten patient access), while on the other, abhor  solutions to remedy the same problem.  Adoption of midlevels (NP’s and PA’s), which obviously are less costly, but also crowd out physicians and encroach on sacred turf is a prime example:

There was an exceptionally well-written piece published in the Washington Post this weekend.  I presume a hospitalist wrote it, which magnifies its significance.  In it, he describes the difficulties in caring for terminally ill patients.

How often do we hear declarative statements rooted in dogma, propagated over decades?  Countless times, physicians providing continuity care for chronically ill patients “assume” that by the very nature of that continuity, they outperform doctors not in that station, especially as it relates to intimate tasks.  “Hospitalists are ill equipped to obtain advanced directives; they don’t know the patient like I do,” or something to that effect.

Would you like to read about some good policy, but bad execution?  Browse on.

On the physician side of the ledger, we trust that observation units, i.e., geographic weigh stations to determine fitness of admission or discharge, are a good thing.  Earlier discharge, focused resource use, possibly less exposure to hospital badness—all winning strategies to improve efficiency.  What is the problem then?  From todays WSJ: