Mistreated: Why We Think We’re Getting Good Health Care—and Why We’re Usually Wrong

It’s no secret that the American healthcare system is broken. While there have been great advances in healthcare that saves lives and improves the quality of lives for so many people, it is still broken. The problem is that we can’t take a step back and fix it because it’s still saving lives every day. Mistreated: Why We Think We’re Getting Good Health Care—and Why We’re Usually Wrong walks through the details of our healthcare system from blind spots and misperception to motivations that are out of alignment with what’s best for the public.

Confronting the Truth

It’s a convenient belief that we have the best healthcare system in the world. It’s convenient, because it fits the facts that we have the most expensive healthcare system in the world. More expensive means better, right? It’s convenient to believe we have the best healthcare system in the world, because we send our loved ones to get healed here, and we want the best for them. We ourselves get our care here, and why wouldn’t we want the best?

The problem is, while it’s convenient to think we have the best healthcare system in the world, that’s far from true. We have “the highest infant mortality rate, the lowest life expectancy, and most preventable deaths per capita” of the modern world. While we spend the most on healthcare, our results are far from the top of the pack. Instead, our system invites waste, greed, and poor outcomes, all the while believing the care we receive is good. At some level, we know that this is lunacy, but it’s a convenient thought that keeps us from confronting the truth. Seventy-six percent of people describe the quality of their care as good or excellent. This statistically can’t be true.

Affordable Care Act

The Affordable Care Act (ACA) is the most sweeping set of healthcare reform that has been done in decades. While focused on making it easier for every American to have access to healthcare, it was able to address some other issues as well. No longer would people be denied insurance because of a preexisting condition. Preventative care was made nearly or completely without cost to the consumer.

While this was important legislation, it didn’t strike at the heart of the structural problems healthcare faces. We pay for services instead of paying for health. We’ve not been able – yet – to transform the relationship to one where the consumer only pays for results. This change can make all the difference.

Unnecessary Surgery

If pain is the symptom, surgery rarely has better outcomes than alternative treatments. Yet we perform surgery to repair a torn meniscus and place stents in people’s arteries at great cost with little or no actual health benefit. The results are in – and they say we shouldn’t do them. Like dozens of other treatments that are ineffective, we still do them because it’s standard practice or because they’re marketed aggressively.

Opioids

There’s a bit of news now about how opioid manufacturers, particularly Purdue Pharmaceuticals, engaged in aggressive marketing of Oxycontin, which had a high potential for abuse but which the company routinely led physicians to believe was safe. Dreamland covers this aspect of our healthcare woes in detail. The short version is that we began treating pain as a vital sign, and physicians began getting more directly measured by their intentionality about treating pain. In most cases, this meant prescribing them a pill.

Pharmaceutical companies learned that, when marketed to them directly, consumers would ask their doctors for the medication. Often, they’d get what they ask for. Doctors are reluctant to deny their patients the medications they’re asking for – even when it’s not effective. Consider the over-prescription of antibiotics. A patient doesn’t feel well, and they make the decision to go to the doctor. They expect the physician will do something to make them better. They expect they’ll get a pill that will make them better. The physician, tired of explaining that an antibiotic won’t help, prescribes it anyway, knowing it won’t make them better. In the next week, the patient feels better and attributes their wellness to the drug – instead of to the virus running its course.

We see this desire of the public to just get a pill and fix it show up in every aspect of healthcare, including mental health, where it’s easier to take an anti-depressant than to deal with the underlying problem. (See Warning: Psychiatry Can Be Hazardous to Your Mental Health for more.)

Generalists and Specialists

The frequency with which you deal with a problem makes a big difference in your outcomes. The truth of the matter is that in medicine – like many other disciplines – you can’t get good at something if you’re never given enough time to practice and learn. Intuitively, it makes sense. If you do one gall bladder surgery a month, you’re not going to be as skilled at it as someone who does 100 a month. However, in most cases, the market doesn’t allow physicians to become hyper-specialized into a single kind of surgical procedure. Even our specialists cover a wide range of procedures and patient problems – too wide to drive the kind of volume in the procedure that would make them truly good at their craft.

What tends to happen is that a generalist treats a few patients a month and gets, at best, middling results from them. Even the specialist can’t afford to be hyper-specialized, because all the generalists are taking the cases they need to stay fully busy and get very good at what they do.

That’s not to say that generalists, like your primary care physician, are bad or not needed. It is believed (based on successes in other nations) that the best solution to the healthcare performance problem in America is to get primary care physicians better at preventative medicine – true health care – instead of trying to triage and route patients who are truly sick.

There’s a very old saying that “a stitch in time saves nine.” Meaning if we catch things early – like before they start – it takes very little to maintain or repair the situation. The later we catch a problem, the more challenging the recovery becomes – but that’s what we reward in our current system. Specialists (such as they are) are paid roughly three times what primary care physicians are paid. We undervalue the preventative measures that can have the greatest impact, and we elevate the heroic, last-minute attempts to help someone survive.

Undervalued

There’s a real soft spot in my heart for the understanding that we undervalue simple interventions that save lives and instead invest our money into technological marvels that have little or no real impact on outcomes. Another big marketing tool that healthcare systems are using is robotic surgery. Again, it makes sense. Doctors’ hands can be shaky, but robotic hands are not. However, the efficacy for robotic surgery isn’t any better than regular surgery – oh, and it takes longer. However, organizations are spending millions of dollars on these robotic surgery devices, which sit idle most of the time. Physicians want to have them but don’t see any need to make their jobs harder without better outcomes.

The soft spot for me comes because of our IV dressing patent. It’s simple. It’s straightforward. And we’re still trying to get the market to accept a change that may impact materials cost by $1 and may substantially reduce healthcare-associated infections (HAIs). It’s not sexy, but it seems to work. That may be why it’s not being used. Because, in the upside-down system of American healthcare, if it doesn’t seem like it’s cool, then it’s not worth doing.

Dr. Pearl shares his appreciation for information technologies and the ability for these simple technologies to improve outcomes.

Diabetes Advantage Program

It seems like a lifetime ago to me now. The study was being done in 1999, and the journal article was about the program titled “A Systematic Approach to Risk Stratification and Intervention Within a Managed Care Environment Improves Diabetes Outcomes and Patient Satisfaction” in Diabetes Care (Volume 24, Number 6, June 2001). The short version is we took patients with diabetes who were being treated by primary care providers, and we gave the primary care providers suggestions for the actions they should take to help their patient better manage the disease. We basically made it easy for the physicians to do the right thing.

The recommendations would print out to add another oral medication, the nurse would write a more specific recommendation in based on the physician and the specific drugs the patient was on, and the physician would sign the orders. The physicians quickly learned to trust the system (and the nurse). They realized the system was giving their patients the benefits of the best research on the disease without them having to study it.

The net result was about a 1-point drop in HbA1c values in 12 months. To put that in perspective, back then, the threshold for having diabetes was 6, and the threshold for uncontrolled diabetes was 8. (These values have been adjusted a bit in more recent standards.) So, a 1-point drop in HbA1c values was a substantial change. Most of that change is attributable to the system “reminding” physicians to do what the research suggested was best.

In short, helping caregivers with information technology works – and we’ve known it works for decades now.

Environment of Care

We tend to overestimate our rational rider and underestimate how much of what we do is shaped by the environments that we are in. Kurt Lewin proposed that human behavior is a function of both person and environment. You can’t predict what a person will do without understanding both. More recently, we’ve seen how people can be made to do awful things to other people with relatively little encouragement. The Nazi extermination of Jews was unfathomable. However, as both Albert Bandura (in Moral Disengagement) and Philip Zimbardo (in The Lucifer Effect) explain, it’s relatively easy to disengage our morality and cause people to behave in ways that don’t make rational sense. They both point to the work of Stanley Milgram after World War II, in which subjects were thought to be giving progressively higher voltage shocks to another subject in the next room. Most continued to give shocks that they perceived to be potentially fatal with little more enticement than knowing it was for the experiment.

It’s surprising how little factors can cause us to take different behaviors. Nudge uses numerous examples of how changing the easy or default answer changes the way people eat and save. When you look at the body of literature around change, you’ll find that, much of the time, making change work is about a few well-placed interventions. (See Switch, Redirect, Change or Die, Change Anything, Made to Stick for examples.)

These same factors hold true whether we’re talking about something truly evil or we’re simply talking about practices that aren’t effective. Once the group establishes a social norm, it’s hard for new people to adjust the norm, even when the new target has better demonstrated outcomes. In short, the team becomes fixed in their perspective and don’t accept the valuable input from the outside. (See Diffusion of Innovations and Hackman’s Collaborative Intelligence for more on the receptiveness of a group or team to outside influence.)

Sometimes, the best examples of what to do are sitting right under our noses. The Washington Post Magazine arranged for internationally-acclaimed virtuoso Joshua Bell to play his violin at a subway stop for spare change. The man who played for presidents and sold out concert halls earned a little more than $32 in his time at the subway station. The expectation that he was simply a street player led nearly everyone to treat him as one. The environment we’re in really does dictate how people respond to us.

Healthcare Is a Team Sport

In America, we’re enamored with the idea of a lone hero charging across the western plains to conquer a new land. The wagon trains of families banding together to face the hostile wilderness just doesn’t sell as well. We want to believe the surgeon has better outcomes while ignoring the impact of the hospital, the nurses, and even the janitors. In healthcare, janitors are called environmental services (EVS) workers. The painful fact is that most EVS workers clean somewhere between 30-50% of the things they’re supposed to clean between patients.

There’s a growing body of research that shows pathogens are being passed from one patient to the next because of improper or incomplete cleaning. Moving the needle from 50% to 80% of the objects cleaned can have a reduction in HAIs of about 20%. To put that in perspective, that’s more than one infection saved per EVS worker per year.

Nursing, too, has been shown to have a critical role in the outcomes for the patient. “Better” nursing care is associated with better outcomes. Subtle things like the degree of burnout nurses experience has an impact on the patient outcomes.

Everywhere we look, there is evidence that it’s more than the gifted surgeon that makes the difference in the outcomes. Now more than ever, healthcare is a team sport – and one that is sure to continue. The silent member of the team – but the one that is always present – is the patient.

Patient Non-compliance

One frustrating aspect of healthcare is that frequently the patient is non-compliant with the protocols they’ve been given by the healthcare staff. Whether that’s failing to take medications or it’s not doing the prescribed exercises, getting the patient to behave in their best interests is often a frustratingly difficult challenge. To be fair, most of the challenges here are ones that educational folks have learned to address but healthcare hasn’t picked up on.

Healthcare workers aren’t careful about educating patients and asking questions for which the correct answer is no. By default, humans will answer yes if we don’t understand. So, asking questions that have no as answers can help ensure the patient understands. (See Incognito, Predictably Irrational, and The Hidden Brain for more.) For instance, instead of asking “Do you understand that you should take this with a meal?” you might ask “So, do you believe you should you take this on an empty stomach?” Healthcare workers suffer from the curse of knowledge, which means they fail to explain in a way that patients can understand. (See The Art of Explanation for more.)

What’s more, healthcare workers haven’t been taught to give patients productivity aids to help make them more successful. (See Job Aids and Performance Support for more.) The handouts they give patients are largely unintelligible even by healthcare workers, and they aren’t inviting to someone who’s unfamiliar with healthcare and what’s happening to them. Beyond the paper they’re given, they’re rarely pointed towards tools that can help them be more compliant – like an application for their smart phone that will remind them when it’s time to take medications.

If we’re going to make healthcare better, we’ve got a long way to go. We’ve got to address the motivators that cause people to take advantage of others. We’ve got to move towards higher specialization and more preventative medicine. And we need to get everyone on the team – including the patient – so we can prevent more people from being Mistreated.