Risk and risk-tolerance

And its dramatic impact on the costs of healthcare.  

Make no mistake, risk plays an important role in the cost of health care and it does so in at least two related ways. At some point during the recent debate about how America will deal with healthcare most people have heard that medical malpractice plays a role in the costs of care. Of course, the process of litigation (attorneys, expert witnesses, etc.) all cost something but the more significant costs are those attributed to the practice of so-called “defensive medicine”. That is just another way of saying, “Mrs. Smith, in my clinical opinion this test is unnecessary because there is a minuscule chance that you actually have the problem that it is intended to detect. Nonetheless, should you prove to be unlucky enough to have this disease, I am afraid that you will sue me and that I might lose that lawsuit if I did not do everything possible.”

So, if we arrived at a national solution to the medical malpractice problem would that end the practice of defensive medicine? While I do believe that a rational solution to the medical malpractice situation; one that fairly compensates patients who have been injured, protects physicians and hospitals who are practicing good care, and identifies and weeds out those who are not; is necessary before we can make any real progress toward reform, in my opinion, malpractice reform alone will not end defensive medicine. Why? Because changing the malpractice environment does not address the second problem: human nature.

Most of us have a friend or relative who just loves to gamble. One of my relatives will board a small plane in the early morning hours, fly to Atlantic City, gamble all day and into the evening, and arrive home late at night, all for the “fun” of losing their hard-earned money in the casinos. Or perhaps you know someone who has a very dangerous hobby like free climbing. These people, each in their own way, are risk takers. On the other hand, we all know people who find gardening or reading a good book stimulating enough. Of course, the people I have described exist on opposite ends of a risk tolerance spectrum.  Physicians are no different. Some are very comfortable with risk, some less so, and some are completely unnerved by the thought that anything might be left to chance. And, when it comes to healthcare, the people they treat are also no different. One patient might demand that every rock be overturned in search of a diagnosis while another might be comfortable after a single office visit. The doctor who is too comfortable with risk might not do enough and the one who is risk-intolerant might do too much. Both can harm the patient; the former by failing to make a timely diagnosis and the latter by exposing his/her patient to complications associated with unnecessary testing (for example, every CT scan very slightly increases the patient’s lifetime risk of cancer). And, both can contribute to escalating healthcare costs. Failure to make an early diagnosis can mean treatment at a later stage of illness, which is almost always more expensive. But, doing too much consumes resources without adding benefit. Making a more rational tort system will not solve this problem. To make matters worse, the basic construct of a person’s personality is difficult (some would say impossible) to change. It is unrealistic to expect the gardener to suddenly take up hang-gliding and it is just as unrealistic to expect the risk-averse physician to become risk-tolerant.

While we may not be able to alter the doctor’s world view, we should not abandon all hope of making changes. Human beings are social creatures and decades of social science research demonstrates the powerful influence of social factors on behavior. It might be impossible for me to make you comfortable with more or less risk but I can do things to alter your behavior. One example is a treatment protocol or clinical guideline. Well constructed guidelines can increase compliance with recommended treatment and testing regimens by adding the imprimatur of authority (e.g. The Society for Left Big Toe Care guidelines) and, to some extent, by removing some of the physician’s personal motivation and replacing it with the guideline. Following the guideline should help to insure that practitioners order the appropriate tests and perform the correct procedures, reducing what the operations engineers call “unexpected variation”.

Unfortunately, too little is known about some conditions to allow for the creation of an effective guideline. Furthermore, every guideline has to allow for judgment in its implementation. Physicians must still have the ability to make the cognitive leaps necessary to make difficult diagnoses and to find creative solutions to problems. So, guidelines cannot and will not solve everything but they can help us do a better job in managing some common and expensive conditions.

But, then, there is the problem of those risk-tolerant physicians who get a thrill ignoring guidelines…