Maybe it’s because I’m not a physician, a nurse or any other type of health care provider. Maybe it’s because I’m merely a dull-witted heart attack survivor. Maybe it’s because I spent virtually all of my 35+ year professional career in the field of public relations. But the reality is that I seem to think about health care more like a marketer than the average person might, and as such, I’ve been puzzled for some time about recent quality of care debates on whether patients should be considered “consumers” or not.
In one debate camp, you have doctors like Dr. Atul Gawande, whose Big Med article in The New Yorker caused apoplectic sputtering among some of his colleagues when it was published last August. That’s because Dr. Gawande touted a national restaurant chain as a potential model of the kind of standardization and quality that have been so lacking in health care.
He argued, for example:
“The Cheesecake Factory delivers delicious meals that represent just the kind of affordable, reliable product that would better fit the budgets of cost-conscious health care providers – and meet the needs of their ‘customers’ – in the competitive new world of medicine.
The chain’s highly profitable and efficient model of quality control represents our best prospect for change in health care.”
In the other camp are the esteemed brainiacs over at The Harvard Business Review, who ran a column called The Trouble With Treating Patients as Consumers, which claimed:
“Treating patients as typical proactive, in control, well-informed consumers can backfire. Asked to take on increasingly complex decisions and digest ever-larger amounts of information, patients find themselves placed — often by design — in the driver’s seat.
“The ’empowered patient’ movement encourages patients to become hyper-informed and to take control over their care. But providing greater information, access and autonomy — so often successful in consumer settings — does not necessarily drive better care or experience.We see three main reasons why treating patients as consumers can create problems.
Patients don’t want to be there: People don’t seek out health care without a reason. Something is wrong and patients want to solve it and get back to normal. When patients are required to be proactive decision-makers, the health care system is often casting a very reluctant hero into the role.
Patients aren’t equipped to be there: Even when patients are willing to be decision makers, they may not have the tools. At a time of unusual stress, the system asks them to absorb technical information and make difficult decisions that require specialized expertise.
Patients aren’t in it alone: To design for patients alone is to forget that they are part of a complex system and aren’t often independent decision-makers. Decisions are shaped by other stakeholders: friends and family who support the patient, the insurance company who foots the bill, practitioners who provide care and expert advice, the hospital administrators who inform system-level protocol, and so on.”
These seem like sound arguments at first blush, especially if you’re arguing in favour of maintaining a status quo that is working well. But as Dr. Gawande describes his own health care system:
“Our costs are soaring, the service is typically mediocre, and the quality is unreliable. Every clinician has his or her own way of doing things, and the rates of failure and complication (not to mention the costs) for a given service routinely vary by a factor of two or three, even within the same hospital.”
Let’s take a look at that last statement: “... vary by a factor of two, or three, even within the same hospital.” Doctors call this “practice variation”.
But in my Ethical Nag essay called “Why Do Doctors Call It Practice Variation Instead of Poor Care?”, I questioned why, according to data published by Dartmouth Health Atlas researchers:
- – Medicare patients in Fort Myers, Florida, are more than twice as likely to receive hip replacement surgeries compared to their counterparts across the Everglades in Miami?
- – a person living in St. Cloud, Minnesota is twice as likely to undergo invasive back surgeryas a patient with a virtually identical diagnosis living in Rochester? (Rochester is home to Mayo Clinic, where surgeons are on salary and thus not motivated to do unnecessary surgical procedures)
- – Manhattan had the lowest rate of knee replacement surgeries (4.0 per 1,000) while Lincoln, Nebraska, had the highest rate (15.7 per 1,000)?
Add to these disparities. . .
- – the catastrophic losses caused by medical errors perpetrated on patients (the Institute of Medicine, for example, tells us that as many as 98,000 Americans die each year as a direct result of medical errors
- – the growing incidence of hospital-acquired infections in patients
- – the pervasive influence of the pharmaceutical industry on what’s now called “marketing-based medicine“ on patients
- – stent-happy cardiologists who are implanting unnecessary coronary stents while fraudulently altering the medical records of patients
- – the meek expectation that there’s nothing we can do about intolerable health care wait times or downright rude behaviour because we’re just patients
. . . and you have on your hands a crisis in consumer protection.
Here’s a real-life example. Hugo Campos is a California heart patient who does indeed think of himself as a medical consumer. He writes:
“Ever since I was twice misdiagnosed and mistreated for Hypertrophic Cardiomyopathy (HCM) – a potentially deadly form of cardiomyopathy, I’ve realized that being just a patient would lead me to my demise.
“Once I took matters into my own hands, educated myself about HCM and its management, fired the old doctors and picked out a new set of specialists, everything changed. Today, I am an empowered consumer of health care in the sense that I am the one in charge, not my doctor.
“That’s how a consumer is different than a patient. I learned the hard way that I should consult with my doctor as I do with my financial advisor. He gives me his expert opinion on my choices and the best course of action, and I decide what to do.
“After all, it’s my life and I am the one in charge.”
And here’s another real-life example: Toyota was forced to recall 8 million vehicles worldwide after news that at least 34 deaths had been linked to Toyota problems going back as far as 2004.
But compare those 34 deaths with the FDA’s estimates that the diabetes drug Avandia is linked to as many as 100,000 heart attacks and/or deaths in the patients with Type 2 diabetes who took the drug. Clinical studies have revealed that this drug increases the risk of heart attack by 43 percent, and can double the risk of heart failure after only one year of treatment. In fact, the Avandia death rate has been described by an Institute for Safe Medication Practices report as “more than any other drug we monitor.”
And as John Mack, editor of Pharma Marketing News, observed:
“If people are afraid to buy Toyotas, then based on average yearly death rates, they should be about 400 times more afraid to take Avandia.”
Yet, astonishingly, Avandia is still being sold and prescribed by physicians to their patients.
I just cannot help but wonder: if doctors started thinking of these patients as consumers, would they be more careful to avoid the very public wrath of a wronged marketplace?
So, let’s review: Toyota (because it knows full well that the people they make products for are consumers) has to recall millions of potentially dangerous vehicles to protect consumer safety. But GlaxoSmithKline (because they’re a powerful drug company that calls the people they make products for patients) makes a potentially dangerous drug – and the worst that happens is that the FDA forces them to put a “black box” warning on the drug packaging.
Oh, that – plus maybe the fact that they’ve been slapped with a $3 billion charge to settle U.S. criminal and civil probes into illegal marketing of Avandia and other GSK medications.
And that is why The Harvard Business Review has it wrong.
In fact, much of their article sounds downright patronizing (like the part about patients being somehow unable to manage shared decision-making because – Golly! It’s just so darned hard!)
I like what physician Dr. Joe Ketcherside has to say to his worried colleagues feeling reluctant to reconsider patients as consumers, actually able to make hard decisions about their own health:
“Normal people gather information on all kinds of topics and evaluate its content and reliability all the time.
“We have to decide what car to buy, how to refinish the floor, what type of mortgage to use on a home purchase, where to vacation.
“We often also have a job that has professional responsibilities and must maintain our knowledge of our specialty. We sometimes have actually gone to college and even graduate school where we learn all about doing research.
“So – sorry to the other physicians who disagree – but a great many of your patients are perfectly capable of researching their illness and in short order, knowing more about it than you do.”
In conclusion, we patients continue to reject the label of consumer at our peril.
Q: Should more patients take on a “consumer” role?
NOTE FROM CAROLYN: I wrote more about the complicated reality of becoming a “patient” in my book A Woman’s Guide to Living with Heart Disease (Johns Hopkins University Press, 2017). You can ask for this book at your local bookshop, or order it online (paperback, hardcover or e-book) at Amazon, or order it directly from Johns Hopkins University Press (use their code HTWN to save 20% off the list price when you order).
- Say what? Do patients really hear what doctors tell them?
- Your health care decisions: don’t worry your pretty little head over them
- The lost art of common courtesy in medicine
- Experts: why so wrong so often?
- How a heart attack turned me into an “information flâneuse”
- When you fear being labelled a “difficult” patient
- Would it kill you to treat your patients with respect?
- My lowly beginnings as an empowered patient
- Stupid things that doctors say to heart patients