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More on Activist Medicine

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About the case I discussed earlier where a young woman received extensive services for eye inflammation, Ben England writes,

Activist care in an academic setting is a little different than activist care in general. To be trained as a physician in a high tech setting, one must learn to use the tools available. This includes working up a lot of low probability cases (most of which will yield negative results) in order to get a feel for the best utility of the test, understanding normals, and putting clinical findings in context.

...Instead of raging against the system, I think she should pause for a second and think very deeply about how incredibly lucky she was. She could have very easily lost her vision or worse, and much of the rest of the world would kill for all the resources at her disposal. To be honest, in a couple of generations, we may look back and be thinking the same thing.

For Discussion. Read England's entire piece and comment.

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COMMENTS (8 to date)
EyeDoc writes:

I'll second what Ben England said, and emphasize a few other points. One is that much of this is defensive medicine and malpractice reform would help reduce this. Thirty years ago we didn't have the treatments and technology we have now, but we also didn't need to be anywhere near as defensive as we do now either.

Second, all we have is this person's anecdotal report of what happened. I will tell you having practiced ophthalmology for about 15 years, what a patient thinks happened and thinks was said to them, and what really happened and was said to them can often be nothing close to each other.

And third, if you go to a teaching hospital you're going to see a lot of doctors in training and probably have more tests than you need.

She sounds like she is quite fortunate though, and rather ungrateful. Everybody today wants excellent medical care for free, and it just doesn't work that way.

spencer writes:

In the end England is still talking about rationing healthcare and talks about 3 solutions.
1. Insurance companies.
2. the government
3. the individual

Each will have its advantages and its disadvantages. Moreover, it does not get around the problem of uncertainty. Neither of the 3 alternatives will be fool proof and under each we will still have some people not getting the treatment they should and some treatment being wasted. I suspect having the individual paying for their own care would generate the greatest number of cases not getting the treatment they need and the insurance solution would generate the greatest ammount of wasted treatment. Of course this is just a biased guess.

Boonton writes:

Here is a simple solution I've advocated just about every time this topic comes up.

1. Establish a universal voucher for medical coverage.

2. Mandate that insurance companies accepting the voucher can charge what they want however their premiums have to be roughly equal for all customers with some variation. (In other words, they can't price sick people out of the market. The price of the voucher is having to accept everyone who wants insurance just like the price of getting IBM or Intel as a client is having to cover all their employees...sick and healthy).

3. People are free to purchase additional coverage with their own funds (or buy medical care directly if they wish) or cash their vouchers in against employer provided coverage. Insurance companies are free to offer any type of coverage they want whether it be catastrophic policies, HMO types or various hybreds.

4. The voucher will be paid for by a dedicated tax (such as a VAT or sales tax) and fixed by the revenue raised by that tax. In other words it will not be an open ended entitlement like Medicare.


A. Universal coverage
B. Lower health costs since everyone will be paid for in one way or another.
C. Market freedom since the private sector can offer any plan it wants and individuals can even choose to go outside of the system if they don't like the choices.
D. Budget neutral. If people want better coverage they have to vote for the tax increases to pay for it. If they want lower taxes they must vote to lower the voucher.

Ben England writes:

We don't need to shoulder the entire burden of health care spending on the individual. Health insurance came about because such a thing is unfeasable. We just need to have enough cost sharing to influence behaviour.

Human nature is trying to maximize our return while minimizing our investments. Think of our health care system as the buffet table, with each person in the restaurant trying to out-gorge the patron next to them. Someone's got to pay for the food after after going past the $10.95 mark. If it's not the diners, they're going to keep eating until the table's empty.

If you start charging per food item, you'll start seeing some disgression. People are more than willing to spend as much of someone else's money as possible for their own health. The problem is we are paying for it, but we rarely get to see the entire bill.

(Come to think of it, maybe we should start charging members of congress a small percentage of every spending bill they pass...)

In the face of uncontrolled spending, each of the three groups (state, insurance companies, and individuals) will enact measures to contain the problem. Two of them have their own interests in mind, not yours. I trust myself far more to determine what's needed and not needed than a politician or an insurance agent.

spencer writes:

If I were a high income medical doctor I would also trust myself to make better medical decisions about my treatment.

OK, we have taken care of maybe 1% of the population, but the rest of us are still left with the problem of making decision where our knowledge is probably inadequate and instutions whether market, government or whatever strongly constrain our ability to act..

Galen writes:

Perhaps I should let the car salesman pick out a car for me, since I'm not an expert in automobiles.

Spencer, I think you've missed the point. Some cases, activist care is necessary, but other times it's not. This is where to use your physician as a guide to determine if an expensive intervention is needed or just wasteful spending. Or (as many patients do) do some investigation yourself. Unless you have a direct stake in the amount spent, it is easy for our system to turn into an all activist-all the time model.

Neither the state, nor third party payers have decided to fund this model. This means that they're going to restrict things without giving you a voice in how it's done.

I would agree that this would mean that people would have to start paying a lot more attention to their health problems and the medical system in general. Our collective willingness to turn the decision making over to someone else thus far is making matters worse, not better.

Lawrance George Lux writes:

Consultant Specialists hold low esteem, and should be paid even less. During the process of my mother's dying, the Primary Care physican called in about 15 Specialists who spent less than ten minutes with my mother--nothing more than checking her Chart, with at most a Cursory Examination. I thought about impeding the payment of about $2000 they charged--as it was obvious add-on Rent-seeking--but knew I would only cause myself grief. lgl

a macauley writes:

The point that annoyed me most is the implication that it is fine for doctors to require others, particularly insurance companies, to pay for their training. The implication derives from the comment that an important part of the value of the process of activist medicine is the learning acquired by doctors during the use of the additional tests and procedures. First it is unclear to me either that this is an efficient approach or that useful learning occurs during the process. Given that much of it would occur without oversight from someone well versed in the technology there would be little immediate feedback to drive learning. Ultimately the point would be, although patients benefit from the doctors learning, it is the doctor that benefits most and should bear the majority of the cost of training not the insurance company or individual.

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