There is an information asymmetry problem in healthcare. Patients have been exploited because they have less knowledge than experts and must rely on them. Here, we will review the sources of bias that lead these experts, knowingly and unknowingly, to misinform patients, and discuss strategies to reduce bias.
The two main sources of bias are: financial and specialists.
Financial sources of bias
The Fee-for-service model is the most common way to reimburse healthcare practitioners. Whether it is a neurosurgeon or an acupuncturist. The model reimburses for each visit and each treatment - not whether the patient is brought back to health. As a result, it incentivizes quantity not quality. More diagnosis, more treatments, and more visits. Even treatment failures and side effects are opportunities for more testing, treatments, and visits.
For example, studies show that fee-for-service surgeons are more likely to perform surgery than salaried military surgeons. Surgeons that own a surgical center are more likely to perform surgery than those who do not.
Another way to drive treatments and office visits is to make more diagnosis. In fact, the sicker you can be made to look, the better. More tests lead to more diagnoses; more diagnoses lead to more treatments; and more treatments lead to more follow-up visits. This had lead to a problem called over-diagnosed - being diagnosed with a disease that will not bother you during the course of you life. Over-diagnosis is particularly prevalent in cancer screening. Cancer can be found at such an early stage that many of them will not likely progress: examples include: prostate cancer, breast cancer, thyroid cancer, kidney cancer, and melanoma. Over-diagnosis is also prevalent in Functional Medicine and Naturopathy where many diagnoses are based on unvalidated tests from private out-of-pocket laboratories.
To make things worse, the industries manufacturing the tests and treatments play an active role in enticing doctors to use their products. They include: laboratories, imaging centers, pharmaceutical companies, supplement companies, therapy centers, and device manufacturers. In a single year the pharmaceutical industry alone spent $60 billion marketing to doctors. This is not money wasted. Observational studies show that doctors are far more likely to prescribe a pharmaceutical company's drug after exposure to their marketing.
The specialist as a source of bias
Despite our veneration of specialists, they are particularly prone to bias. They are financially, philosophically, and personally bound to their specialty and its ideas. They tend to see all disease from the perspective of their specialty, and treat all disease with the tools of their specialty. As psychiatrist Abraham Maslow famously said in the 1950's,
"I suppose it is tempting, if the only tool you have is a hammer, to treat everything as if it were a nail".
This was in response to the overuse of the newly discovered antipsychotic drug, Thorazine. Psychiatrists were using it indiscriminately for almost every psychiatric condition.
A great example of specialty bias is the many approaches to back pain. There are several specialties that deal with back pain: Surgeons, Chiropractors, Acupuncturists, and Physical therapists. However, each one will diagnose and treat the same patient completely differently: the Spine Surgeon will see mechanical defects on MRI and fix it with surgery, the Chiropractor will find vertebral subluxations on exam and fix it with spinal adjustment, the Acupuncturist will detect blocked Chi and fix it by inserting needles into the problematic meridian, and the Physical Therapist will observe muscle imbalances and fix it by strengthening and stretching. Which one of the above treatments actually works for back pain?
Ironically, the worst person to ask, is one of the four specialists. Imagine if a new definitive study emerged disproving the Chiropractic theory. The last person to accept this new evidence would be the Chiropractor. After all, the Chiropractor's livelihood depends on spinal adjustments working. As American author Upton Sinclair once said,
"It is difficult to get a man to understand something when his salary depends upon his not understanding it."
Like all specialists, the Chiropractor is driven to defend his ideas. This is easily accomplished by creating an echo-chamber: surrounding oneself with other like-minded individuals. Other Chiropractors, Chiropractic specialty journals, and patients that love Chiropractors.
Designing a practice to reduce bias
Bias in healthcare is unavoidable. Specialists will love their specialty and industry is driven by profit, and both are responsible for the majority of the research. The key to empowering patients is to provide them with an accurate source of information to counter this bias. Your generalist (primary care doctor) is your best option. However, this depends on the design of their practice and their practice philosophy.
This is where the marriage of Concierge Medicine and Critical Thinking works so well. I have been able to not only design a practice with reduced bypass but to evaluate bias in other. The following is a list of features I have incorporated into my practice to reduce bias:
Review of specialists - Because specialists in medicine are so prone to bias it is essential to review their recommendations. The importance of this cannot be overstated. Specialists are entrusted to make the most critical medical decisions, whether you should undertake an experimental stem cell infusion or get chemotherapy.
Remain a generalist - Concierge doctor that specialize in Functional medicine, or Longevity medicine, or Integrative medicine, for example, lose their unbiased perspective. Your primary care doctor should always be learning, not specializing.
Fee structure that aligns with patient goals - I generate income solely from my annual concierge fee. There are no financial incentives for more tests, treatments, and visits. Instead, my financial incentives are in line with your goals - keep you healthy and happy. If you are satisfied with my performance you will renew with me the following year.
Deny other sources of income - My annual fee generates enough income so that I don't have to turn other sources of income. This includes: no sale of supplements, no cosmetic procedures, no links to laboratories or imaging centers, no links to device or pharmaceutical companies, no paid speaking engagements, no links to medical start-ups or hospitals, no stakes in books, no stakes in clinics.
Who should review specialists?
Primary care doctor are ideal to review specialists. They have a broad and comprehensive understanding of medicine, they see you as a whole person, and they understand your values and preferences. Unfortunately, there are several obstacles preventing primary care doctors from providing this service: lack of time, lack of incentive, bias, and lack of critical thinking skills:
Lack of time
Review of specialists takes time. It is very labor intensive. This is, by far, the rate limiting step for primary care doctors. They are overwhelmed as it is with patients and paperwork. Physician burnout rates over 50% in primary care. There is simply no time in the day to provide this crucial service.
Lack of incentive
Review of specialists is not a billable item. The current fee-for-service model does not reimburse for solving problems. It only reimburses for office visits, and procedures. In fact, it incentivizes the primary care doctor to punt your problems off to the specialist.
Bias
Reviewers of specialists must be objective and willing to change their beliefs based on evidence. Primary care doctors are mostly unbiased. For example, when evaluating treatments of back pain, my livelihood does not depend on Surgery, Spinal Adjustment, Acupuncture, or Physical Therapy. As a result, I have no issue dropping or accepting any or all of the four treatments. I have no skin in the game. My only concern is to get you better. However, some primary care doctors are biased, and some are actually specialists in disguise; such as, doctors that sell supplements, doctors that offer Acupuncture, or doctors that practice Homeopathy, Functional Medicine, or Anti-Aging Medicine. They are promoting a pet idea or treatment, which makes them specialists. They have skin in the game, and it is difficult for them to remain unbiased.
Beware of primary care doctors with bias, or primary care doctors that are specialists in disguise.
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