There is an important study in the Archives for Internal Medicine last month, which escalates an ongoing row as to whether patient satisfaction is in any way correlated with positive medical outcomes. The answer is yes, and the correlation is negative.
This finding is of critical importance, not just in understanding why American medicine is a hopeless, costly mess, but also as a window into how easy it is for buyers of complex services to be hoodwinked by their servicer provider, whether via the provider being incorrectly confident about his ability to do a good job or having nefarious intent.
Let’s deal with health care case first. The study in question was large scale, of 52,000 patients from 2000 to 2007. This summary comes from the Emergency Physicians blog (hat tip Julie W):
Results of the study showed that patients who had the highest satisfaction ratings spent 9% more on health care and prescription medications than did patients who had the lowest satisfaction ratings. In addition, the most satisfied patients had a 26% greater risk of death compared to least satisfied patients. When patients in poor health were excluded, the risk of death for these highly-satisfied “healthy” patients increased to 44% more than their least-satisfied counterparts.
In commentary accompanying the article, Dr. Brenda Sirovich suggested that discretionary testing is likely the cause of both the increased costs and the increased mortality in highly satisfied patients. Patient perceptions, even if medically inappropriate, drive testing and treatment. Antibiotics are harmful in patients with viral infections, yet a substantial subset of patients are not satisfied without an antibiotic prescription for their colds. Large studies show no link between PSA screening and either overall survival or prostate cancer survival. However, any patient whose life has been “saved” by a PSA screen is often quite satisfied. In both scenarios, there is no perceived negative effect from treatment. Patients will recover from their colds with or without antibiotics. Patients likely would not have died from their prostate cancer even if it was left untreated.
And consider: drug research shows a fairly significant placebo effect. So one would assume that satisfied patients would show positive results merely from placebo effect. The fact that the overall results are decidedly negative doesn’t merely say that more treatment and more testing are ineffective, it suggests they actually do harm.
The article uses the PSA test as an example of ineffective screening. I’m pretty healthy, yet I’ve seen this bias to overtest and overtreat first hand, and I can’t imagine what people who are less than robust must go through.
Readers have seen me rant upon occasion in comments about mammograms. They are a terrible test. They are bad at capturing the dangerous-fast moving cancers and produce a lot of false positives (benign slow moving growths which won’t kill you even if you live to be 100) which lead to unnecessary procedures. Oh, and no one factors in the risk of annual exposure of soft tissue to radiation. Manual breast exams by an experienced examiner are far better at detecting the dangerous growths, and thermal imagining is also more accurate than mammograms and does not involve radiation. But radiologists have an installed base of equipment and will hector you if you refuse to get a mammogram.
Similarly, there are only a few knee operations (surgeries for a torn medial meniscus and torn ACLs) that have a high efficacy rate. Yet with my long-standing knee problem (which is my case is due to foot and ankle instability but the overwhelming majority of orthopedists won’t even look at my gait), the standard answer from an orthopedist is, in the absence of ANYTHING sus on an MRI: “Let me go in and have a look and I’ll clean it up.” I’m not about to let a doctor go on a fishing expedition in my knee, yet that seems to be considered acceptable.
The inherent problem of medicine American-style was set forth longer form in the Maggie Mahar book, Money Driven Medicine which shows why the market has failed. One big culprit is information asymmetry. One of the conditions for a market to function well is that buyers and sellers have perfect information. In the medical arena, there is often a lack of good data as to what constitutes optimal practice. Among the many examples are the backing and forthing on hormone replacement therapy and the above mentioned mammograms. Now condiser: these treatments have been the subject of multiple large scale studies. Most protocols haven’t been investigated this intensely. And even when there is good information, the patient is at the mercy of his medical providers, the drug companies, and device makers. He can’t challenge their views; his best hope is to shop for a better practitioner, which is a costly, time consuming, and deeply flawed process (how can he judge whether a doctor is making sound recommendations?).
The other major element of market failure is the considerable disparity in buyer and seller power. If you are very sick, you will do anything to get better, which includes spending a lot of money. And our can-do, technology-loving culture favors doing more, whether beneficial or not.
We’ve seen how resistant patients are to evidence-driven medicine, particularly when the finding is less is more. Women seemed distressed to be told that mammograms were being overadministered (the old recommendation had been to get them annually starting at age 40, the new recommendations are ex a family history of cancer, to start getting them at 50 and have them done every other year through age 74). And patient confusion was not helped by self-serving radiologists taking issue with the study conclusions. And we have drug companies expertly playing on patients’ “more must be more” bias: advertising aggressively for new drugs, when they are typically much more expensive than older ones, often with little or no improvement in efficacy. Doctors seem remarkably disinclined to argue with patients who want a particular drug (indeed, I’ve seen how trigger happy doctors are to hand out pills. Say you are tired and in NYC that’s treated as code not for a vitamin B-12 shot, but either Adderall or anti-depressants).
The bigger issue is that in many fields, customers have no real ability to judge service quality. Like the satisfied patients, they too often rely on proxies, like bedside manner or being with the “right” firm, when big firms have first and second strings, and if you aren’t an actual or prospective big ticket you are usually better served finding a good partner at a smaller shop. I’ve been more exposed to top lawyers and litigation by virtue of working on complicated deals, having some clients get involved in lawsuits, and often talking shop with some savvy lawyer friends. As a result, I’ve mainly have very good experiences the few times I have had to hire a lawyer, but even I had one stuff up. And I’ve seen too many times in client situations where they appeared not to understand that their counsel was not up to snuff for the task at hand, but it would have been close to impossible to get them displaced.
I’ve similarly seen friends make bad decisions because they trusted their advisor when they shouldn’t have. I remember a long argument with a savvy investor friend who liked and trusted her broker at Citigroup, and took his advice to buy Citigroup at $45. She wouldn’t listen to contrary information, in fact, she was convinced he had some special insight by virtue of being at the bank (as opposed to he might be getting bonus credits). We know how well that trade worked out.
And that’s one reason I’m more sympathetic with duped investors than other readers probably are. Hindsight is always 20/20. The mortgage securities market had seemed to work well for nearly two decades. Bernanke kept insisting household balance sheets were fine and there was no reason to worry about housing prices, that prices would at worst stabilize. And most people trust people they do business with. That’s a big factor that enabled looting by the securities industry. People simply don’t want to believe that someone who seemed sincere and should have an interest in keeping them as a client would fleece them.
The message, sadly, is clear: satisfaction is not always in a customer’s best interest. But most of us don’t have the time or psychic energy to be vigilant.