Physicians and Their Stockholm Syndrome

(This blog is the Gordon Reid MacDonald Memorial Lecture which I have been asked to deliver in Edmonton Alberta this month. It is much longer than my usual blogs)

If there is one thing that the pandemic has shown us, it is that modern healthcare is undemocratic, antisocial and thus largely unresponsive to its patients’ needs. Never before has healthcare been so far removed from the people it services and the clinicians who service it. Our fragmented systems of silos of clinicians, administrators, funders, policy makers and governments make it almost impossible for participants to have an informed choice about what they do and who will lead current healthcare to a healthier place – if anyone.

And physicians are caught in this Stockholm syndrome.  

Administrators and algorithm developers are captors, promoting standardization of services, while physicians are expected to fulfil the multiple roles funders assign them as gatekeepers, resource managers, clinical standards arbitrators, educators, researchers, and patient advocates.

The plain truth is, a new kind of healthcare is being constructed right in front of our eyes as we battle hopelessly to hold onto the tired old one that we are used to. 

The last episode of the Big Bang theory, called the Stockholm Syndrome, was the most watched show in Canada after Sports.  The Stockholm Syndrome, of course, refers to the phenomenon of hostages developing feelings of trust or affection towards their captors.  In the show, Leonard, Penny, Howard, Raj, Bernadette and Amy weren’t locked up in a bank with Sheldon but they still put up with a litany of unreasonable requests, and while they each showed annoyance with Sheldon over the years, none was willing to just walk away.

We physicians are the same.

My stethoscope is a diagnostic dinosaur. It is more than half my age and every year it gets proportionally closer to my age. It doesn’t have an expiration date and works just fine but now spends more time hanging around my neck than on patient’s chests. My smartphone can do almost everything it does. And soon bots or macros in my EMR will be taking over my diagnostic interviewing.

So, should I sit around and watch myself fade into insignificance as I wait for E health to make me and most other clinicians redundant. 

Funders hold us ransom to “quality” – what is quality but a euphemism for them trying to reduce the cost of health care. It is an anathema to the intellectual and creative components of medicine, which make up the art part of the science and allow the best outcome for each individual patient. And we physicians, together with our patients, sit by and watch the capacity to develop customized treatments ride off into the E sunset.

To determine quality, you must have something to measure. That is why disease classification has become so important.  Consider The International Classification of Diseases 10 (ICD 10), the disease bible. The latest edition took 18 years to complete (1990) and added an extra 6400 categories to the 7600 in its predecessor, ICD 9. Of those 6K odd extra diseases, only one third were accompanied by treatment categories. More than 4K new diseases without a treatment. How can quality be measured when there is no outcome beyond a disease label? It’s no matter, I doubt many clinicians know more than a handful of codes beyond those they deal with everyday.

It is no wonder that ICD 11 is already half a decade behind its completion date and with the reduction in WHO funding, it is likely never to be completed. The problem with classification goes beyond the disease-treatment mismatch. The linear hierarchical structure has never, nor can it ever, cope with severity of illness, especially across multiple co-morbidities.

If Classification can’t really help measure quality, then who are the main beneficiaries of Classification systems? Those who get paid according to it – pharma companies, EMRs and health insurers – all of whom use disease get to their funding.  Because, of course, if there are new diseases, there must be funding to find new treatments.  And if there are new disease categories, we must order more and more costly tests to reach a conclusive diagnosis.

So, pharma and software developers and insurance companies benefit — with our help.

Once you have made a classification system, especially one with limited treatment options, you have to find a way to get clinicians to use it. So, last century, we witnessed the birth of guidelines. This is the best way to link single disease entities to management options where there is and probably can never be much high-quality evidence.

Guidelines are a limited instrument, probably only good for junior doctors and older clinicians re-entering the workforce.  And only then as a starting point.

In a systematic review that we conducted on guidelines for the management of hypertension, we found that 75% of them provided inconclusive recommendations to support a particular treatment pathway and in all of them, there was inadequate reporting of potential adverse effects or incidence of harm.  

And it only takes a pandemic to show how easily guidelines fall apart. Take orthopaedic surgery. A recent survey of guidance regarding the continuation of orthopaedic procedures during the COVID-19 pandemic was conducted in 20 US States. 

The authors of the paper, conclude as we expected, “guidance has come from a variety of organizations and frequently has been vague, putting the onus of decision-making on individual hospital systems as well as surgeons. Ultimately, surgeons must weigh the benefits of performing surgery with the potential impact on public health.” So most experienced physicians leave the search for certainty that guidelines offer to the inexperienced and retraining.  We must emphasize with them that, while guidelines are safe, both from a legal viewpoint and a funding viewpoint, our patients deserve more.  We must think beyond guidelines for effective treatment and health management, particularly when dealing with the real world multi comorbidities that our patients often present.

So, if guidance is so inadequate, why does the concept still have momentum? Because guidance is used with great effect by litigators and health insurers – both to punish and reward. 

We know better but say nothing, acting like the hostages in the Big Bang Theory.

Let’s look at a vexatious piece of science fiction plaguing your fine Province. Health Insurance – so controversial it usurped opiates as the topic for this lecture. Health insurance is a misnomer. We can’t insure our health. It is not like motor vehicle insurance where the guarantee is that our damaged cars will be repaired or written off.  

For humans, as opposed to cars, insurance provides no guarantees. We can’t buy insurance that will ensure that our health will return to its previous functional level when it is damaged. Nor can we buy insurance that guarantees we will not be placed into bankruptcy by health care costs.  Also, unlike cars, an interaction with the health care industry at some time in our lives is inevitable for all of us. Each of us will get sick at some point; use healthcare services; and many of us will die in health care institutions – usually, later in life, after an extended period of high cost health care.

So, to Private or Public that is the question?

NHS England is the grand matriarch of all nationalized health care – as English as chips or a cuppa. 

Every patient must be treated in exactly the same prescribed way, irrespective of individual values and preferences.  Noble sentiments in a country that has been significantly reducing its public expenditure in real terms for decades – and it shows.

Let’s look at stroke patients.  

Depending on where the patient lives, their admission to an acute stroke unit within the guidelines of four hours can vary by a factor of four, so admission can take up to 16 hours in some locations.

Regionality plays more of a role than individuality. Regionality is really a proxy for workforce. When you look at the data on acute heart failure half the number of patients receiving specialist medical input die compared with those patients not receiving that input. 

So, workforce supply plays more of a role than guidelines. I’d imagine it’s the same in Alberta.

With public sector funding of health care we know where the funding comes from – our taxes. How does private health insurance make its money? Healthy, richer, low risk people subsidize the higher risk individuals. Young adults are wooed to private health cover by reduced rates compared to groups at need and at risk. At competitive premiums, services offered to young applicants usually exclude high-cost coronary care, joint replacement and cataract surgery and usually require extra premiums for pregnancy care coverage.

Increase in family size, education level, income, past hospitalization and perceived poor health status also are consistently correlated with higher willingness to pay for insurance.

It’s no different with car insurance or household insurance. 

Unfortunately, when it comes to complex care, such as you deliver in this institution, the picture is not so clear. Let’s take a look at heart transplantation – not just the surgery, but the continuing care. One in 10 patients transfer from private care to public care after one year. Probably because they can no longer pay the premiums as very few of these patients return to work. 

And change in health insurance can be deadly. 

In a German study, transition from private to public health insurance was associated with increased mortality relative to continuous private health insurance. 

So, outcomes in private health care for complex conditions are contingent on the willingness or capacity of patients to continue to pay premiums.

Instead of finding alternate solutions, communities are caught in their own Stockholm syndrome. Lured into believing that they can have it all. In Canada, where people have gotten used to a national health scheme ensuing a safety net for all, the bait is waiting times.

Wait times are where the health of the public at large comes into conflict with the health of the individual. All countries with predominantly publicly funded health systems have relatively longer wait times. And Alberta

purportedly has wait times for some 13 specialties that are higher than the Canadian average.

The Canadian judiciary has provided some relief 15 years ago in Chaoulli v Quebec, which was clearly a victory for the individual – at least in Quebec. Justice Deschamps held that, given unreasonable wait times in the public system, patients’ rights were unjustifiably infringed by a law prohibiting private insurance for hospital and physician services. 

But should this ruling be extended to Alberta? Do longer wait times really make a difference?

Let’s look first at life-threatening interventions. Studies of coronary artery bypass

 show that long waiting times are not associated with higher in-hospital mortality and only weakly affect the probability of emergency readmission. 

Unfortunately, there is no data on whether there is higher mortality while patients wait for the bypass surgery.

Now let’s have a look at non-intervention wait times. In an Australian study, almost a quarter of the respondents preferred publicly funded services despite having private health cover. Conversely, less than 1 in 10 patients without private health cover would prefer to be cared for in a private for-profit institution as opposed to a not-for-profit hospital. 

What about our position as providers in the public/private health insurance saga?

Should we have a say in our remuneration? Of course, the question is rhetorical. We have very little say in how much we get paid. In settings where the government is a credible authority to the public such as England, Japan, and Korea, the responsibilities for price regulation are established under the relevant government ministries. In the UK, starting out doctors are paid at the grade of teachers – perhaps plus some overtime. This allows for close alignment to government goals – we are viewed as servants of the public and remunerated as such with token input from the profession. 

In Canada, Australia, France, Germany, and some USA, entities exist with the legal authority to set up and control hospital payment rates were established. They have some professional input but broadly speaking, their mandate is to develop a credible price schedule for hospitals. 

Increasingly, the traditional approaches of paying physicians by fee-for-service and capitation are being phased out. Physician burn-out is a major side effect of the long hours required by doctors in fee-for-service to earn the incomes they need, especially given the education debt many young doctors bear, and were led to expect to receive. Capitation also causes burn-out from its obsessions with monitoring, measuring and incentivizing physicians’ performance based on the quality measurements I discussed earlier in this lecture. 

So, however we get paid we can get overloaded. In terms of remuneration, fee-for-service still provides physicians with the best incomes – provided all patients have private health insurance. Privately health insured patients in the ambulatory sector in Germany ensure between 20% to 35% higher revenue than publicly insured patients.

But does it really make a difference to patient and community outcomes how we are paid?

Folk wisdom has us believe that compared to the private sector, public-sector physicians are more socially motivated towards their patients and performance pay would dampen public sector motivation. The scant evidence we have – in the case of blood donations — suggests this may be true.  

And interestingly it is gendered. 

The supply of male blood donors is unchanged when a monetary payment is introduced. 

In contrast, the female supply decreases by almost half when blood donors receive monetary payments. So the same number of men donate blood regardless of whether they get paid, but the number of women donors is cut in half if they are paid for their donations.  Allowing individual women to donate the payment to charity fully counteracts the crowding‐out effect and brings the donations back to the original level. 

There is no equivalent evidence from physician studies but I am sure governments would like to introduce a trial where physicians could opt for their payments to be donated to charities on a regular basis.

What happens when physicians are incentivized in other ways besides taxation breaks?

Counterintuitively, the level of incentive has very little effect on the behaviour of physicians.  An increase in a physician’s maximum attainable payoffs by 5% and 20% are similarly effective in inducing a higher quality of care. The most impressive outcome from incentivization is when it is linked to severity of illness. Adjusting performance pay to a patient’s severity of illness counteracts the recognized undertreatment of high-severity patients demonstrated in capitation settings.

Confusing to say the least. 

The fact is, when we are freed from our captors we will realize that both private and public health insurance are unsuitable for 21st century health care.

As clinicians AND patients, we have little control over what or how much we want to spend to “insure” our future illness care and the care of those who are close to us. A first step could be the transfer of greater control of health care funding from insurers – governments or otherwise, and providers – both public and private, to individuals and families. 

Yet, in other areas such as pensions and education, we are able to personalise our assets in a tax efficient manner.

Are there any other possible ways of funding? How about health banks and transferrable loyalty policies?

For example, accrued health care policies could be transferrable – in the same way that blood transfusion sharing and pension allocation are now routine – even in situations where the families are disrupted such as after divorce. 

The person who is accruing the health pension fund may not be the one who needs it in the future. Allocation of accrued benefits from healthy individuals to their sicker family members should be as simple as transferring loyalty points.

That doesn’t mean that such a system would not require education and government support, like those available in the US to enrol in Obamacare or choose a drug plan.  

Such a system should have no effect on the availability of newer medical equipment, but going forward, irrespective of who funds it, rising costs may lead to serious shrinkages in supply and interventive services. The cost of buying new equipment annually has increased by more than 5 percent over the last 20 years. Less than one eighth of medical supplies are recyclable and nearly a quarter contains radiological, biological or chemical hazards. 

And it’s just not cost and recyclability. When you have a pandemic, certain supplies get prioritized and everyone else suffers. My clinic, which is a community-based clinic which services disadvantaged patients, has run out of the N 95 masks which were donated privately, and we have no more swabs for testing anything except CoVID.

Of course, health insurance – public and private can only operate in monopoly environment – where control of health vests in institutions. That is so last Century. 

E-health has become the promise of this Century. 

“Health” is the second most frequently searched term in Google, resulting in 57% of the more than two trillion searches in 2016.Currently, there are more than 300,000 health apps listed on the Internet. 

If you looked at one a day, it would take you 800 years to review them all.

But quantity does not necessarily equate with quality and audiences can get bewildered by content and lured by user-friendliness. Unfortunately, when you take a closer look, health apps deliver much less than they promise. A systematic review of 23 trials of health apps that promised a specific outcome, such as losing weight, showed a meaningful result in less than half of them and most of the trials were only small studies over short periods of time. 

For-profit E-health apps focus on low hanging fruit, such as single topic areas that have been well researched such diabetes or hypertension. Even then – caveat emptor – or buyer beware. E-app Toxicity can take many forms: out-of-date information, inaccessible or expired sites, lack of supporting references and author information. Surprisingly, men are the greatest victims.

Studies of men’s health E apps and sites reveal a dangerously high level of toxicity. For example, only one in four prostate cancer websites identify the author of the information. More than half had no references and when references were provided, less than a quarter cited were reliable.

Half of recently reviewed health apps for gout, a predominantly male condition, were either no longer available to download or had not been updated since their release (over a year or more before). 

Poor health apps are toxic in unexpected ways. For example, they steal time from everyone, but particularly from traditionally underserved populations. People living with disabilities and those of us who are chronically ill spend double the amount of time online than our well counterparts. 

We are on the verge of an e-health epidemic that has the potential to distract and confuse people and offer counterproductive – and even dangerous — remedies rather than help them. 

Global and regional health agencies such as WHO and NIH should lobby for public safeguards just as have been established in other areas of E malfeasance. Just as Archie Cochrane, the co-founder of evidence-based medicine, provided some rigor to research data, and citizen science projects have assisted the processing of large data sets from bees to Higgs-Bosons, there needs to be a project to enlist the enormous computing power vesting in our communities to assist the processing of health information. 

Using all our computing resources to help a world-wide movement to handle the data from complex and often multiple morbidities, such as depression, substance abuse, obesity and cancer – may prevent people ending up in expensive hospital-based care.  So rather than an E-health solution we have a C-health community of solutions. 

We work in a rapidly changing environment where the ultimate question is not whether public or private funding of healthcare is best.  As physicians, we must struggle against the Stockholm Syndrome and constantly focus on what will allow us to provide effective individualized care to our patients.

For more on any of these topics are the references, please look up my unsponsored, ad-free blog http://www.thethinker.co

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