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From WSJ
Should everyone take vitamin D, and if so, how much? At what age and how often should a woman have a mammogram? Should a healthy man be screened for prostate cancer, and if cancer is diagnosed, how should he be treated?
As the health-care debate heats up again in Washington, both Democrats and Republicans will try to convince us that they have the experts to answer all our health questions. President Barack Obama and the Democrats propose panels of government experts to evaluate treatments and, in the president's words, "Figure out what works and what doesn't." Republicans claim that the free market (that is, insurance companies with their own experts) will pay for value and empower consumers. Both sides insist that no one will come between us and our doctors.
Patients and doctors can differ with experts and not be ignorant—despite what politicians think.
Democrats and Republicans share a fundamental misconception about medical care. Both assume that, as in mathematics, there is a single right answer for every health problem. These "best practices," they believe, can be found by gathering large amounts of data for experts to analyze. The experts will then identify remedies based strictly on science—impartial and objective.
Yet in medicine, there are many contrary opinions about "best practices." You cannot pick up a newspaper, turn on the TV or surf the Internet without encountering conflicting reports about various tests and treatments. Medical experts disagree about many issues, often dramatically.
This has not stopped a government panel of experts, the U.S. Preventive Services Task Force, from issuing sweeping recommendations regarding clinical care. In November 2009, this government group announced that women under 50 should no longer undergo routine mammograms. Despite an estimate that as many as 12,000 lives could be saved by earlier screening, the panel concluded that the potential benefit was not sufficient to balance the pain and suffering related to false positive diagnoses, unnecessary biopsies, the unknown risks of exposure to radiation and toxic treatment of cancers that might ultimately prove indolent. A statistician on the panel told reporters that the decision was a "no brainer." Last autumn, the Preventive Services Task Force declared that healthy men should no longer be tested for prostate cancer, another "no brainer" according to the panel's chair.
But these are hardly consensus positions. The American Cancer Society's own experts took a very different view of the trade-offs between risks and benefits. They still recommend mammograms for women under 50, and they believe that the issue of screening for prostate cancer is not settled.
Ashby Jones on Lunch Break examines the three days of arguments over the Obama health-care law before the Supreme Court, including key takeaways and what the justices' questions suggest about the court's decision.
Republicans take a different approach to health-care reform; they depend on insurance companies and their experts to determine the best care. Consider the recent marketing campaign of United Healthcare, one of the largest insurers in the country. It is called "Health in Numbers," and the insurer promises that, by trusting its expert data and analysis, patients will have the right outcomes. But this is a false promise. No one can guarantee the right outcome from a treatment for any individual patient.
And where do patients stand in all of this? In June 2009, President Obama voiced a common point of view when he told Diane Sawyer of ABC News, "If we know what those best practices are, then I'm confident that doctors are going to want to engage in best practices. But I'm also confident patients are going to insist on it.… In some cases, people just don't know what the best practices are."
But every patient does not, in fact, react in the same way to expert opinion. Research shows that the more patients understand the risks and benefits of treatments, the more varied are their choices. They do not conform to the advice of a single group of experts.
Over the past four years, we have interviewed scores of patients around the country about how they make medical decisions. We found "maximalists" who want to do everything possible and "minimalists" who are convinced that less is more; "believers" who are certain that a good solution exists for their illness and "doubters" who worry that almost any treatment will be worse than the disease. They developed these mind-sets largely based on past experience with illness, and they use them as a starting point for weighing risks and benefits in their health care.
Experts also have these distinct mind-sets, both as individuals and as groups. The federal Preventive Services Task Force, for one, embodies a minimalist, doubter mind-set. That is why experts can look at the same data and still disagree about what is best.
For patients and experts alike, there is a subjective core to every medical decision. The truth is that, despite many advances, much of medicine still exists in a gray zone where there is not one right answer. No one can say with certainty who will benefit by taking a certain drug and who will not. Nor can we say with certainty what impact a medical condition will have on someone's life or how they might experience a treatment's side effects. The path to maintaining or regaining health is not the same for everyone; our preferences really do matter.
For much of the 20th century, the model of medical care was paternalism: A doctor dictated what was to be done and the patient complied. This model has largely been abandoned, but now Democrats and Republicans are offering a new form of paternalism, based on the assumption that Americans are not receiving "quality" care. A lucrative industry has grown up to generate ever more medical metrics, to give report cards to doctors and hospitals, and to base payments on compliance with "best practices." Yet beyond safety protocols, there is scant evidence that such measures improve our health.
Patients and doctors can differ with experts and not be ignorant or irrational. Policy makers need to abandon the idea that experts know what is best. In medical care, the "right" clinical decisions turn out to be those that are based on a patient's goals and values.
—Drs. Hartzband and Groopman are on the faculty of the Harvard Medical School and the Beth Israel Deaconess Medical Center in Boston. They are co-authors of "Your Medical Mind: How to Decide What Is Right for You."
Should everyone take vitamin D, and if so, how much? At what age and how often should a woman have a mammogram? Should a healthy man be screened for prostate cancer, and if cancer is diagnosed, how should he be treated?
As the health-care debate heats up again in Washington, both Democrats and Republicans will try to convince us that they have the experts to answer all our health questions. President Barack Obama and the Democrats propose panels of government experts to evaluate treatments and, in the president's words, "Figure out what works and what doesn't." Republicans claim that the free market (that is, insurance companies with their own experts) will pay for value and empower consumers. Both sides insist that no one will come between us and our doctors.
Patients and doctors can differ with experts and not be ignorant—despite what politicians think.
Democrats and Republicans share a fundamental misconception about medical care. Both assume that, as in mathematics, there is a single right answer for every health problem. These "best practices," they believe, can be found by gathering large amounts of data for experts to analyze. The experts will then identify remedies based strictly on science—impartial and objective.
Yet in medicine, there are many contrary opinions about "best practices." You cannot pick up a newspaper, turn on the TV or surf the Internet without encountering conflicting reports about various tests and treatments. Medical experts disagree about many issues, often dramatically.
This has not stopped a government panel of experts, the U.S. Preventive Services Task Force, from issuing sweeping recommendations regarding clinical care. In November 2009, this government group announced that women under 50 should no longer undergo routine mammograms. Despite an estimate that as many as 12,000 lives could be saved by earlier screening, the panel concluded that the potential benefit was not sufficient to balance the pain and suffering related to false positive diagnoses, unnecessary biopsies, the unknown risks of exposure to radiation and toxic treatment of cancers that might ultimately prove indolent. A statistician on the panel told reporters that the decision was a "no brainer." Last autumn, the Preventive Services Task Force declared that healthy men should no longer be tested for prostate cancer, another "no brainer" according to the panel's chair.
But these are hardly consensus positions. The American Cancer Society's own experts took a very different view of the trade-offs between risks and benefits. They still recommend mammograms for women under 50, and they believe that the issue of screening for prostate cancer is not settled.
Ashby Jones on Lunch Break examines the three days of arguments over the Obama health-care law before the Supreme Court, including key takeaways and what the justices' questions suggest about the court's decision.
Republicans take a different approach to health-care reform; they depend on insurance companies and their experts to determine the best care. Consider the recent marketing campaign of United Healthcare, one of the largest insurers in the country. It is called "Health in Numbers," and the insurer promises that, by trusting its expert data and analysis, patients will have the right outcomes. But this is a false promise. No one can guarantee the right outcome from a treatment for any individual patient.
And where do patients stand in all of this? In June 2009, President Obama voiced a common point of view when he told Diane Sawyer of ABC News, "If we know what those best practices are, then I'm confident that doctors are going to want to engage in best practices. But I'm also confident patients are going to insist on it.… In some cases, people just don't know what the best practices are."
But every patient does not, in fact, react in the same way to expert opinion. Research shows that the more patients understand the risks and benefits of treatments, the more varied are their choices. They do not conform to the advice of a single group of experts.
Over the past four years, we have interviewed scores of patients around the country about how they make medical decisions. We found "maximalists" who want to do everything possible and "minimalists" who are convinced that less is more; "believers" who are certain that a good solution exists for their illness and "doubters" who worry that almost any treatment will be worse than the disease. They developed these mind-sets largely based on past experience with illness, and they use them as a starting point for weighing risks and benefits in their health care.
Experts also have these distinct mind-sets, both as individuals and as groups. The federal Preventive Services Task Force, for one, embodies a minimalist, doubter mind-set. That is why experts can look at the same data and still disagree about what is best.
For patients and experts alike, there is a subjective core to every medical decision. The truth is that, despite many advances, much of medicine still exists in a gray zone where there is not one right answer. No one can say with certainty who will benefit by taking a certain drug and who will not. Nor can we say with certainty what impact a medical condition will have on someone's life or how they might experience a treatment's side effects. The path to maintaining or regaining health is not the same for everyone; our preferences really do matter.
For much of the 20th century, the model of medical care was paternalism: A doctor dictated what was to be done and the patient complied. This model has largely been abandoned, but now Democrats and Republicans are offering a new form of paternalism, based on the assumption that Americans are not receiving "quality" care. A lucrative industry has grown up to generate ever more medical metrics, to give report cards to doctors and hospitals, and to base payments on compliance with "best practices." Yet beyond safety protocols, there is scant evidence that such measures improve our health.
Patients and doctors can differ with experts and not be ignorant or irrational. Policy makers need to abandon the idea that experts know what is best. In medical care, the "right" clinical decisions turn out to be those that are based on a patient's goals and values.
—Drs. Hartzband and Groopman are on the faculty of the Harvard Medical School and the Beth Israel Deaconess Medical Center in Boston. They are co-authors of "Your Medical Mind: How to Decide What Is Right for You."
