There’s crap that fills your nostrils with such stench that it’s immediately recognizable, and there’s no doubt in anybody’s mind that it is, well, crap! Then there’s crap that hides beneath a veneer of believability. I call this varnished crap. Eventually, cracks are revealed in the veneer, and, hoo boy, does it smell when it breaks the surface! But the foulest of all forms of crap is that which is permitted to rot beneath layers of varnished crap. So nasty is this form of crap, that the only appropriate name is for it is “perfect crap.” When it finally makes it to the world of the sun, all creatures must leave the room immediately. It’s that bad.

There’s another characteristic of perfect crap that bears noting: the one who deposits it actually believes that it’s not crap and, therefore, it initially fills the room with the sweet smell of truth.

After I wrote about “experience expertise,” an old friend sent me a link to a “study” (you can find a lot of perfect crap buried under statistics) by four doctors trying to connect informed patients with a reduction in the quality of health care. Here’s the abstract:

Consumerism arises when patients acquire and use medical information from sources apart from their physicians, such as the Internet and direct-to-patient advertising. Consumerism has been hailed as a means of improving quality. This need not be the result. Consumerist patients place additional demands on their doctors’ time, thus imposing a negative externality on other patients. Our theoretical model has the physician treat both consumerist and ordinary patients under a binding time budget. Relative to a world in which consumerism does not exist, consumerism is never Pareto improving, and in some cases harms both consumerist and ordinary patients. Data from a large national survey of physicians shows that high levels of consumerism are associated with lower perceived quality. Three different measures of quality were employed. The analysis uses instrumental variables to control for the endogeneity of consumerism. A control function approach is employed, since our dependent variable is ordered and categorical, not continuous.

Can you smell it? Trust me, it’s there, for this is one of the most remarkable deposits of perfect crap ever dropped on the planet.

Not content to just go off on an abstract, I paid my five dollars and bought the report that was written by four doctors. Absent any real data on the question, they chose to blend data from disconnected studies to come up with “empirical” evidence that informed patients waste doctor’s time and, therefore, are a blight on healthcare, stealing precious time from physicians who often have “an incentive to move on.”

This is the modernist/colonialist institution of medicine striking back at the customer revolt, and it’s perfect crap. Read what these otherwise intelligent men have to say in “DEMANDING CUSTOMERS: CONSUMERIST PATIENTS AND QUALITY OF CARE.” My comments will be in red text:

Perhaps as a reaction to their dissatisfaction with managed care, consumers in recent years have come to play a much more active role in their personal medical care decisions (Robinson, 2005), a phenomenon that has become known as “consumerism” (Teutsch, 2003; Rosenthal and Milstein, 2004; Dutta-Bergman, 2003; Havlin et al., 2003).1 At the same time, there has been a rapid increase in the availability of medical information to consumers, from health-care report card programs, direct-to-consumer advertising, and particularly over the internet. (There it is, that bad Internet.)

As in the case of private competition and managed care, many have argued that consumerism will provide a lever to improve quality. As patients learn more about their medical needs and the quality of different providers, they will flock to the best ones, which will, in turn, give providers an incentive to increase quality. Further, since the success of modern medical treatment often requires high levels of compliance by patients, consumerism promises the additional benefit that, more-informed patients will be better patients. Moreover, to the extent that physicians value patient input and involvement in decision-making, more inquisitive and questioning patients may be seen as desirable and complementary to the physician’s efforts to provide high-quality care. For example, consumers — who have greater interest in their health than do their physicians — might do considerable research on their conditions, which could complement or stimulate the relevant knowledge of the doctor. More knowledge by consumers could make them better able or more willing to follow the doctor’s instructions, for example in taking prescribed medications. (Here comes the “but…”)

While the potential of consumerism to improve quality is clear, there is a darker side to the phenomenon, and a-priori, the relationship between consumerism and quality of care is indeterminate. On the negative side, consumerist patients might follow their own beliefs, as opposed to those of their more knowledgeable physicians, in effect undermining the physician’s clinical autonomy, taking more physician time, and perverting the agency relationship. (”Clinical autonomy” means the freedom to determine patient care on their own, and “agency relationship” involves the agreement that allows the doctor to perform on behalf of the patient. Both of these suggest a modernist/colonialist view of the all-knowing doctor and the ignorant patient. It’s, after all, the way things have always been.) A recent article on physician interactions with consumerist patients is quite telling:

A few months ago, Dr. David Golden says, he had to fire a patient for being obnoxious. The patient had a cough. After examining him, Golden recommended a medication. But the patient did his own research and became worried about side effects. “He said, ‘But I read about this on the Internet, and I know this and I know that, and I know I’m right.’ “remembered Golden, an allergist in Maryland. Golden says he tried to explain why the side effects weren’t as bad as the patient thought, and why the medicine would take care of his cough. “But he wasn’t open to discussing anything. He countermanded everything I said. So I told him, `You know it all, so go take care of yourself. I’m not your doctor any more.’ “Golden says he’s all for empowered and educated patients, but some patients have become so empowered, they’re actually putting their care in jeopardy. “I’ve been doing this for 28 years, and unquestionably it’s gotten much worse,” Golden says. (Cohen, 2008)

This incredible paragraph is an extreme — but convenient — example, and frankly, the patient here deserved to be “fired” (a curious term). The doctor’s response is defensive, and Dr. Golden is hardly “all for” empowered and educated patients. And, in the most elitist, colonialist statement in the whole report, he makes the argument that (stupid) patients like these are “actually putting their care in jeopardy.” I don’t question Dr. Golden’s sincerity; I just think his use of this argument is convenient and not without bias.)

While such negative interactions are far from an inevitable consequence of consumerist patients (Here comes another “but…”), there is no debate that more consumer involvement in decision making has altered the doctor-patient relationship. Virtually all observers agree. (Including this one, only I think it has altered it in favor of the patient.) A recent editorial (2005) in the Lancet, focused on consumerism and the doctor-patient relationship, but left open the question of effects on quality:

Patients have a wealth of information at their fingertips through the internet. What most do not have, however, is the skill and knowledge to sift useful and valid information and evidence from useless or harmful advice. In a mutually beneficial and effective patient-doctor partnership, medical expertise and knowledge need to be an accepted and valued part of that interaction, just as much as doctors need to have the time and skills to communicate preventive measures and treatment choices to patients appropriately. (p. 343) (This paragraph strikes at the heart of the whole thing, but it ignores the main reason people explore their own health online and elsewhere — like those dreaded friends and family members — namely, an enormous and widespread dissatisfaction with the institution of medicine and a very real sense that the “doctor-patient relationship” is one-way, robotic, and even dehumanizing.)

Consumerist proclivities also have the potential to strongly affect the physician’s time allocation, possibly in a negative fashion. Time is the prime scarce resource in the doctor-patient relationship, and is a fundamental input into quality of care. It is the focus of our theoretical model, and a central element of our empirical study. In this respect, consumerism could be beneficial if it enabled patients to effectively demand more time from their doctor — who often has an incentive to move on — when their condition merits more care and attention. (This statement is the purest form of perfect crap in the whole document. It assumes that the doctor’s time is the only time that matters and attempts to place blame on patients, while conveniently avoiding other aspects that relate to time. There is a sign on the wall at the check-in desk of one of my doctors that essentially reads, “If you are more than 15 minutes late for an appointment, you will be charged for the appointment but will have to reschedule.” I cannot honestly remember a time when I actually got to see the doctor at the time of my appointment, even when that appointment was the first on the doctor’s schedule that day. Again, the doctor’s time is deemed more valuable than mine, which I find insulting.)

On the down side, consumerist patients may in effect be “time hogs,” the “demanding customers” of our title, who describe their symptoms and knowledge at length, perhaps recognizing that more minutes with the doctor may benefit them, if only marginally, even as it takes critical time from others. In the worst case, physicians may have to spend extra time and effort dissuading consumerist patients from requested treatments of dubious value. Recognizing that consumerism could affect the productivity of physician time positively or negatively, the effect of consumerism on the quality of care becomes an empirical issue, which we seek to resolve in this study. (Again, this is perfect crap.)

The “study” then goes on to marry independent reports to make the case for the theories of these four doctors. They admit that this is a “second-best” approach, but their conclusions are based on appeals to reason that are one-sided and patently crapola.

I really appreciate the opportunity to read this report (thanks, Vince), because it proves the painful point that western culture is in the throes of an enormous change, driven by the explosion of knowledge. The transition from premodernism to modernism came following Gutenberg’s movable type and Wycliffe’s common language Bible. The ruling authority at the time — the Catholic Church — did everything they could to stop it, including the use of some of the very arguments offered in this study (”The laity’s spiritual well-being will be injured, if they can study this stuff themselves. They don’t have our skill and expertise.”). Ultimately, the priesthood gave up with the statement, “The Jewel of the Elites is in the hands of the laity.” What is this “Jewel?” Knowledge.

We’re in history’s second Gutenberg Moment, and it would be surprising if the keepers of the various books of knowledge didn’t object. In the end, though, the fear expressed by the status quo will be determined to be unwarranted, even though it might seem justified at the time.

And the good thing about all crap is that the smell goes away as Life reabsorbs it into its perfect flow.

This entry was posted on Saturday, October 4th, 2008 at 9:25 am and is filed under Postmodernism, Culture. You can follow any responses to this entry through the RSS 2.0 feed. You can leave a response, or trackback from your own site.