Lee A. Resnick, MD, FAAFP
Love, politics and drugs were the subjects of Mick Jagger’s self-reflection in the 1960s rock anthem, “You Can’t Always Get What You Want.” Since then, the song’s chorus has been reproduced and repurposed into everything from parenting advice to sociology lectures. Mick’s personal struggles with drugs and other temptations are referenced frequently as the artistic purpose of the song, and while he may not have intended greater ideological meaning, I do not hesitate to declare that the lyrics have had a lasting impression on society and its struggles with selfishness and greed. Parallels can be drawn to all aspects of life in a modern, democratic world. We are only now beginning to appreciate the inherent cost of freedom in a diverse and global world, let alone in healthcare.
Clinical medicine was, for most of its history, a “technocracy”: A professional elite that “ruled” by virtue of being the most knowledgeable and skilled. “Laws” of clinical practice were fairly clear and patients deferred decision-making to the “house of medicine” and its physician representatives. I needn’t tell anyone reading this editorial how times have changed. Medicine has been transformed into a practice entirely driven by the agendas of interest groups far more powerful and numerous than the “house of medicine.” Physicians, on the other hand, have been rendered nearly impotent. Governmental agencies representing the perceived “interests” of patients have rolled out more regulations in healthcare than for nearly any other industry at a cost of hundreds of billions of dollars each year.
As I noted in a previous column, there has been no study to date that has examined whether we have obtained an ounce of quality or cost savings from these efforts. It is undeniable, however, that there have been considerable hard and soft costs that have been paid for mostly by well-meaning physicians. And if that wasn’t enough, professional independence and authority has been further hijacked by other powerful private interests like insurance companies, lawyers, hospitals, and drug and device companies.
And now,for the most powerful and potentially dangerous interest group of them all: Our patients (cringe). There is no greater folly than to call out our patients as contributing to the ills of medicine, but let’s face it, in a democratic society, it is the desires of the people that ultimately drive the political and corporate agenda. More than ever, our patients have insatiable and unrealistic desires…err…demands that render the physician almost paralyzed in practice. Doctors spend an increasing amount of time negotiating with patients…what medications to prescribe, what tests to do,what procedures to perform. While a wonderful ideal in theory, the concept of shared decision-making is, perhaps, the most unrealistic expectation of medicine today.
The process of medical decision-making is the most revered part of clinical medicine. It is the convergence of the physician’s fund of knowledge with the clinical presentation, patient history, epidemiology, pretest probability, and evaluation of risk and benefit. In other words, medical decision-making is, perhaps, too complex to be truly “shared.” What you get instead is a jumbled and distracted process where nobody wins. After all, how can you have “shared” decision-making with a patient “partner” who has no appetite for uncertainty and, understandably, cannot think objectively about his or her problem?
The American desire to control one’s own destiny and the decisions that impact them is powerful indeed. We view authority over these decisions with great skepticism. As it pertains to our healthcare, we want our antibiotics and our MRIs when we want them, we want our knee arthroscopies regardless of proof, and we want it all without any risk of complication. We want it now and, unfortunately, we don’t care if our “wants” are directly contributing to a broken system on the verge of collapse that can- not provide effective or efficient healthcare to its people. This is the system we want. Well, you can’t always get what you want, America. If only we could get what we need!
Hail the Technocracy!