Trust, But Verify

I recently was part of two separate Twitter threads that both ended up with one side -- mostly physicians -- arguing that people should just trust their doctors, while the other argued that trust is good, but let's not forget the data.  Not surprisingly, neither side convinced the other.

The threads made me feel that, even though we're well into the 21st century, some physicians long to go back to a time when physicians were trusted absolutely.

The first thread centered around a tweet that warned people about the risks of overuse of CT scans, claiming they cause 50,000 cancer cases a year.  The tweet advised people:  "Get one if you need it. Refuse it if you don't."

Now, that seems like good advice to me. I thought the 50,000 number was probably overstated, but the point was valid. There are risks to most tests, especially ones involving radiation, and not getting ones that you really don't need to makes sense. It seems like good advice generally when it comes to medical treatment. Just ask Choosing Wisely or the Lown Institute.

Many people did not agree, and most appeared to be physicians. They charged the Twitter user with "giving medical advice." That's right: to them, recommending to be judicious about getting care was giving medical advice.

They were justifiably critical of the 50,000 figure, and felt it was an attempt to scare people away from getting scans. But few seemed to acknowledge that there was overuse, much less that there are health risks to patients from it.

Even when presented with links to studies about overuse of CT scans, they maintained that, well, if they ordered one, it was the right thing to do. After all, they had years of medical study and practice; patients didn't.

A few claimed they were happy to answer any questions patients had about any tests they'd ordered, but it seemed clear that they'd be more interested in explaining why they were right than in actually having an open discussion. They didn't sound like doctors I'd be very comfortable having such a conversation with.

Trust us, we're doctors.

The second thread was on Direct Primary Care (DPC). The original tweet linked to an article in JAMA Network, "Direct Primary Care: One Step Forward, Two Steps Back," by Adashi, et. al. As the title suggests, it allows that the model may be good for some people, but it is "not the promised panacea of payment reform."

A few people, myself included, expressed support for the model, but noted it had to prove itself. I referenced capitation in the 1990's, where the game all-too-often was how to refer sicker patients/more expensive services out of the scope of the capitation. I had, and have, the same concern about DPC.

Don't get me wrong: done right, primary care can help ensure better, more cost-effective care to patients. That is the vision not only for DPC but also for efforts like Patient Centered Medical Homes (PCMH) or Comprehensive Primary Care Plus (CPC+).

It's the "done right" part that is the issue.

Those on my side of the discussion wanted data. Demonstrate that DPC saves money and/or improves care. Show that it works for all types of patients. Explain how it uses data to pinpoint patient needs and develop plans to address them.

It sounded very mom-and-apple pie to me, but it was like throwing a hand grenade into the discussion.

Those on the other side of the discussion -- and, again, many of them appeared to be physicians -- were aghast. Why should they have to prove anything? They don't need data to know the model works. They know what was best for their patients.

Credit AAFP

Some complained about the burden current data requirements have imposed upon practices, especially so-called quality metrics. That complaint has much validity; physicians are asked for a lot of data on a lot of things, few of which are either clearly actually related to quality or meaningful to patients.

But as I said in one reply, OK, the answer to bad data requirements is not to not use data, but to come up with better ones. No one should care more about how to measure quality and effectiveness than the people directly delivering care.

Physicians need data on their patients, and that data can't just cover what happens to them within their practice but also what happens to them in the rest of the healthcare system, and in their lives. DPC or not.

The overwhelming impression from the DPC advocates was that they were tired of the burdens that conventional physician practices placed on them.  DPC allowed them to practice as they thought best, with no insurance company or practice owners (e.g., health systems) second-guessing them.  They were sure that this would end up being better for patients.   

Trust us, we're doctors.

I like the concept of DPC. I hope it works. I think it might. But if physicians go into it mainly to escape oversight and other administrative burdens, then it is going to fail. Better care for patients has to be the goal, not a welcome by-product.

It's the 21st century.  Traditional information asymmetries are narrowing, especially in healthcare.  Physicians should expect -- and encourage -- patients to ask questions, demand answers, and suggest alternatives.  If they're not, they're not yet really engaged about their health, and that is bad not only for them but also for their physician(s).

It's the 21st century.  Data has never been so available, and we've never had such powerful tools to interpret and apply it.  In centuries past, it was enough to rely on physicians' training, skills, and instincts.  Those remain important, but if they're not also using data to deliver care, then they're practicing with blindfolds on. 

This is not about CT scans.  It is not about DPC.  It is about our relationship with, and expectations of, our physicians.  To me, it is incomprehensible that anyone would not want to understand risks/benefits of any recommended treatments and to explore their options.  It is equally baffling to me that some physicians -- not all, hopefully not even most -- would not want this as well.

Trust is a key part of the physician-patient relationship, but blind trust is no longer acceptable.

Trust, but verify.