The failure of the medical system when it comes to
information transfer from doctor to doctor and from test to doctor, is
palpable. Putting all info on a central database which can be seen by all
legitimately interested parties, is an obvious partial fix. But it won’t
address all such problems.

An intractable difficulty is that raw info in a database needs processing if it is to mean anything. Some of this is done automatically in H&Ps, hospital admission and discharge notes, consult initial notes, and so on. But a referral note is exactly a “pause to think” place where a reduction of data into summarized info and questions is needed, and yet this is not done because there is no good mechanism to PAY anyone to do it. The government and insurance companies pay for “face time” and doctors do not write referral summaries while the patient is sitting in front of them. The doctor is paid little to think when the patient is not in front of the doctor, and this
is the basic reason why the medical system does not (and cannot) think much
about people who are not sitting in front of “it” (in the exam room or hospital
bed). Medicine, as we know it, is a giant brain with a bad case of “out of sight, out of mind.”

Even imaging goes badly because doctors are not paid to write a good or even adequate imaging order: “Here’s what should you know about the patient. This is the test is ordered. This is what I want you to look for.” So, a generic order goes out, and
an ignorant radiologist gives a poor read.

Results? Not long ago, I saved a 48 y.o. smoker from a CT guided biopsy of a giant “pleural effusion” found on a routine CXR as pre-op for her plastic surgery. The problem? The ordering physician didn’t know the patient had had the lower 2/3rds
of one lung removed 30 years before, for a benign tumor. The CXR reading
radiologist didn’t know it. The doctor about to do the biopsy didn’t know it.
What looked like effusion was simply normal appearance of previous
pneumonectomy. As a friend of the family who actually interviewed the patient
carefully, as well as her mother, I put it all together and made the patient
refuse the procedure (which had biopsy tray all laid out) until the doc about
to do the procedure understood the problem. But they CT’d her anyway (why
not?). Still, most people don’t have such a watchdog. You can imagine (and in
most cases have seen) what can go wrong, when they do not. As it was, the
patient described above went through two weeks of thinking she was dying of
cancer. And was lucky to get off, with just that.

Until third-party payers pay doctors to think, and until doctors can figure out how to document “thinking,” we’ll all continue to suffer (patients, doctors, society). Thinking and research into the literature can save a patient from further tests, further consults, further treatment, and in general from all the side effects and costs that go with deeper penetration into a procedure-driven system. We want to encourage it, but we do not.

Some doctors think and research twice as well as others, or three times as well. How to bill for that? In a free-market, such doctors would be recognized, and patients themselves would be happy to pay the difference, as they do in “concierge medicine” now. But most of the system has passed well beyond that, and what is left, is a mass of “reflex speed-chess” medical care, combined with systemic amnesia. It is performed by generic interchangeable doctors, often young, and increasingly foreign-trained. Why not? The problem is that patients do not realize how dangerous a straight “bill for procedure” system is, for them. If they did, they might be willing to pay “extra” for the slow and thoughtful and wise approach (though it is not clear if this actually will cost society more).

Even a system in which procedures and payment are completely disconnected, would probably be far less dangerous. A system like ours in which bad outcomes due to lack of thinking-time are carefully kept from patients, means that such feedback is absent. We doctors see it, but we have little incentive to go against a system that systematically penalizes playing outside the rules. Most doctors are rapidly worn down by time and billing constraints, and those that are not, are fired (by HMOs) or else they quit or retire early. The result is a system that costs more and more, and produces less and less. In the U.S., here we are.