Angry Doctor

Wednesday, July 16, 2008

Better, Longer, Cheaper

Pick two.

(emphasis mine)

Playing catch up
Issue at hand: How to improve outcomes while containing costs

EVEN as medical science progresses — contributing to longer life spans — the ways health outcomes are measured have yet to catch up.

Life expectancy has been used as a measure for years, but “there is no quality of life perspective to this, just a number”, said Mr Dean Westcott, a member of the Association of Chartered Certified Accountants (ACCA) governing council at an “ideas forum” yesterday.

There is a need for “more sophisticated measures” of healthcare outcomes, said the finance director and deputy chief executive of a healthcare trust in the United Kingdom.

This was one of the key issues raised at the ACCA session for academics and industry leaders, including from the public and private hospitals.

The roundtable discussion also identified another overarching issue — of how to improve healthcare outcomes while containing costs, which have been rising in recent years, outstripping GDP by two percentage points every year in the Organisation for Economic Co-operation and Development countries.

This is not sustainable, Mr Westcott told Today, adding: “Studies have estimated that by 2020, healthcare expenditure will triple.”

The question to grapple with is how to decide the most efficient level of expenditure.

According to Mr Westcott, the general consensus on efficient resource allocation is a focus on lifestyle and prevention and to have “equity of access”.

This means having people enter the healthcare system early, before conditions become chronic and cause complications.

But political will, patience and foresight is required for this to happen as results may take years, even generations, to realise.

Singapore is one of three cities with different healthcare financing models — alongside London and Washington — sharing its perspective on the issue of healthcare costs versus outcomes, which will shape an ACCA-commissioned study on global healthcare.

Mr Westcott, who moderated yesterday’s forum, said: “We anticipate that it will be used to inform healthcare policy decision making.”

We've discussed this topic before here, and angry doc's view is this:

The fact is people in their last year of life consume a disproportionate percentage of a nation's healthcare spending, ... every life eventually comes (or in this case ends) with a price-tag. In fact, there is also a case to be made that the older this 'last year of life' is, the greater the amount of spending in the last hospitalisation will be.


As long as we see longevity and good health as desirable commodities, healthcare spending will continue to rise.

The question then is not perhaps on how much to spend, but when to stop spending.

Reading between the lines, it seems that Mr Westcott shares a similar view when he said "there is no quality of life perspective to [life expectancy], just a number", and that there is a need for “more sophisticated measures” of healthcare outcomes.

Come on now, people.

We all know what needs to be done here, don't we?



  • I had a recent conversation with a doctor friend (consultant level) where I was saying that I don't want to go into medical school because I believe the "if I give you this drug, your quality of life will improve" relation does not always hold. He said it mostly held true and that the exceptions were ok. Fair enough :) that's why he's still a doctor and why I'm not, isn't it. (To me the exceptions are not ok.) But I wonder why there could be such a "win some, lose some" attitude amongst doctors, towards patients. Is that a sign of burnout, or simply an accepted normal practice, or (as your quoted article indicates) an endemic loophole in the philosophy of medicine?

    Disclaimer: He's already the most open-minded doctor I know, and a great friend. I know why he thinks that, but it's not a reason that's particularly common to the large proportion of doctors at the moment. And no, I can't say.

    By Blogger cognitivedissonance, At July 20, 2008 9:46 pm  

  • I take a more extreme position: I don't think a patient's "quality of life" is the doctor's business.

    OK, that's just me being deliberately provocative again; to phrase it more precisely, I don't think it's my business to tell my patients what his "quality of life" indicators are.

    As a doctor, I see my role as that of providing health promotion, primary, secondary, tertiary and palliative care. At each stage I try to identify the problems and educate patients on the future risks to themselves based on their risk factors and conditions, and what are the interventions in the forms of advice on lifestyle and behavioural modifications, pharmacological, surgical or physical therapies I can offer, and what the risks and benefits of each are. All those are scientific and objective.

    Whether the patient thinks the risks I stated are of concern to him, and whether he thinks the intervention I offered are worthwhile to him, are totally subjective - he can choose to take it or leave it.

    The science behind medicine is largely objective, but "quality of life" is at the end of the day individual and subjective.

    A doctor may know that smoking is bad for the patient's health, but the patient can and often will decide that the benefits he derives from smoking exceeds the risks *for him*. The doctor must play the role of an advocate for his patient and advise him on the risks of smoking, but he must also respect the patient's autonomy on the decision to smoke.

    Health is an important dimension of life, but it is not the only, nor in many cases the most important dimension.

    Patients sometimes get too hung up on the pursuit of ideal health, usually represented by longevity and freedom from diseases, and feel guilt or anxiety when they fail to live up the the standards set by "medicine".

    Doctors, on the other hand sometimes see patients' death or failure to avoid or achieve certain health outcomes as personal failures, and can feel frustration and resentment with patients.

    Both sides need to see that health is merely a means to an end - to live life the way we want to.

    Perhaps if patients can understand that healthcare 'consumption' should be a matter of balance between the costs he is willing to pay for the benefits he might achieve, and doctors can get more used to the idea that "ideal health" is not every patient's aim, then we can all feel better.

    Unfortunately the human body does not allow us to make very accurate predictions, so much of medicine as it is applied to individuals is still fraught with uncertainty; most doctors will want extra margin of safety, and some patients will take risks and hope to be lucky.

    We necessarily win some, and lose some - it is not something I have a choice over.

    I guess what I am saying is that each patient should be the one to decide what constitutes "winning" for he himself.

    By Blogger angry doc, At July 20, 2008 10:45 pm  

  • Angrydoc:

    Appreciate your reply. I think it's wonderful. :)

    And of course I agree with it because I am a social work student, etc etc. Now doing an internship in a hospital and letting off some steam over the things I see ;)

    Would you hold to your position if this patient were repeatedly admitted into hospital and spent long periods in the ward convalescing?

    It's not that I mind the repeated referrals to the medical social work department for these (hypothetical) patients, because they may have other presenting issues that arise afresh each time. I can do the check each time, it's fine. It's sometimes the younger doctors who insist that the patient must give up his habits and expect the medical social workers to work wonders. We can only do so much, and report what we do. I hope more doctors could realize that, and I am pleasantly surprised that you concur with the patient's right to self-determination of what constitutes his quality of life.

    By Blogger cognitivedissonance, At July 21, 2008 12:10 am  

  • (I should also add that as a matter of procedure the medical social workers do point out to the patient that his frequent admissions are depleting his/family's Medisave, and ask him what he wants to do in light of that situation.)

    By Blogger cognitivedissonance, At July 21, 2008 12:24 am  

  • "Would you hold to your position if this patient were repeatedly admitted into hospital and spent long periods in the ward convalescing?"

    "I am pleasantly surprised that you concur with the patient's right to self-determination of what constitutes his quality of life."

    It's not like we have a choice, is it? :)

    By Blogger angry doc, At July 21, 2008 10:57 am  

  • So, I do not really imagine this is likely to have success.
    site | site | link

    By Anonymous Vincent, At July 02, 2012 11:36 pm  

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