Some months back I read an interesting interview with Jonathan Skinner, a researcher who works with the group at the renowned Dartmouth Atlas of Health Care. More than anyone else I can think of, the people at the Dartmouth Atlas have studied and tried both to understand and to explain the amazing variations we see in how medicine is practiced in various parts of the country. It turns out that specific conditions are treated in quite different ways depending upon where you live. Atul Gawande documented a detailed example of the phenomenon in an excellent New Yorker article here. A major determinant appears to be local physician culture, how we doctors “do things here.” The disturbing observation is that patient outcomes aren’t much different, just cost. Of course it’s more than cost. Doing more things to patients also increases risk, and adding risk without benefit is not what we want to be doing.
Skinner is interested in something else, a phenomenon he calls “cowboy doctors.” By this he means physicians who are individual outliers, who go against the grain by substituting their own individual judgements for those of the majority of their peers. In theory such lone wolf practitioners could go both ways. They could do less than the norm, but almost invariably they do more — more tests, more treatments, more procedures. Such physicians not only may put their patients at higher risk, they also add to medical costs. I have met physicians like that and have usually found them to be defiant in their nonconformity. A few revel in it. They maintain they are doing it for the good of their patients, but there is more than a little of that old physician ego involved. There is also the subtext of what many physicians feel these days, especially old codgers like me who have been practicing for 35 years: it is the tension between older notions of medicine as an art, a craft, and newer evidence-based, team driven practice. Skinner describes it this way:
It’s the individual craftsman versus the member of a team. And you could say, ‘Well, but these are the pioneers.’ But they’re less likely to be board-certified; there’s no evidence that what they’re doing is leading to better outcomes. So we conclude that this is a characteristic of a profession that’s torn between the artisan, the single Marcus Welby who knows everything, versus the idea of doctors who adapt to clinical evidence and who may drop procedures that have been shown not to be effective.
Leaving aside outcomes and moving on to costs, Skinner and his colleagues were quite surprised to discover how much these self-styled cowboys and cowgirls were adding to the nation’s medical bills. They found that such physicians accounted for around 17% of the variability in regional healthcare costs. To put that in dollars, it amounts to a half-trillion dollars. That is an astounding number.
So what we are looking at here is a dichotomous explanation for the huge regional variations in medical costs. On the one hand we have physicians who conform to the local culture, stay members of the herd and go along with the group, even if the group does things in a much more expensive way that confers no additional benefit to patients. On the other hand we have self-styled mavericks who scorn the herd and believe they have special insight into what is best, even if all the research shows they’re wrong.
I think what is coming from all this cost and outcome research is that best practice, evidence-based medicine (when we have that — often we don’t for many diseases) will be enforced by the people who pay the bills and professional organizations. Yes, some will bemoan this as the loss of physician autonomy and the reduction of medical practice to cookbooks and protocols. I sympathize with that viewpoint a little, especially since I am the son and grandson of physicians whose practice experience goes back to 1903. But really, there are many things we used to do that we know now are useless or even harmful. An old professor of mine had a favorite saying for overeager residents: “Don’t just do something — stand there!”
For those who would like to dive into the data and see the actual research paper from the National Bureau of Economic Research describing all this, you can read it here.