Robert Alan McNutt, MD: What’s Wrong with Medical Care?

We welcome a guest post today from Robert Alan McNutt, M.D., author of Your Health, Your Decisions: How to Work with Your Doctor to Become a Knowledge-Powered Patient. In nearly every medical-decision-making encounter, the physician is at the center of the discussion, with the patient the recipient of the physician’s decisions. Dr. McNutt starts from a very different premise: the patient should be at the center. McNutt challenges the physician-directed, medical-expertise model of making decisions, presenting a practical approach augmented by formal exercises designed to give patients the tools and confidence to compare and contrast their health-care options so they can make their own choices.

In today’s guest post, Dr. McNutt argues that sick patients can be very wise patients.

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What is wrong with medical care? Physicians, rather than patients, make decisions.

I have practiced medicine for over 40 years. I have yet to find a physician without a chronic disease who is smarter than a person with that chronic disease. I have been impressed that a patient’s numeric insights and intuitions when they are ill surpass their skills when they were not ill. All a patient needs is information, in all its glory and messiness, to know if the information is worth anything to them when they face a medical decision. Patients, in my view, are the best information managers and evidence experts I have ever seen, and I know a bunch of evidence experts to draw upon for the comparison. I have been doing shared consults with patients for twenty-plus years and I have learned that patients are smart. Consider the following:

• The man had been advised to have surgery. The man and his wife stared in stunned silence at the data on prostate cancer treatment outcomes with surgery. The study was described in detail, including a description of the people who were studied. The wife finally spoke, “You mean to tell us you want my husband to have surgery when so few have been studied! You mean to tell us that not a single person of our cultural heritage has been tested in the study?” I responded and reminded, “I am not asking you to have surgery. We are going over information of potential benefit and harm that you must balance for your choice.” They were kind in response, refused to consider surgery or further discussion, and, instead, chose to enter a clinical study.

• He had been advised to have a CT to screen for lung cancer. He exclaimed, “Let me get this straight. You are saying that out of nearly 55,000 people studied, there were only about 30-80 fewer deaths from lung cancer over nearly 5 years if a low dose computerized scan (LDCT) was done rather than a chest-x-ray?” I replied, “Yes, that is correct. There were, remember, about 100 fewer patients dying of any cause if they received the LDCT rather than the chest-x-ray. As you also know, alternatively, about 10 extra people getting the LDCT died or got a complication within 60 days of the exam due to the work-up of abnormal findings on the exam. That is your trade-off for having a LDCT; a potential small benefit in the future balanced by a potential small chance of dying or having a severe complication early due to a work-up.” He replied, “I am not a scientist, but these numbers represent miniscule differences. The study could be wrong. I am not willing to take the LDCT scan based on the data.”

Medical care has been described as a “philosophy informed by science.” There is a subtle problem with this view, however. It suggests that evidence informs the philosophy of how medical care should be delivered. It may be, however, as others have suggested, that evidence might be produced in biased ways by the prevailing philosophy. If this is true, then we have to sit up straight and reconsider our philosophy of medical care. Trying to fix the present medical care system based on a philosophy that allows physicians to be the decision makers will be like trying to float a sinking battleship with bubble gum. It is impossible to overcome a poor philosophy of care with edicts, ruminations, and patchwork insurance fixes.

It is time to rethink the goals of best medical care. Patients will tell us what evidence is worthwhile and what their care is worth. It will never work the other way around.

Robert Alan McNutt, M.D, is a clinician, researcher, teacher, decision analyst, former medical editor, and, now, a decision-making consultant. He is the president and CEO of YouChooseMedical, LLC. Visit his website at sharedmedchoice.com. His book Your Health, Your Decisions: How to Work with Your Doctor to Become a Knowledge-Powered Patient is now available.