Reader Dan: Medical Care, Part 3

Reader Dan, part 3 on medical care.

Hat tip to Angry Bear reader Buffpilot for joining voices in a liberal/conservative plea for doing the right thing. Please refer to this post for context on PTSD, healthcare, and Therapist1 comments. Clearly there is great need to increase funding for cognitive sciences and occupational therapy needed for our soldiers and their families in Tricare.

Next a post on medical care and cognitive science reimbursements in a scholarly piece by Dr. Jerome Groopman is useful to further thoughts on our next step to thinking about our health system, cognitive sciences, and other medical fields. Hat tip to Angry Bear reader Coberly.

Another piece in the New England Journal of Medicine that I found of interest was a series of letters about medical education. I feel strongly that it is time to integrate cognitive psychology into the curriculum. Physicians are making decisions all the time under conditions of uncertainty, with limited data. The human mind is wired to take shortcuts, and our biases and emotions can strongly color our reasoning. Scant attention is paid to this critical cognitive dimension which underlies misdiagnosis.

Changing behavior is difficult, but, in my experience, most likely succeeds when there is time allotted to the discussion, a close bond between the patient and doctor, and continuing encouragement. It boils down to words and positive feelings, and the health benefits can be extraordinary. Much of what primary care physicians do involves preventive medicine. Unfortunately, the system, based on its payments, is telling us that this has meager value.

As Ginsburg and Berenson point out (in the New England Journal of Medicine), there are powerful lobbying forces against changing payment schedules, and even though a bone is thrown on occasion to increase payment for a certain cognitive practice, at the same time, payments are reduced for other kinds of thinking medicine. It ends up as a wash, if not a reduction in rewards for those doctors who are trying to prevent disease or make a thoughtful diagnosis that takes time.

The question remains, who is a good doctor, and, moreover, who is the right doctor for any individual? The best answer that I have found for myself and my family is a doctor who thinks with us, explains clearly what is in her mind, how she arrived at her working diagnosis, and why the offered treatment makes sense for us as individuals. She may refer to guidelines and “best practices,” but clearly takes into account the spectrum of human biology and customizes our care to fit both our clinical needs as well as our emotional, social, and psychological dimensions.

We currently have a system that costs too much but appears to have professionals leaving in significant numbers because the pay is too low. It was developed as a cost containment structure based on metrics and evidenced based best practice as developed by insurance companies. The question then is to ask who gets rewarded, and what kinds of procedures are rewarded. Clearly it is not cognitive sciences. Who else?