TCS Daily

Only in America: Activist Medicine

By Arnold Kling - May 11, 2005 12:00 AM

"The trouble started innocently enough. I had something in my eye, so I rubbed it. As any mother or eye doctor can tell you, that didn't help. Three days later my left eye was swelling visibly and growing more painful by the hour...At eight thirty in the morning, my partner, Paul, drove me to the emergency room... At eleven, I was trundled off for a CAT scan...The doctor decided my case needed input from a specialist...When the ENT doctor arrived, he ...referred me to an eye specialist at the Dean McGee Eye Institute...The doctor gave me an IV dose of broad-spectrum antibiotics, just in case the swelling was caused by infection, and told us to get to the hospital immediately...We arrived at the emergency entrance to one of the big local hospitals at one thirty...[first-year resident] Dr. Murphy took a history of the condition, did a number of tests, and then couldn't manage to measure my intraocular pressure...called in a third-year resident. The new doctor went over the diagnostic data, looked at my horrific eye, and both doctors decided they needed to confer with the orbital tissues specialist...Dr. Murphy had ordered the strongest stuff known to science, vancomycin, in the fear that I might have a drug-resistant infection...When the doctor came, it turned out I was to go to the Eye Institute itself for my eye exam. Apparently, I was an "interesting case" and there would be several doctors. There were. The small examining room filled up with white coats...the next day I woke feeling much better. The pain was noticeably reduced, although the swelling was down only slightly. Dr. Sigler still didn't approve, ordered another CAT scan, and started me on IV corticosteroids."
-- "Quixote"


"Quixote" ends her dramatic story, which deserves to be picked up by a top-flight magazine, with a discussion of the medical bills that ensued, for which she blames... the U.S. private insurance system. Frankly, my reaction is a bit different. I believe that what she describes is a quintessential case of what I call "activist medicine."


I believe that I am considerably older than "Quixote," and I believe that thirty years ago or so her case would have proceeded differently. (Keep in mind, however, that I am not in the medical profession. These are strictly amateur observations.) My guess is that the CT scan would have been considered too exotic and expensive, and that the specialists would not have been so available. The internist in the emergency room would have been forced to make a decision, and he or she probably would have chosen to treat the eye inflammation "empirically" (a medical term for trial-and-error). The doctor probably would have prescribed an ordinary antibiotic, and perhaps prednisone (a steroid used to reduce inflammation), and sent the patient home, saying, "See me if it doesn't get better."


As it turned out, what brought relief to "Quixote" was an antibiotic and prednisone. Modern activist medicine could not diagnose her illness any more precisely. After all of the consultations and investigations, she wound up with the treatment that, a generation ago, would have been all that was available.


I am not saying that activist medicine is wrong, and that we should go back to an older way of practicing medicine. There probably really were conditions that might have caused her eye inflammation for which treatment with antibiotics and prednisone would have been insufficient, or even harmful. Activist medicine served to reduce the risks that she faced. But whatever benefits activist medicine provides, it is certainly costly.


The Benefits of Activist Medicine


I define activist medicine as procedures, treatments, and consultations that have a low probability of affecting the outcome. The procedures and consultations are undertaken to rule out unlikely possibilities, to confirm diagnoses, to improve chances of success, and to reassure patients.


I mean for the term "activist medicine" to be neutral, rather than positive or pejorative. I believe that there are people walking around healthy today only because an activist practitioner found something on an MRI or in a consultation in time for treatment. Just because the probability is low does not mean that the outcome is unimportant to the individual.


Consider another example of activist medicine. A few years ago, my wife was diagnosed with breast cancer. After radiation therapy, her oncologist recommended a drug called Tamoxifen. She showed us data that indicated that my wife's probability of surviving five years would rise from about 94 percent without taking the drug to about 96 percent with the drug. We agreed that this would be a good thing. Although there is only a small probability that Tamoxifen will affect the outcome, we agreed with the oncologist that doing something to improve the odds is all for the better.


The Conditions for Activist Medicine


I suspect the United States leads the world in the practice of activist medicine. I think that there are several reasons for this, including:


  • abundant medical resources, particularly availability of specialists and diagnostic imaging technology
  • high expectations on the part of patients
  • strong desire on the part of doctors to meet impossibly high expectations
  • fear of the consequences of not following activist procedures, in part because of malpractice litigation
  • belief that for patients with insurance, no consideration needs to be given to cost


Together, these cultural factors tend to foster activist medicine in the United States. By definition, activist medicine means incurring high costs with only occasional changes to the outcome. Thus, it should not be surprising that whatever benefits activist medicine provides are difficult to discern from aggregate national statistics.


Further Research Needed


I believe that before the United States embarks on health care reform, the issue of activist medicine ought to be investigated further. One concern I have is with those who have already decided that for whatever problems that might exist in the U.S. health care system, the solution is a "single payer" model or some other approach that increases the share of personal health care spending financed by government. Currently, socialized systems operate in other countries, where resources are less plentiful, so that "Quixote" probably would have been treated the old-fashioned way, rather than with activist medicine.


In the United States, if we were to overlay a system in which government pays for health care on top of a culture that expects activist medicine whenever the patient has insurance, the result could be upward pressure on spending. Unless "Quixote" is correct in attributing the expense of her ailment to insurance company inefficiency rather than to activist medicine, the "single payer" solution will turn out to make matters worse, at least from the standpoint of holding down health costs.


Instead, I hope that economists and medical professionals will undertake more research. How prevalent is activist medicine? Is it a significant factor in the performance of the U.S. health care system? Most important, are its benefits greater than its costs? If so, then perhaps we ought to be grateful for the high level of medical spending in this country. If not, then we ought to be thinking about reforms that change our health care culture, and not simply hope that "single payer" will save the day.



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