Health Care Reform: The Difference Between Rationing and Rational

When Clinical Science and Clinical Judgment are Dissonant

Not long ago, I attended "Grand Rounds" at a prominent medical school where the professor and director of the Cardiac Catheterization Laboratory was holding forth on the mechanisms by which newer stents can stay open longer. I asked him how he explains the stent option to a patient with chest pain in view of the results of OAT, COURAGE, BARI 2D and RITA-2.

He, of course, was aware of all these trials. Even though the trials recruited patients with four very typical patterns of disease, he suggested many patients do not quite fit these categories. He was willing to rely on his clinical judgment to infer that a particular patient would be advantaged because he is endowed with a special level of expertise.

I asked him if he told the patient that his judgment was superseding a compelling science and that his judgment had not been subjected to testing. He ducked the question. As far as I'm concerned, when the precedent is not even encouraging, such an inference demands scientific validation before it is put into clinical practice.

The Lottery Mentality

For me, this is irrational behavior on the part of the patient and worse on the part of the navigator. It survives in America because of what I call the "lottery" mentality: "Doc, if you can get me through this and it only works one time in a thousand, I want to be that one. Go for it!"

True, someone wins the lottery, even if it's exceedingly improbable. But the science we're considering is not a lottery. The argument that pertains is that the patient is as likely to do as well without the procedure as with it. It would be as if you could win the lottery without buying a ticket.

Furthermore, would the American lottery mentality drive clinical decision making if the patient had to buy the "ticket" instead of all of us sharing its cost. And if we knew the science, would we be willing to share the cost. If not, is that rationing, or rational?

Rational Reform

Interventional cardiology for coronary artery disease consumes about a third of the finite health care resource and advantages no patient. If we couple that with common practices where studies lead to a conclusion of "no discernible benefit," we can free up about half of the finite resource and easily provide rational care and caring for all.

Then we can tackle the thorny issues of interventions that work sometimes or just a little, and of interventions yet to be discovered. If we hold the care of the patient as the entire reason for the enterprise, even the thorniest of issues are surmountable.

Dr. Nortin Hadler is professor of medicine and microbiology/immunology at the University of North Carolina at Chapel Hill, and an attending rheumatologist at University of North Carolina Hospitals. He is the author of "Worried Sick: A Prescription for Health in an Overtreated America" and "The Last Well Person."

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