Richard Smith: Where is the value in medical care?

richard_smith2We have an old dog we love, and my wife and I have been debating whether to take him to the vet. Will it be worth it, asks my wife. The dog is coming up to 13 (91 in “human years”). He has a large lipoma. Some of his teeth are bad. He may be a little deaf, and he doesn’t see well. He may have arthritis in his back legs, and we wonder if he’s demented.
We’ve shortened his walks. He sleeps most of the day and still enjoys his dinner.

“What will the vet do if we take him,” wonders my wife. “If we get one of those young useless ones they’ll want to X ray him, do blood tests, and anaesthetise him to look at his teeth and possibly remove his lipoma. They’ll find other things, and before we know it, we’ll have spent £2000 and have a proposal for £5000 more. It isn’t worth it. Maybe we could take him to the old vet and simply ask if there’s anything that might make him more comfortable, but he doesn’t seem that uncomfortable. Let’s not bother.” Doesn’t the same go for human beings?

Vets have a financial incentive to order tests and complicate management. Doctors in Britain don’t have the same direct financial incentive, but they do have a financial incentive in that if doctors didn’t do lots of tests and interventions, we wouldn’t need so many doctors. This sounds outrageous, and I’m not suggesting that doctors are making a direct connection between having a job and doing more tests and making more interventions. Rather they are trained to “get to the bottom of things and sort them out.” They are not trained to think: “Is this worth it from the patient’s or society’s point of view,” although many doctors learn it with age. “Good surgeons know how to operate, better surgeons know when to operate, and the best surgeons know when not to operate.”

I think of my father, dead for just over 10 years. He may have had value added by the warfarin for his atrial fibrillation in that he didn’t ever have a heart attack or a stroke. He died of renal carcinoma, and value was probably added by the bronchoscopy in that his chest mass might have been treatable. But his hospital admission subtracted value in that they stopped all his drugs and got him into an uncomfortable mess. We avoided the interferon that would have cost a lot and done no good. There was value in his terminal care, but it was in the people, the conversations, and the nursing—not any kind of medical intervention.

My mother is still alive in a nursing home with no short term memory. She takes no drugs, and no value was added by her MRI scan, her visits to the GP and the memory clinic, and her elaborate psychological tests—all of which she hated. Mostly, these expensive activities subtracted value, but there was bureaucratic value in that she was diagnosed as having dementia, which opened up various financial benefits. Value has, however, come from the carers who visited her when she was at home and the home where she now lives, but we have had to pay for all of that. It seems ironic to me that the bit with no (or negative) value is free, but we have to pay for the bit that does add value.

Although with medical care—for dogs and humans—it’s easy to do a lot and end up subtracting, rather than adding value, people across the world must value medical care because there is a very close correlation between the amount that countries spend on healthcare and their GDP. As we get richer, we spend more on healthcare. But what value do we think we are getting? Economic studies show that we are willing to pay huge amounts to fend off death for a few weeks, even if the quality of those weeks is horribly low. Most medical care costs arise in the last months of life, and the value seems to lie in keeping death at bay—or rather the perception that we are keeping death at bay. We know that people who move from “curative” (completely the wrong word) to “palliative” care often live longer than those who stay with “curative” care, which is not surprising in that many of the “cures” kill us. It’s the same logic that leads to death rates going down when doctors strike.

We can’t really know the value in fending off death in that we know not what we fly to; the dreams that may come give us pause. If you believe that you are going to fry or freeze in hell for all eternity, then there seems to be lots of value in fending off death for another few minutes; although mathematicians, and even a friend’s four year old, will point out that “eternity minus a few minutes” still equals eternity. If you believe in heaven, then there can be no value in fending off death. If, like most Britons, you don’t believe in either, then I can’t see the value in spending lots on medical care to fend off death. Death, I suggest, is a very value added state: profound peace at no cost, and not even any carbon consumption.

In contrast, there seems to be little value in a horrible old age, the curse of many. The mantra has to be that an “aging society,” some of it the result of medical care, is a good thing, but is it really? A politically minded friend, who is 51, says “assisted suicide will have to come as there won’t be the money or the people to keep us when we’re old.”
My message to young doctors and vets is that it’s all too easy to spend a life working hard at medicine, and end up subtracting rather than adding value.

Richard Smith was the editor of the BMJ until 2004 and is now chair of the board of trustees of icddr,b [formerly International Centre for Diarrhoeal Disease Research, Bangladesh] and chair of the board of Patients Know Best. He is also a trustee of C3 Collaborating for Health.