Richard Dolinar, M.D., writes,

The physician has taken the history, performed the physical, reviewed the labs, and discussed the illness with the patient and family. He knows the patient’s wishes, desires, and values. All this critical information must be considered when treating patients.

…It is absurd to think that a third party, operating at a distance in time and space from the patient being treated, is able to make a better medical decision than the treating physician and therefore should be allowed to preempt the treating physician’s decisions.

It is absurd to think that a baseball statistician, operating at a distance in time and space from a player being scouted, is able to make a better decision about the player’s likelihood of major league success than a local scout. Except that it happens.

It is absurd to think that credit scoring models are better predictors of default than human underwriters. Except they are.Today, we are in between two images of the doctor. One image is the heroic personal savior, who uses his own experience and intimate knowledge of the patient to make the best decisions. The other image is the trained technician, who gathers data, feeds it into a decision tree, and implements that recommended course of action.

I think we need to combine the two images, rather than treat doctors solely as heroic personal saviors. Too often, doctors’ personal experience provides nothing but availability bias. As for intimate knowledge of patients, often you’re kidding yourself if you think that your doctor has even digested what’s in your folder.

The odd thing about “pay for performance” is that it mixes up the two images. It uses the trained-technician image to determine what doctors ought to be doing. But then it gears the bonuses and penalties to individual doctors, as if they were heroic personal saviors.

My own view is that a remote third party probably can use statistical evidence to make good recommendations for a course of treatment. Patients should be aware of those recommendations, and doctors should allow patients to choose between the statistical recommendations and the doctor’s personal recommendation. I would like to see consumers responsible for more of their own health care spending, with access to the third-party information, and with doctors not being so ego-driven in claiming that they know best. In that case, consumers would have the means, the motive, and the opportunity to make cost-effective decisions.