Media Myths about Dr. Donald Berwick; Is There A Chance He Won’t Be Confirmed to Head Medicare & Medicaid?

Kaiser Health News (KHN) reports that “the nomination of Dr. Donald Berwick to run the agency overseeing Medicare appears to be languishing.”   Friday, KHN’s “Health Policy Week in Review” quoted a story that appeared in the New York Times a few days earlier:

"Hospital executives who have worked with Dr. Berwick describe him as a visionary, inspiring leader. But a battle has erupted over his nomination, suggesting that Dr. Berwick faces a long uphill struggle to win Senate confirmation. Republicans are using the nomination to revive their arguments against the new health care law, which they see as a potent issue in this fall's elections, and Dr. Berwick has given them plenty of ammunition. In two decades as a professor of health policy and as a prolific writer, he has spoken of the need to ration health care and cap spending and has confessed to a love affair with the British health care system." 

KHN also points out that according to The Hill, although Senate leaders are nearing an agreement to allow more than 60 Obama nominees to be approved to begin work, Berwick is not on the list  . "'He will not get unanimous consent,' a spokesman for Senate Minority Leader Mitch McConnell (R-Ky.) told The Hill.

I am not at all persuaded that Berwick’s confirmation is in trouble.

  As the highly-respected president and CEO of the Institute for Health Care Improvement, Dr. Berwick enjoys support that ranges from the AARP to three former directors of the Centers for Medicare and Medicaid (CMS) who served under Republican presidents. “This is not really about Don Berwick,” John Rother, executive vice president for policy and strategy at the AARP told McClatchy Newspapers. "In ordinary times, the nomination of somebody with Don's record and standing in the field would not be controversial.” Thomas Scully, who led the CMS under President George W. Bush agrees: "He's universally regarded and a thoughtful guy who is not partisan. I think it's more about … the health care bill. You could nominate Gandhi to be head of CMS and that would be controversial right now."

Berwick also enjoys warm endorsements from the American Association of Family Physicians, the American Medical Association, and the American Hospital Association. He is known for his ability to listen to other medical professionals, hear their concerns, and collaborate with them.

That said, I do think that conservatives will do their best to postpone the confirmation hearing. And the longer they defer the hearing, the more time they will have to try to demonize Berwick.  

Plucking Quotes Out of Context

The Times suggests that “Berwick has given them plenty of ammunition,” implying that it might be Berwick’s own fault if his opponents turn his words against him. But, in fact, Berwick chooses his words with great care. He  hones his speeches; he is not a loose cannon.

 Nevertheless, conservatives are adept at “cherry-picking” quotations, plucking one or two sentences out of context to suggest, for example, that Berwick would like to “ration” Medicare. And in a world of “cut and paste” journalism, truncated quotes are repeated over and over, until they become facts.

The Columbia Journalism Review’s Trudy Lieberman recently described how the myth-making machines works:  “Republican senators are out for Berwick’s scalp and have begun using the specter of medical rationing as the way to turn him into a headhunting trophy. They like to bring up certain statements that Berwick has made like this one: “The decision is not whether or not we will ration care. The decision is whether we ration care with our eyes open.
As Lieberman points out “opponents usually omit the last sentence of the quote, “And right now, we are doing it blindly.” Ripping two lines out of context, critics also tend to ignore the first sentence of Berwick’s statement. Here is what he actually said, in a 2009 interview with Biotechnology Healthcare: “We make these decisions all of the time. The decision is not whether or not we will ration care. The decision is whether we ration care with our eyes open. And right now, we are doing it blindly.”    

Rationing “With Our Eyes Wide Open”

In context, it’s clear that Berwick is saying that we already do ration care, but we do it wantonly, according to ability to pay, without regard to whether the patient needs the treatment. Berwick suggests that we should decide which treatments to pay for “with our eyes wide open” –looking at medical evidence about risks and benefits. If even a small pool of patients who fit a particular medical profile would be helped by a service or product, they should get it: “’Evidence-based medicine’ is not just a catch phrase;” he writes, “it is a promise we want to make to our patients – to use all the care – and only the care – that can help them.”   Somehow this last sentence never seems to show up in the hundreds of blog posts and news stories that have been written about Berwick in the last two months.

Usually we think of “rationing” as restricting consumption of a commodity that is in short supply. But in fact, the root of the word “ration” is “reason” and this is much closer Berwick’s meaning. His aim is to make the system more rational by using medical evidence to distribute products and services.  The goal: “to get the right care to the right patient at the right time.”

His aim is not cut  to Medicare, but to improve it by eliminating some of the waste that clogs our bloated system—the unnecessary, often redundant tests, the ineffective, unproven treatments that expose patients to risk without benefit . . . and the hospital errors that, too often, lead to longer stays, more medication, another surgery.

In December, Berwick made his agenda clear when he challenged an audience of doctors and hospital administrators to reduce the number of tests and treatments that their patients undergo “by 10 percent”:  “Do that without a single instance of harm, without rationing effective care, without excluding needed services for any population you serve." (Hat tip to McClatchy Newspapers’ reporter David Goldstein for calling attention to Berwick’s words)

But do we have the medical evidence needed to cut waste without lowering the quality of care? Yes, says Berwick: “Through modern clinical epidemiology, technology assessment, and clinical research, we have developed powerful new tools to assemble, digest, and judge the evidence-base for clinical practice. Rational care plans can emerge, based firmly in scientific evidence, and drawing on research published in hundreds of journals that serve as the basis for the expert opinions and guidance of professional medical societies."

At the same time, he would not impose comparative-effectiveness research (CER) on doctors and patients. In the Biotechnology interview, he agrees that “mandatory compliance with CER directives could be dangerous, if you overdo the tightness of the connection between the knowledge of effectiveness and the rules of compliance. Then you get into the ‘proletarianization’ of medicine — physicians, payers, and patients being told what to do instead of being able to use their own judgment. There’s a balance here between advisory declarations with enough knowledge that they really have some force, and requirements.”

Trudy Lieberman Calls for Context and Clarity

At the end of her column in the June 14 issue of the Columbia Journalism Review, Lieberman notes that conservatives have a way of making a sound-bite their own: “As we reported in the March/April 2010 issue  of the Columbia Journalism Review, when the discussion of ‘death panels’ made its way into the media, the press let right wing ideologues set the agenda and spread misinformation, allowing weeks to pass before refuting their false claims. By then it was too little too late.

“This time, we’d like to see the media act as leaders instead of followers.” Lieberman writes. “For starters, they can begin to quote Berwick accurately . . . None of this business about selective quotes that opponents will inevitably use.

Unfortunately it may once again be too late.

If you Google “Berwick” and “the decision is not whether or not we will ration care,” you will find those two lines culled from a 1200-word interview have been repeated more than 10,000 times. One wonders how many reporters actually read the piece in Biotechnology Healthcare— and how many were simply repeating what they read in another paper, or on another blog.

How Cherry-Picked Quotes Wind Up in the Mainstream Media

No surprise, the  truncated quote often shows up  on avowedly conservative blogs such as netrightdaily , Redstate.comAmericans for Prosperity, and As well as in local newspapers such as The Trentonian

But you’ll also find it in a Boston Globe Op-ed written by Jeff Jacoby, a Globe columnist, and  in the news article published last week in the New York Times.

The Times story is instructive; it shows how much confusion a few familiar quotes repeated out of context can create.  The article does not set out to bludgeon Berwick.  It begins by describing him as “a man with a mission, a preacher and a teacher who has been showing hospitals how they can save lives and money by zealously adhering to clinical protocols for the treatment of patients.”  (Though, at the very end, the lead wobbles. Is “zealously” adhering to protocols good or bad? Hard to say.)

New York Times’ reporter Robert Pear goes on to suggest that Berwick faces a “long uphill battle to win confirmation.” And in describing the “ammunition” that Berwick has given his opponents, the reporter  notes that Berwick “has spoken of the need to ration health care . . . and has confessed to a love affair with the British health care system.”

Throughout the piece, rationing becomes a leitmotif: “The Senate Republican leader, Mitch McConnell of Kentucky, describes Dr. Berwick as an ‘expert on rationing.’  Senator Pat Roberts, Republican of Kansas, calls him “the perfect nominee for a president whose aim has always been to save money by rationing health care.’ . . . Senator Charles E. Grassley of Iowa, the senior Republican on the Finance Committee, said he had no doubts about Dr. Berwick’s academic and professional qualifications, but wanted him to explain his comments on rationing.”

Pear acknowledges that, according to administration officials “Republicans have taken his comments out of context.”  But the reporter doesn’t seem to buy that argument, noting that, “In fact, many of the comments have been repeated, with slight variations, in Dr. Berwick’s articles and lectures over the years.”  Then, Pear offers an example:

 “In an interview, last year in the journal Biotechnology Healthcare, Dr. Berwick said, “The decision is not whether or not we will ration care — the decision is whether we will ration with our eyes open.”

Oh no, not again. The same two sentences—cast in the future tense—with no hint that we already ration care and do it in an irrational way. Ironically, Pear is using a snippet that has been ripped out of context to counter the argument that Republicans have taken Berwick’s comments out of context.

Pear does give Reid H. Cherlin, a White House spokesman, a chance to explain: “Rationing is rampant in the system today, as insurers make arbitrary decisions about who can get the care they need. Don Berwick wants to see a system in which those decisions are transparent, and the people who make them are held accountable.”

But because the quote omits the two sentences that frame the statement, a reader may well be left with the impression that Berwick favors “transparent rationing.” In other words, as one of his critics puts it, “we’ll know who is on the death panel.”

An alert reader will notice that, in the middle of the article, Pear offers two good examples of what Berwick actually means by “rationing”:  “In his book, Escape Fire: Designs for the Future of Health Care, Dr. Berwick sharply criticized ‘the dangerous, toxic and expensive assumption that more is better.’ He insists that the nation can cut health costs without harming patients because vast sums are misspent. . . .” He explains how Berwick would “ration” end-of-life care: “Long before the uproar over ‘death panels’ last year, Dr. Berwick was urging health care providers to ‘reduce the use of unwanted and ineffective medical procedures at the end of life. Using unwanted procedures in terminal illness is a form of assault’” he said in 1993 at the annual conference of his institute. ‘In economic terms, it is waste.’”

But as the Times’ article moves forward, it continues to see-saw.“’I have said it before, and I’ll stand behind it, that the waste level in American medicine approaches 50 percent,’” Berwick declared in an interview in the journal Health Affairs in 2005. “Dr. Berwick has championed efforts to ‘reduce the total supply of high-technology medical and surgical care’ and to consolidate services in regional centers,” Pear adds.  Does this mean that Berwick views “high tech surgery” as “waste”?

If only reporters would quote one or two other lines from the same 2005  Health Affairs interview: “Innovation is absolutely crucial, and I don’t think we should slow down our investment in better technologies,” Berwick said.  But, he explained, “we have a learning disability in this country with respect to the difference between technologies that really do help and technologies that are only adding money to the margins of the companies that make them, without essentially paying their way in value. . . One of the drivers of low value in health care today is the continuous entrance of new technologies, devices, and drugs that add no value to care. If we had strong national policy, it would allow us to know the difference,”  he adds, referring to the fact that, under current law, the FDA does not ask drug-makers or device-makers to show that a new product is in any way better than –or even as good as—products that are already on the market.

As the Times' story rolls toward a conclusion, the emphasis seems to falls on restricting healthcare in order to save money: “On more than one occasion, Dr. Berwick has suggested a need for a cap on total health spending, with limits on annual increases.

 “In speeches and articles celebrating the 60th anniversary of Britain’s National Health Service in 2008, Dr. Berwick said he was ‘in love with the N.H.S.’ and explained why it was ‘such a seductress.’

“The N.H.S. is not just a national treasure,’ he wrote; ‘it is a global treasure.’”

“Among its virtues, he told a British audience, is that ‘you cap your health care budget.’”

Some might well call this type of reporting “balanced.” But as a reader trying to thread my way through a controversy, I find it dizzying. I want to know: is Berwick’s idea of “rationing” a threat to Medicare, or not?  If I were a Medicare patient, I would be nervous.

If Berwick said one thing in one speech, and something else in another speech, one would have to say that that the fault is his. He changes the message, depending on the audience. But the truth is, if you look at any of the conservatives’ favorite “pull-out quotes” in context, you’ll find  that the message is the same: “rationing” is never about cutting care that would help a patient.  Don Berwick wants to save money by improving Medicare. 

Berwick’s “Love” For the U.K.’s National Health Service

If you think conservatives are fond of the phrase “rationing with our eyes wide open” imagine what they do with Berwick’s declaration of love for the NHS.  “I am romantic about the NHS,” Berwick said in July 2008. “I love it. All I need to do to rediscover the romance is to look at health care in my own country.”

In May, Kansas Sen. Pat Roberts read the lines on the Senate floor and then asked, rhetorically: “Why is this important? Because the NHS rations health care.”

At the beginning of this month David Catron reprised the quote in the American Spectator, followed by several paragraphs denouncing the NHS as “a third-world operation that employs Soviet-style central planning to produce terrible care and worse outcomes.  . . . if confirmed, this man will do real damage.".

Two weeks ago, right-wing pundit Betsy McCaughey used the same familiar lines in a New York Post.Op-ed, explaining that Berwick likes the NHS for its “central planning, frugality, wealth redistribution and rationing.” 

Fox & Friends, The Boston Globe Op-ed, the New York Times article, and virtually all of the blogs cited above bring up Berwick’s admiration for the UK’s healthcare system.  Google “Berwick” and “love” and “NHS” and you’ll get 18,400 results..

What most fail to mention is the context. Berwick made the speech on the occasion of the NHS’ 60th birthday. Quite naturally, he had some nice things to say. You don’t go to a birthday party and begin your toast by roasting your host.

But Berwick’s detractors ignore the second half of the 3,000-word speech which begins: “Is the NHS perfect?  Far, far from it.  I know that as well as anyone in this room.  From front line to Whitehall, I have had the privilege to observe its performance and even to help to measure it.  The large scale facts are most recently summarized in the magisterial report by Sheila Leatherman and Kim Sutherland sponsored by The Nuffield Trust called The Quest for Quality: Refining the NHS Reforms.  They find some good news.  For example, after ten years of reinvestment and redesign, the NHS has more evidence-based care, lower mortality rates for major disease groups (especially cardiovascular diseases), lower waiting times for hospital, outpatient, and cancer care, more staff and technologies available, in some places better community-based mental health care, and falling rates of hospital infection.   . . . There is less progress in some areas, especially by comparison with other European systems, such as in specialty access, cancer outcomes, patient-centeredness, life expectancy and infant mortality for socially deprived populations. In other words, in improving its quality, two facts are true: the NHS is en route, and the NHS has a lot more work ahead.”

Berwick then devotes 1250 words to “ten suggestions” as to how the National Health Service could do better.
He begins by urging the NHS to “put the patient at the center – at the absolute center of your system of care.   . . . It means asking, “How would you like this done?” It means asking, “How can I help you?” and then you fall silent and you listen.”
He goes on to tell the NHS that it should  “strengthen the local health care systems – community care systems – as a whole.”  In addition, he argues that NHS must “reinvest in general practice and primary care.  These, not hospital care, are the soul of a proper, community-oriented, health-preserving care system.  General practice, not the hospital, is the jewel in the crown . . . “

Berwick explains that the many “governmental and quasi-governmental organizations concerned with assessing, assuring, and improving the performance of the NHS need to collaborate. . . . they do not work well with each other.  The nation lacks a consistent, agreed map of roles and responsibilities that amount, in aggregate, to a coherent system of aim-setting, oversight, and assistance.”

Finally, Berwick exhorts the NHS to “train your health care workforce for the future, not the past.  That workforce needs to master a whole new set of skills relevant to the leadership of and citizenship in the improvement of health care as a system – patient safety, continual improvement, teamwork, measurement, and patient-centered care, to name a few.”

The speech ends with a question: “Would it not be thrilling in the next decade for the NHS – the National Health Service – to live fully up to its middle name?” If someone other than Berwick had said this, it definitely would have sounded snarky. Coming from Berwick, it was meant as inspiration, and my guess is that the audience took it that way.

Nevertheless by the time Berwick finished with his “10 suggestions, I can only imagine that his audience was exhausted at the thought of how much work lies ahead. If this is “love” it is what they call “tough love.”

Does Berwick want to model Medicare on the NHS? I don't think so.

18 thoughts on “Media Myths about Dr. Donald Berwick; Is There A Chance He Won’t Be Confirmed to Head Medicare & Medicaid?

  1. Maggie,
    Very happy to hear you believe Berwick still has a good shot at the job.
    In my opinion the right and other vested interests WILL continue to demonize him.
    His biggest hurdle? Attributing to him the “R” word or rationing which will be spun by Berwick’s opponents to freighten especially the elderly.
    This fear card might work to block him? But I would have Berwick continue to emphasize quality patient centered care.
    He should not use the phrase “assault on patients” ever again. It is much too aggressive.
    Conversely on death and dying he should use my quote that “Every American citizen DESERVES as dignified and as pain free a death as modern bio-medicine can possibly provide”-ral
    Thanks for this great article.
    Dr. Rick Lippin

  2. He might not want to model Medicare on the NHS, but I think he would give a virtual right arm for something approaching our primary care system, and his exhortation to have a ‘health’ service (and not a ‘healthcare’ service) recognises that the UK is some way ahead of the US in having a service that combines the wider determinants of health, although of course both the UK and the US have the widest inequalities of all developed countries.

  3. Hit pieces like that piece in the Times are beyond ugly. I printed it out and counted no less than twenty negative words or phrases in the short space of thirty little paragraphs. My blog post said in part…
    “Dr. Berwick is clean as a pin, the perfect candidate to head CMS. He has the enthusiastic support of all the right professionals. But for political reasons his nomination will be another opportunity for continued partisan carping and misrepresentation to pollute the broadcast and print media coming out of Washington. I will be watching C-SPAN closely to see if anyone uses both hands to drink from water glasses during Congressional hearings. It will be an indication that the slime in the room is so thick that drinking with one hand might risk spilling.”
    GOP grandstanding and obstructionism got another boost with the passing of Senator Byrd. Carefully calibrated negotiations approving financial reforms were still wet on the page and before another sundown two Republicans were kicking it while it was down instead of demonstrating a shred of comity.
    I get more disgusted with Washington politics as the weeks and days pass. Maggie, you are a model of deportment I wish I could imitate.

  4. Charles , Dr. Rick, Marc, John:
    Charles–Welcome (I don’t recognize your name from past comments)—and thanks much for the kind words.
    Dr. Rick–
    Thanks as always.
    I like your formulation on end-of-life care: “Every American citizen DESERVES as dignified and as pain free a death as modern bio-medicine can possibly provide”
    On the use of the word “assulat”: I suspect that many people who have seen relatives or close friends die in a hospital can relate to the notion that providing Unwanted treatment to a patient who, in some cases, is actually strapped to a hospital bed is an “assualt on patients.”
    But, I agree, I wouldn’t advise using that language in Senate confirmation hearings!
    Marc– I entirely agree; Berwick sees the strenghts of the NHS.
    At the same time, he is not calling for limiting care for people over a certain age (which is most people think of when they hear the words “NHS” and “rationing” ) As Berwick puts it, we want to give patients “all” of the care that will help them, but not more (at the point where you begin to harm them.)
    Thank you very much. And, yes, the negative words and phrases did pile up. . .
    “Clean as a pin” describes Berwick to a T.
    I’m not quite a “model of deportment.” Long-time readers know that sometimes, I lose it.
    But I try.

  5. I actually think that Dr. Berwick has a much bigger problem than his affection for NHS and his statements on rationing care.
    It seems that by all accounts he is a “visionary, inspiring leader”, and visionary and inspiring leaders don’t fare well in Washington nowadays. Small minded bureaucrats are afraid of visionary leaders. They’d much prefer that everybody wears the same shade of gray. It’s safer that way. Just imagine if he could actually put a serious dent in CMS expenditures. How would we continue to scare people with the specter of all those welfare related “unfunded liabilities”?
    As to end-of-life, I’m afraid I disagree with your advice Dr. Lippin. I don’t believe it’s Government’s place to define what assault is and it’s not Government place to define what patients deserve either. The point here should be that every American should have a RIGHT to choose how he/she wants to be treated, and every American should have a RIGHT to receive the necessary information so they can make an informed decision based on their personal values and preferences. And this includes end-of-life treatment.

  6. Margalit–
    Don Berwick understands what Washington is like. It is rough, but I think he’ll be able to deal with it,
    On end-of-life care: Berwick, like most reformers, totally believes in palliative care–which means that a palliative care tean lays out the options– including possible risks and posslbe benfit with each treatmetn– and lets the paieint make a truly informed choice.

  7. Is the stuff I’ve been reading about Berwick’s views on the supremacy of “patient centered-ness” similarly cherry-picked? Specifically, he’s been quoted as saying, “I’m somewhat of an extremist when it comes to patient choice,” meaning that if a patient wants a scan or test shown not to be medically necessary (or cost-effective) that the patient ought to receive it anyway. This doesn’t bode well for cutting the waste from a bloated system. I have a general wariness of all extremists, especially self-described ones.

  8. I’m all for palliative care, laying out options and truly informed medical choices in end of life situations. In a world of finite resources, however, there is an issue of where to draw the line at making taxpayer resources available to pay for extremely expensive and often futile care. By contrast, anyone willing and able to self-pay or who can find a charity to pay on their behalf can have anything they want, no matter how cost-ineffective.
    The majority of end of life situations in the U.S. likely involve patients suffering from heart failure, cancer, advanced dementia or Alzheimer’s. In the case of the latter two, the patient is likely to be elderly and, in the advanced stages, no longer able to even recognize family members. Healthcare decisions must be made by surrogates, hopefully, informed by previously executed living wills or advance medical directives. For cancer patients, choices usually involve whether or not to undergo chemo drugs which can be both expensive and include serious side effects. For patients with heart failure, there could be frequent admissions to the hospital to have fluid removed that has built up due to poor kidney function. Also, doctors may recommend expensive surgical procedures that include insertion of devices to keep the heart functioning awhile longer.
    So, in addition to palliative care teams laying out the medical options and the quality of life implications of each, I think Medicare and Medicaid patients and families especially should also be informed of the likely cost of care, not to the patient, the family, Medicare, Medicaid or the government, but to taxpayers. Also, if family members are providing custodial care at considerable financial sacrifice and emotional cost, that burden should be reflected in the ultimate decision as well. I reject the notion that patients and families should be entitled to unlimited care, no matter how expensive, futile or cost ineffective while they expect someone else to pay the bill.
    It would be helpful if the Senate confirmation hearing has Dr. Berwick provide considerably more detail about his thinking around end of life care, how we can better control costs and improve the value for money that patients, their families and taxpayers receive.

  9. Dinosaur #1, Barry
    Yes, that’s also cherry-picked.
    Here’s the full context, near the end of the essay:
    “First, leaving choice ultimately up to the patient and family means that evidence-based medicine may sometimes take a back seat. One e-mail correspondent asked me, “Should patient ‘wants’ override professional judgment about whether an MRI is needed?” My answer is, basically, “Yes.” On the whole, I prefer that we take the risk of overuse along with the burden of giving real meaning to the phrase “a fully informed patient.” [In other words, he wouldn’t just say “no”, he’d have a conversation with the patient about the MRI]
    I contemplate in this a mature dialogue, in which an informed professional engages in a full conversation about why he or she—the professional—disagrees with a patient’s choice.
    If, over time, a pattern emerges of scientifically unwise or unsubstantiated choices—like lots and lots of patients’ choosing scientifically needless MRIs—then we should seek to improve our messages, instructions, educational processes, and dialogue to understand and seek to remedy the mismatch. , ,
    I can imagine just as easily as my critics can a crazy patient request—one so clearly unreasonable that it is time to say, “No.” A purely foolish, crazy, or venal patient “want” should be declined. But my wife, a lawyer, told me long ago the aphorism in her field: “Hard cases make bad law.” So it is in medicine: “Exceptional cases make bad rules.” You do not successfully rebut my plea for extreme patient-centeredness by telling me that, on rare occasions, we ought to say, “No.” I say, “Your ‘rare occasions’ make for very bad rules for the usual occasions.”
    . A second objection emphasizes the duty of the professional as steward of social resources. Is patient-centeredness of the type I envision socially responsible? No one can yet know the answer to that question.[Because we haven’t yet gotten in the habit of giving patients all the infomration they need about risks and benefits so that they can share in the decision. Usually, doctors just prescribe and patients say “Okay.”]
    Pandora’s box may be empty. O’Connor and colleagues’ summary of shared decision making for surgery cuts the other way: more sharing, less invasive care; and the work of Wennberg and Elliott Fisher suggests that supply drives demand, not the other way around.
    At a minimum, I suggest that becoming responsive to individual needs and wants can give us the information we need for informed social choices to be made where they mostly belong: at the level of public policy.”
    What he is saying is first: If a patient asks for an MRI and the doctor doesn’t think he needs it, the doctor shouldn’t just say “no.” Patient-centeredness means talking to the patient about why he thinks he needs it (maybe he’s scared; maybe his brother died of a brain tumor)–give him a chance to express his anxiety. Then, the doctor would engage in a conversation, explaining why he doesn’t think the patient needs the MRI. At that point most patients would accept the doctor’s decision.
    IF one patient remains convinced he needs the MRI , Berwick would give it to him–just to calm him down (It might will have a placebo effect—i.e. the headache he thought was a brain tumor would go away., That would be worth the price of the MRI.)
    Bewick goes on to say that if many patients were asking for MRIs then physicians should re-think how to educate patients about MRIs. (For instance, right now many medical professionals as well as the American Cancer Society are trying to re-educate men about PSA testing–the hazards, the limited benefit, etc. )
    He also says “OF course, sometimes a patient will make an entirely unreasonable request and one must just say no.” But those are the exceptions. You don’t make rules from exceptions.
    On the idea that the doctor should be trying to make sure we’re not wasting medical resources, Berwick generally agrees with that idea, but he says “Pandora’s box may be empty”—patients demanding more care than they need may not really be the big problem driving health care costs higher.
    We know that most over-treatment is “supply-driven”– the patient didn’t demand surgery, the doctor tells him he needs a bypass.
    When patients are fully informed about risks and benefits, and given a chances to share in decison-making, all of the reserach shows that they are likely to want less treatment than a doctor would prescribe. In cases where patients are considering elective surgery (for instance, an knee-implant)
    if they are given all of the info, 20% to 30% decide against the surgery.
    So Berwick is saying, rather than launching a campaign telling doctors “You must say NO more often” we need to launch a campaign telling doctors: “You should explain risks and benefits of any treatment to the patient, give him time to think about it, and share in the decision as to whether he wants the treatment.”
    If we did that, health care costs would automatically fall.
    Here’s the whole essay– the most interesting part is in the first half:
    You seem to be saying that if someone is demented we shouldn’t spend resources on keeping them alive.
    I agree that we shouldn’t go to extraordinary lenghts to keep the body alive -implanting a pace-maker, for instance–
    but do you think we should continue to give custodial care– medication for infections? food? water?
    Unfortuately, many Alzheimer’s patients live for quite a long time, and custodial care is expensive. But would you really recommend starving them to death, or letting an infection overtake the body?
    If so, should we provide custodial care for severely retarded children?
    Brain-damaged adults?
    Moreover, as palliative care specialist Diane Meier points out: very often we just don’t know which patients in an ICU will die and which will survive.
    It’s particularly difficult to predict whether patients suffering from heart disease are close to death.
    Are you suggesting that if an otherwise pretty healthy 82-year-old needs heart surgery, he shouldn’t get it based on his age?
    How about a 79-year-old who is also a diabetic–but has the diabetes more or less under control?
    What about a 75-year old who is mentally sharp, but blind, and needs heart surgery–should he get it?
    I could go on. I think you get the point.
    This is why, in our culture, we do our best to let the individual make end-of-life decisions.
    Moreover, 80% of our health care dollars are spent, not on end-of-life care, but on care of people suffering from chronic diseases.
    By definition “chronic” means diseases that they can live with for a long time. That’s why they are so expensive.

  10. Maggie,
    For patients with advanced dementia or Alzheimer’s, I think surgical interventions are inappropriate under most circumstances. I certainly did not suggest simply starving them to death. Just because I’m more conservative than you are, I’m not a mean, heartless or unreasonable person. As these patients deteriorate, however, they often reach the point where they cannot survive much longer unless a feeding tube is inserted. An honest and thorough discussion with family members or other surrogate(s) is needed to determine whether a PEG tube should be inserted or not. When a friend’s mother was dying of Alzheimer’s and reached this point, the people in the nursing home told him that they could probably keep her alive for a considerable period with a feeding tube but her mind is in the process of shutting down. Do you think she would want to be kept alive under these circumstances? Is that what you and your siblings want? Their answer was no.
    For cancer patients, the issue is drugs, their side effects and their cost vs. their potential to extend life or prolong dying. The palliative care team needs to play a strong role in these cases whether surgeons and oncologists like it or not.
    In the last category, I was talking about congestive heart failure, not the broad spectrum of ordinary heart disease much of which can be controlled well with medication or dealt with quite effectively with surgery. Patients with CHF have very poor heart function, often with ejection fractions of 25 or lower. This can lead to kidney failure and frequent fluid buildup in the lungs and/or abdomen.
    “If so, should we provide custodial care for severely retarded children?”
    My brother, who will be 59 later this year, is severely retarded and has lived in a state institution or group home for the last 40 years. Custodial care is appropriate for him and for everyone else similarly situated. However, if he reached the point where he needed a feeding tube I don’t think he should get it. Nature should be allowed to take its course.
    Dementia and Alzheimer’s patients often die in nursing homes while those with cancer or CHF are more likely to die in a hospital setting. In all cases, both nursing homes and hospitals are paid more if they do more. More care is not better care, especially here.
    Finally, you often seem to say that you wish the U.S. were more like Europe. Well, when it comes to end of life care, I wish our healthcare system were more like those in Europe. As for the series of hypothetical situations that you listed as to whether or not care should be provided, perhaps we should look to your friends in France and Germany and take a close look at how they handle the issue. While we’re at it, we could do the same with medical dispute resolution / tort reform.

  11. Barry–
    I was not suggesting that you are a mean or heartless person. I was simply trying to illustrate how such decisions can put a society on a slippery slope.
    I tend to agree that a feeding tube isn’t appropriate for a demented person–but what if he has made a living will saying that he does not want food or water withdrawn, under any circumstances? If I were his wife, and knew that he was terrified of this prospect, I would insist on the feeding tube–even though I wouldn’t want it for myself. (Some people who have not gotten feeding tubes have survived and report feeling that they were starving to death.)
    I am very sorry about your brother. Had I known, I never would have used that example. I’m sorry.
    I used it becuause I was quite certain that you would say, of course, a severely retarded adult
    deserves custodial care.
    I agree that palliative care specialists should play a major role with cancer patients–and oncologists or other doctors should not be able to block access.
    But you need to understand that the palliative care specailist will support what the patient wants to do. The palliative care specialist is not there to save money; he or she is trained help the patient discover what he or she truly wants–and to give him the information so that he can make an informed choice.
    Some people want to fight to the end, for a variety of reasons, ranging from religous beliefs to the fact that they have young children, and feel that a few more months will give them time to explain to the children what is happening, explain that they are not abandoing them, love them, etc. (This may not be true. A five-year-old may not understand. But if the parent believes that she will, I would want to give her those extra months.)
    Palliative care specialists are not there to talk patients into “letting go”–they are there to give the patient a clear picture of options, and to give the patient an opportunity to express his will.
    On congestive heart failure– as you know, patients can live for quite a long time while suffering from congestive heart failure.
    I’m not sure what you’re suggesting in these cases.
    It seems to me we want to give CHF patients as much care as we can, for as long as it helps them.
    Finally, end-of-life issues are handled differently in many European countires because most Europeans don’t share our great fear of death.
    Our culture is grounded in belief in the importance of the individual. This means that the disappearnce (death) of an individual is a calamity.
    European cultures tend ot put more empahsis on society as a whole, not the individual. Thus, the disappearnce of an individual is not seen as something unnatural, a mistake of some kind, or something that shouldn’t happen.
    If we accepted death, our health care system would be far more rational.
    Again, I’m sorry if I seemed to imply that you are heartless. I just think that in real life, end-of-life situations can be very complicated–often it’s not even clear whether the patient will die– and so the appropriate response is just not that clear.

  12. Maggie,
    I fully understand that some people want to fight to stay alive as long as possible and may well have executed a living will with those instructions. At the population level, however, if everyone had access to palliative care services for end of life situations, I think we would probably save money relative to the system we have now even though the team is there to explain options and offer support, not to steer the patient one way or the other.
    I wonder, though, how many of these people who want to try anything and everything to stay alive as long as possible would make that choice if they had to pay for it themselves even if they were wealthy or at least could comfortably afford to pay the bills out of savings when that money could be used instead to pay for a grandchild’s college education or make a significant donation to a favorite charity or cause. If they wouldn’t be prepared to spend their own resources in this manner, if they had the resources, it doesn’t seem right to me to expect taxpayers to finance largely futile care that most people neither want nor expect themselves.
    Regarding heart failure, my father had this toward the end of his life, along with diabetes and ESRD. He could have gone on dialysis and lived somewhat longer but I gently discouraged it because I could see how miserable he was. His mind was sharp but he was no longer able to walk and it was clear that he wasn’t ever going to be able to leave the nursing home. He was incredibly frustrated and refused to take part in any of the social activities the nursing home offered. For him, declining dialysis, which would have meant traveling by ambulance to the local hospital three times a week and back to the nursing home, was the right decision. For someone else with similar medical issues and advanced age but with a different attitude and outlook, dialysis might be a perfectly reasonable choice.
    Sometimes I think doctors are guilty of holding out false hope when the chances of any meaningful benefit from further treatment are remote at best. If they really think there is nothing more that can be done that could benefit the patient, they should say that there is nothing more that I / we can do for you.
    Finally, I didn’t take any offense at the custodial care for the retarded example.

  13. Barry-
    People who, for one reason or another, are determined to fight death really don’t care how much it costs.
    It could be their money, or somone else’s money. If you are willing to prolong the pain of dying it is because your desire to live-or your fear of death–is much, much stronger than practical decisons about money
    Of course, I’m speculating here, but intuitively, I’m pretty sure that this is true of 95% of patients hwo fight to the end.

  14. Oh dear, Maggie. The old “just give them more information and eventually they’ll see the light” trope.
    For what it’s worth, unlike Dr. Berwick (or you) I actually do this every single day. My practice isn’t nearly as busy as most, so I have the time for these extensive discussions (whether or not I get paid for it is another matter, one that is seldom addressed).
    By definition, it is impossible to give people enough information to make them doctors. I have very well-informed patients (I know; I do my best to inform them; I review what they find on the internet, help explain it at length) and still the desire for the unnecessary MRI is rampant. It is NOT a rare occurence by any means. It happens nearly every day.
    The reality of the current dysfunctional tort system is that the ultimate answer still has to be “yes”. But enshrining that into Medicare policy will do nothing to cut waste.
    I favor something like a “loser pays” scheme, in which patients must pay for physician-deemed unnecessary tests only if they are negative. “Peace of mind” has its costs; it seems fairer that they be borne by the patient instead of society, especially since there are a lot of people out there who cannot be reassured regardless of how many negative tests I order (and who categorically refuse to address the emotional issues usually at the root of this situation. I see a lot of depressed and anxious people who insist on another MRI instead of appropriate psychiatric treatment).

  15. Hi,
    I just stumbled upon your blog while preparing a post to my own blog “So what do you think about that?” I am writing about my own experiences as a layperson doing some self-directed study on the U.S. health care system and one of my readers posted a comment citing the myths about Berwick. I was excited to read your excellent piece, and I’ve now subscribed to your blog. Looking forward to reading you regularly.

  16. This was indeed an outstanding piece of journalism, but unfortunately, it turns out that there are 42 fools in the Senate who will not confirm Dr. Berwick.