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ONLINE FIRST
Scan for Author
Audio Interview
INVITED COMMENTARY
How to Feed and Grow
Your Health Care System
N
ot long before the editorial deadline for this
Invi ted Commentary, I headed of f on
vacation to warmer climes (this is not diffi-
cult when leaving from northern New England). But
would a week in tropical paradise be worth the frus-
tration and indignity of commercial air travel? It turns
out I was lucky. The lead flight attendant ran a
tight ship, assuring us an orderly, safe, and comfort-
able trip. Maybe I should plan more discretionary
travel.
According to the findings of a study published in this
issue of the Archives, had my recent shoulder surgery gone
more smoothly, I might instead be planning more dis-
cretionary health care.
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2012 American Medical Association. All rights reserved.
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Fentonandcolleagues
1
followedmore than50000adult
participants in the National Center for Health Statistics
Medical Expenditure Panel Survey over a 2-year period
(longer for mortality). Judging from patients reported
satisfaction with their physicians after year one, the au-
thors found that, compared with patients in the lowest
quartile of satisfaction, patients in the highest quartile
were subsequently less likely to be seen in an emergency
department, but more likely to be hospitalized, were re-
sponsible for more prescription drug and total health care
expenditures, and were more likely to die. These relation-
ships held after controlling for numerous potential con-
founders, including year one health care utilization,
health status, income, and health insurance.
The authors infer that efforts to cater to patient sat-
isfaction may be ill guided; by implicitly encouraging
health care providers to honor requests for (or to explic-
itly offer) discretionary health care services, such ef-
forts may lead to overutilization, higher costs, and worse
outcomes.
There is, however, reason to question the validity of
the inference. One of the primary findings itself raises
concerna 26% mortality excess among the most sat-
isfied patients, an effect size that far exceeds that for all
other, more immediate, study outcomes (eg, a 12% ex-
cess in hospitalizations). While the authors have at-
tempted to separate patient satisfaction from correlates
(eg, older age, more comorbidities) that might instead
be responsible for higher utilization and worse out-
comes, the likelihood of an unmeasured confounder re-
mains high. One nominationis that a patients strong sense
of connection to the health care system, related perhaps
to (unmeasured) vulnerability or frailty, might predict
more satisfaction, hospitalization, and death.
And yet the inference is entirely believableand cause
for concern. The direct relationship between customer
satisfaction and subsequent consumption is doctrine in
commerce and business.
2
The customer is always right,
a phrase likely coined by Marshall Field, the depart-
ment store magnate, in the late 19th century,
3
is a credo
that we, as consumers, may wish we encountered more
often. Is health care any different?
Apparently not.
But it should be.
While most Americans may accurately assess howwell
their washing machines, their hairdressers, or even their
airlines are performing, their evaluations of physicians
and health care interventions may have limited validity.
A dozen years ago, the New Yorker published a won-
derful personal reflection by Joseph Epstein.
4
Subtitled
A Healthy Mans Nightmare, it recounts the authors
journey from a healthy, health conscious, and physi-
cally active 62-year-old literature professor to a survi-
vor of coronary artery bypass surgery (a brutal piece of
work), weakened, with a lasting sense of vulnerability
that he eloquently labels heart-consciousness.
4
He won-
ders, one year afterwards, whether he will ever return to
his previous sense of well-being. Epsteins journey started
with a routine physicalhis gift to his wife on the oc-
casion of his 60th birthdaythat revealed a low high-
density lipoprotein cholesterol level, which in turn led
directly to a stress test. Even more remarkable than the
journey is the authors conclusion: he considers himself
lucky, attributing his good fortune to his physicians, para-
gons of excellence.
Regardless of whether one believes Mr Epstein to have
been ultimately helped or harmed by his screening stress
test, his satisfaction with the experience should perhaps
not be as surprising as I initially found it. Satisfaction with
seemingly adverse outcomes of potentially excessive medi-
cal care appears to be the norm. Numerous studies have
found that patients are consistently highly satisfied with
one of the most common downsides of medical care
false-positive test results and the downstreamevents that
follow.
5,6
Moreover, such patients are more likely to un-
dergo the same (and likely other) testing in the future,
dismissing their anxiety and other adverse effects as a neg-
ligible price for a good outcome.
The same heuristic operates on the physician. Ran-
sohoff et al
7
proposed, a decade ago, that prostate-
specific antigen (PSA) screening for prostate cancer ex-
emplifies a systemwithout negative feedback. Regardless
of the true net effect (beneficial or harmful) of screen-
ing, a physician ordering a screening PSA receives a fa-
vorable result: he can reassure the patient with a normal
PSA result; celebrate with the patient who has over-
come a false positive; or (most compelling for the phy-
sician) offer potentially life-saving treatment to the pa-
tient whose prostate cancer was caught early
notwithstanding the likelihood that the patients outcome
may be worse because of early detection. Regardless, the
physician can feel satisfied, and more certain that order-
ing the next screening PSA will be the right decision,
which will then appear to be the case, and so on.
Positive feedback systems abound in health care,
for both physicians and patients. Diagnostically,
almost any unnecessary, or discretionary, test (par-
ticularly imaging) has a good chance of detecting an
abnormality. Acting on that abnormality has an excel-
lent chance of producing a favorable outcome (be-
cause a good outcome was already highly likely). Hav-
ing obtained an excellent outcome, ostensibly owing
to a test that was seemingly unnecessary, a natural
reaction would be thereafter to perform (or, for
patients, undergo) even more discretionary testing in
patients with an increasingly negligible likelihood of
benefitand greater risk of net harm.
Consider thyroid cancer: incidence of papillary car-
cinoma (by far the most common type) has tripled over
a 30-year period, with an abundance of very small can-
cers that appear nonlethal.
8
The excess cases almost cer-
tainly represent pseudodisease (destined never to cause
symptoms during a patients lifetime)patients who can-
not possibly benefit from having had their cancer de-
tected, but can be, and likely are, harmed. However, in
the eyes of the patient, her loved ones (and casual ac-
quaintances), and her physicians, she was snatched from
the jaws of a premature death by a vigilant physician who
thought he felt something on examination or who inex-
plicably ordered a thyroid ultrasound examination. The
lesson learned, for all, will surely be to be increasingly
vigilant in the future.
Ransohoff et al
7(p665)
explains, The point is that . . . de-
cisions for aggressive interventionscreening or treat-
ARCH INTERN MED/ VOL 172 (NO. 5), MAR 12, 2012 WWW.ARCHINTERNMED.COM
412
2012 American Medical Association. All rights reserved.
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mentmay be positively reinforced when patients and
physicians viewthe decisions fromthe perspective of an
individual person.
Even if patients and physicians were to see through
this illusion, overcoming the more is always better fal-
lacy of health care remains an enormous challenge. In a
recent survey published in the Archives,
9
we found that
nearly half of US primary care physicians believed that
their own patients were receiving too much medical care,
and they identified potent systemic incentives encour-
aging aggressive practice. Practicing physicians have
learnedfrom reimbursement systems, the medical li-
ability environment, and clinical performance scorekeep-
ersthat they will be rewarded for excess and penalized
if they risk not doing enough.
More aggressive practice, therefore, improves not only
patients perceived outcomes, but also those of physi-
cians (reimbursement, performance ratings, protection
against lawsuits), and the positive feedback loop of health
care utilization is fueled at two ends.
As any engineer will tell you (and as my father, an ap-
plied mathematician, wanted to make sure I understood
as he read this over my shoulder during our tropical va-
cation), a positive feedback system is not in fact positive
(ie, favorable)it represents an unstable system, one that
cannot control its own growth, or demise. We, as a pro-
fession and as a society, can take responsibility for con-
trolling this unrestrained system only if we commit to
overcoming the widespread misconceptionthat more care
is necessarily better care, and to realigning the incen-
tives that help nurture this belief.
Published Online: February 13, 2012. doi:10.1001
/archinternmed.2012.62
Author Affiliations: Department of Veterans Affairs Medi-
cal Center, VA Outcomes Group, White River Junction,
Vermont, and The Dartmouth Institute for Health Policy
and Clinical Practice, Lebanon, New Hampshire.
Correspondence: Dr Sirovich, Department of Veterans
Affairs Medical Center, VAOutcomes Group (111B), 215
N Main St, White River Junction, VT 05009 (brenda
.sirovich@dartmouth.edu).
Financial Disclosure: None reported.
Disclaimer: The views expressed herein do not neces-
sarily represent the views of the Department of Veterans
Affairs or the US government.
Online-Only Material: Visit http://www.archinternmed
.com to listen to an author interview about this article.
Additional Information: Nathaniel Hochman, BA, MSc,
provided valuable comments on an earlier draft of this
Invited Commentary.
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Brenda E. Sirovich, MD, MS
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2012 American Medical Association. All rights reserved.
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