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Gardiner Harris, Report Cited by Obama on Hospitals Is Criticized, NY Times 2/18/2010
My understanding of Wennberg’s work is that he says there are three reasons for geographic variation. One is over-utilization of services (aka waste). The second is under-utilization of services (aka the poor or rural communities that lack certain medical equipment) and the third is preference-based care. This last is very important. He says that when medicine is uncertain and more than one viable treatment approach exists (think breast cancer and prostate cancer), the treatment option belongs to the patient in consultation with the treating physician and that variation because of this is acceptable variation. This is because risk/benefit decisions need to be made at the individual level taking into account how ill this patient is, whether they have responded to certain treatments in the past, what allergies or other side effect issues they may have, and their values.
Much of medicine is unknown; treatment studies cannot be done to resolve every question; science shifts and changes–variation based on individualized care is important. Another point he made was that patients, given the choice, commonly choose less invasive and, therefore less expensive care. This year my mom died and the entire family was against invasive measures that might prolong a life that lacked quality and had suffering. I see this shift in thinking more and more–patients don’t want to bankroll services that don’t restore health or improve quality of life.
A recent article by Dr. Stricker and me in Philosophy, Ethics, Humanities and Medicine focuses on medical guidelines when there is scientific uncertainty and when treatment options should be preserved for the patient. This is a critical question in medicine today.
You can follow additional comments on Lyme policy at www.lymepolicywonk.org. You can contact Lorraine Johnson at lbjohnson@lymedisease.org.
