Taking care of our health has always been a major concern for most of us. As the economic condition improves, healthcare service becomes increasingly accessible. When the number of private hospitals increases, we don’t have to queue for hours at a public hospital (well, if we can pay for private service). We don’t have to rely on health insurance to cover the cost. And, as some of my friends who had been in other countries remarked, healthcare in Vietnam is really cheap. Therefore, we rarely have to worry that our illness won’t be treated. But with the increasing availability of healthcare service, a new set of problems arises. We can be over-treated, treated incorrectly, or even treated without us having any health problems. Here, I want to dig into these issues and point out the causes, with the hope of providing some points to consider before going to a hospital or a health clinic, taking any drug, or undergoing any treatment. But before I start, there are some points which I want to clarify. First, I don’t want to generalize to all health service providers, all doctors. There are certainly good, humble and prudent doctors. Second, my experience is limited to healthcare service in Vietnam. In developed countries, from what I read in several books, the situation might be better, but some issues still exist or in even worse form than those in Vietnam. Now, let’s go through the causes of what can be called a new “healthcare crisis” one by one.
The first problem to consider is the classic principal-agent problem. The principal is the one who delegates responsibility to someone else, the agent, to act in the principal’s interest. The agent knows something that the principal doesn’t, and uses it to take advantage of the principal, and act in his interest instead. In this situation, we are the principal, who delegates part of the responsibility to take care of our health to our physician, who should consider our health his highest responsibility (well, at least for the duration of the visit). But it is usually not the case. The physician might prescribe some drugs or procedures that are unnecessary, or might even harm us, to gain a handsome amount of money, in the form of commission or operating fee. Even if it is not about money, the doctor might still do it to protect himself from being blamed, to keep his reputation. Which leads us to another problem: the dumb-principal problem, which exacerbates the previous one, to the detriment of the patient’s health. In the dumb-principal problem, the same agent-issue occurs, but the principal is the one to be blamed, for his inability to create an environment in which the agent can serve the principal’s interest. Let me use an example to illustrate this point. Let’s say I came to a doctor, feeling a bit unwell. After careful examination, he concluded that I was suffering from a mild form of illness, and treatment was not required. So I went home, and after some time, the illness became severe, for some unknown reasons. What would I do then? If I was like most people, I would blame the doctor for not doing anything. I wouldn’t care that the chance of the illness becoming severe is one in a million, or that I was ill because of other reasons that happened after the visit, or that, this is the crucial point, the doctor had made the best decision, to my best interest, with the information available at that time. Therefore, from the doctor’s point of view, doing something is always better than not doing anything, regardless of the result, since he can avoid being blamed and losing his reputation, by replying: at least I tried. The one to blame is us – the dumb principal, when both our psychology and our culture prefer addition and intervention to omission, judge the quality of a decision based on the result, not by the information available at the time of decision. I will conclude the discussion of the first problem with this advice: before taking any drug or procedure suggested by a doctor, consider whether he has anything to gain from it, or anything to lose from not doing it.
The second problem is the limitation of knowledge. We might think that our doctor is an expert in his own field, who can cure most of the related diseases, but in fact he isn’t. It is an undeniable truth that there are many conditions for which we don’t have a cure. We don’t have a cure for AIDS. We don’t have a cure for every type of cancer. Why? Because the human body, a biological system, is extremely complex, with interdependency between different parts. Medicine and biology are not mechanics or physical science, just like the body, shaped by billions of years of evolution, is not a simple, artificial machine. We don’t have the knowledge to cure all diseases efficiently and locally yet. Even if there is a cure, there is usually difficulty in execution, side effects, complications, and a lot of uncertainty in the outcome. At this point, we might say, yeah, admitted, but what is the point? The point is, our doctor usually doesn’t admit his limitation, and doesn’t present the problem to us in this way. Overconfidence is the biggest issue when knowledge is limited. This problem is especially acute in Vietnam, where the patients don’t have enough basic knowledge to question even the most questionable decision of a doctor. A doctor is then getting used to being in a high, authoritative position. So he doesn’t inform us of the necessary stuff, the unknown or uncertain stuff, because he thinks it is not necessary, or maybe he doesn’t even think of it. He prescribes drugs as if there is no side effect. He prescribes procedures as if there is no complication. I’m not even exaggerating. Just think about the last time we visited a doctor. Did he tell us about the side effects, or just quickly write down all the drugs that we need to buy? Did he, before prescribing a procedure, tell us about all the alternatives, the statistics related to each, including possibilities of complications, the time we need to recover, how our life will be changed afterward? Did he give us the time to calm our emotions, to think it through, to consult our family, who will inevitably be affected? Did he discuss with doctors in other departments, consider our body as a whole, not just a combination of independent parts to be treated independently, without any consideration of other parts? So what can we do to alleviate this problem? I think we should always have a plan, a list of questions to ask our physician. Never assume he knows everything and can cure everything. And take our time before making an important decision.
The last problem is the problem of information. Having a lot of data is not necessarily good for us. More data could mean more noise and less signal. To make good decisions, especially those concerning our well-being, we need signals, not noise. But in many cases, we get noise, not signal, when we go to the hospital, particularly during some routine check-ups while we are feeling perfectly well. Where does the noise come from? It comes from the inherent variations in our biological process. Consider this example: our blood pressure. It varies according to many factors: time of the day, what we just eat, how we currently feel, or just because of nothing at all. If we sample our blood pressure every hour, and then take drugs to increase it when it is low, then take drugs to decrease it when it is high, we will end up worse, not better. What we really need to do is, well, nothing at all. But this kind of interventionism is exactly what we get when we do regular health screening. Noise also comes from irrelevant, misleading tests and measurements. Take the new, “advanced” HP bacteria test service, with all the drugs and treatments that follow as an example. It is said that HP leads to inflammation, cancer and all the scary stuff. But it is also said that 70% of Vietnamese people have HP in their guts. What? 70%? Do 70% of Vietnamese people have cancer? I don’t think so. People have lived with HP for years without any problems. The problem is whether we should know about it. I certainly think we shouldn’t. But if we know about it, then we have to know enough about it. Not the kind of junk information on the Internet, somehow uttered in the same form by highly educated doctors. We need the statistics, not sheer possibilities. HP could lead to cancer, but what is the probability? I can say that eating could lead to cancer. Should we stop eating then? There are inherent risks in all living activities.The point is not to eliminate all the risks, regardless of the cost, but to make informed decisions, to avoid the high risk and live with the insignificant one. The same applies to medical decision-making: avoid regular check-ups, ignore superficial claims, and choose intervention only when the condition is severe.
To summarize, all we need to do is to be aware. Be aware that the physician might not act in our best interest. Be aware that there are many things he doesn’t know, and might not tell us about. Be aware that it is not wise to know about something and try to act on it when the knowledge is insufficient or framed in a certain way. And, above all, be aware that it is our responsibility to take care of our health. So think carefully, and trust nobody (including me).
(Most of the ideas are borrowed from Taleb and Nassim Nicholas Taleb and Atul Gawande. Read them if you have time. They are certainly more knowledgeable and enjoyable than me.)