Tuesday, April 28, 2020

42. Best Practices Medicine vs. Triage Medicine (Demographic Doom Podcast)

This is the script for my Demographic Doom podcast episode (#42) released on 29 April 2020. It may differ slightly from the final broadcast. This episode is available on major podcast platforms, including PodbeanApple Podcasts and a video version on YouTube. See the description on the YouTube version for annotations, links and corrections. You can also comment on this episode there. (If you leave comments on this blog post, I might not see them.) The main website for this project is DemographicDoom.com

I’m Glenn Campbell. I call myself a demographic philosopher. I’m looking at life and trying to predict the future through the lens of demography, or the study of human populations. I'm trying to view the world from the widest possible angle, as aliens would see us from space, so I am interested in what large groups of people are doing, rather than individuals.

In this episode I want to return to a topic I've touched on earlier: It's a basic dilemma faced by modern medicine: Do you throw all of your resources into saving just a few people, or do you distribute your resources, trying to save as many people as possible? Saving as many people as possible involves a rationing of medical care, because there is never enough medical resources to serve everyone.

I brought this up in Episode #37 earlier this month. This was an hour-long personal podcast about my cancer relapse and how my hospital was handling Covid-19, but there's actually some demographic philosophy buried in there, and I'd like to flesh it out a little. First, let me replay the relevant part of that episode on April 5. It's about six minutes long.
There's a conflict in medicine that I've touched on in previous podcasts and videos and that's the difference between best-practices medicine and triage medicine. 
Best practices medicine is when you pull out all the stops to save one patient. You want to give him the best of everything and you try not to expose him to any kind of risk, and that's how how medicine is practiced in the developed world. Whatever risk there is, we're going to mitigate it. Whatever the patient needs we're gonna give it to them. We're not going to compromise on anything. 
And this is actually backed up by our tort legal system in America, our system of lawsuits. If ever a doctor were to give a patient less than optimal care and something bad were to happen, the patient or their family is going to sue that doctor. That's how America works so American hospitals have no choice but to offer optimal care, best practices care to everyone. 
The alternative to that would be triage medicine. Triage medicine is when you don't have the resources available to treat everyone, and this is true in over half the world. They don't have the medical systems to treat everyone, so they have to parcel out their resources in such a way is to save the maximum number of people. 
This is the sort of thing that would happen on a battlefield. Let's say you have a battlefield Hospital and you have a hundred wounded sword soldiers that come in, and you've got beds for only a dozen of them. Who are you going to serve, and how are you going to serve them? That's a an exercise in triage, in deciding how to parcel out your very inadequate resources.  
In the case of a wartime hospital you're going to focus on the patients that you could do the most for. in other words there's soldiers that come in that are so badly wounded that you can't do anything for them. They're probably going to die anyway so you shunt them aside to begin with. And then there are soldiers who are so lightly wounded that they're going to survive no matter what you do for them, and they can can get away for a while without medical treatment, so you put them aside, and what you focus on is that middle range of patients who can be most helped by the limited resources that you have.  
And you don't try to give them perfect care. You give them just good enough care that you save them and can move on to the next patient. And you're playing a game of numbers here. Maybe you save them. maybe don't. You're just going to trying to increase their odds, but when you're in triage situation you have no choice. You have to make do with the resources you have.
And that's rapidly approaching with the Covid-19 thing, that we're going to be in situations here where we don't have enough ventilators. We don't have enough facilities and doctors and everything to treat everybody, so somebody at some point has to make some triage decisions about who gets treated, but from the hospital's standpoint, it doesn't happen here. It doesn't happen in Beth Israel, because Beth Israel, like every other Hospital in the country, is focused on best practices and giving the the patient everything they need without any compromises. It's essentially unsustainable in an epidemic like this. 
It's unsustainable, but there is this firewall between the hospital and the outside world. The outside world might have to deal with triage, but the hospital itself doesn't. Once you get into the hospital you're guaranteed optimal care within the resources that they have. They might still have not have enough ventilators, but they're going to do everything in their power to eliminate risks and give you everything you need to survive. 
Best practices is also essentially the the philosophy behind all of these lockdowns. So when New York State or Massachusetts tells all of their citizens to go home and don't interact with anybody and keep a 6-foot distance between all people, they're really practicing this sort of perfect medicine where they're trying to eliminate any kind of risk whatsoever. 
And I think the silliest example of that is closing in the beaches in Massachusetts and elsewhere. The place you're least likely to catch a disease would be a beach because there's all this huge distance between you and your fellow beachgoer. There is virtually no chance of catching Covid-19, but it falls under this blanket thing. Lock downs are basically a sledgehammer approach where we're going to eliminate every possible source of infection no matter how unlikely. 
And like best practices elsewhere, the only problem is that it is frightfully expensive to do this. The horrible expense here is that by locking down everything and shutting down the economy, you are destroying people's livelihoods, you are assuring a massive depression that's going to be caused a lot more human misery than the virus itself.  
So the virus itself will be under control by the end of 2020, but the great depression, the huge economic collapse is going to go on for years and decades and it's going to be made all the worse by the fact that these these municipalities and states and countries impose these draconian lockdown rules instead of addressing the things that really matter.
So I'm back at the end of April again, four weeks later, and I've been in an out of the hospital in my cancer treatment, and I've seen a lot of best-practices medicine and virtually no triage medicine. When the slightest anomaly happens, they order a whole slew of very expensive tests, which happened to me only a few days ago. I had this disruption in my vision where everything in my left visual field was blotchy. It made it impossible to work on my computer. Within half hour of it happening, I reported it to my nurse, and that set all the wheels in motion: two MRIs, a CAT scan, an EKG, consultations with two neurologists and an opthalmologist, and they hooked me up to a heart rate monitor that I'm still wearing so they didn't miss anything.

Without getting too deep into the details, there were two explanations: the benign explanation and the slightly scary explanation that might affect my treatment. There's a high probability—I'd say 99%—that the benign explanation is true. It's only the 1% scary possibility that triggered all the tests. And that in a nutshell is the problem with best-practices. It is largely incapable of making compromises. Even a one in a thousand chance of the bad thing is enough for the specialists to be all over it and to order all the tests, and they won't rest until they have definitively ruled out the bad diagnosis.

That's one of the reasons health care costs are so high. It's not just a screwed up delivery system or all the well known problems of American health care. There's also the problem that no responsible doctor can leave any stone unturned in assuring the health of their patient. If there's a one-in-a-thousand chance of something bad happening, and it's within your power to diagnose or treat it, then you're obligated to run down that one-in-a-thousand possibility, at a huge cost to the system.

Never mind that the patient is obese or a smoker, or the patient is ninety years old and will probably die before this one-in-a-thousand risk ever happens. Doctors are obligated by the medical system, the legal system and probably their Hippocratic Oath to do everything they can for their patient, even if this risk is trivial compared to real-world concerns.

Triage medicine, on the other hand, would have to take into account the real-world costs of diagnosis and treatment, and it wouldn't bother with relatively trivial risks. In my case where there's a 99% chance this thing is benign, the triage physician would say, "Okay, those are pretty good odds, so let's forget about that other unlikely possibility." If doctors were allowed to make judgment calls like this, you might be saving 50% of all medical expenses, which ultimately means that more people are going to get served and more lives are going to be saved.

There's only place I'm aware of in modern hospitals where triage medicine is actually employed. It's when there are multiple competing diseases in the same patient, and doctors have to prioritize them to save the patient's life. The patient has cancer, but he also might have heart issues or vision issues or dental issues. The patient is dying, so you can't use best-practices for everything. You have to focus on the one thing that's most important right now, that's going to save the patient's life, and everything else is pushed into the background. As soon as the patient is saved, and the time pressure is gone, then the system falls back into best-practices mode.

This isn't a matter of socialized medicine vs. the American capitalist model. This is a dilemma faced by any medical system, even in Canada or the UK or any other country where health care is free. Health care, of course, isn't really free. Somebody pays for it, and medical expenses are rising everywhere, helping to bankrupt countries like Canada and the UK. As long as medicine keeps advancing, it naturally gets more expensive, if for no other reason that when you save someone's life, you're guaranteeing more medical expenses for that person for all those extra years. If the patient lives to be 90 because you saved him from a heart attack when he was 60, you've guaranteed 30 more years of medical expenses that society has to somehow pay.

In Canada and the UK, they still use the best-practices model, which means that if there's a 1% chance of something bad happening, they still got to run all the tests. No medical system in the developed world is capable of making triage decisions, where you prioritize patients to save as many lives as possible. In the modern world, survival is more a matter of whether or not you get into the hospital at all. If you get into the hospital, you get optimal treatment. If you don't get into the hospital, you don't get treated at all and you die. There's no middle ground.

I'm not saying there's a solution. In an ideal world, you would ration medical care to save the most lives, without any delineation between rich and poor, but in the real world, it's more likely to be the rich with good health insurance who get treated. At the same time, a lot of people who have taken very poor care of themselves are also getting optimal care. If you never exercise, smoke like a chimney and couldn't care less what you eat, the best-practices system is going to treat you no differently than someone who has done everything right. In fact, the people with poor health habits are soaking up a disproportionate amount of medical resources, because the best-practices system is not allowed to discriminate against them.

No doctor is allowed to judge whether or not someone deserves to live. This means, ironically, that a 60-year-old Death Row inmate is going to receive exactly the same medical attention as a law-biding college student with their whole life ahead of them.

A public hospital in a poor Third-World country is more likely to adopt the triage model. There's way too many patients and not enough resources, so someone has to make some hard choices about how those resources are used. If the choice is between saving one patient at enormous cost or ten patients at the same cost, the ten patients are going to win, and life-saving treatment will be denied to that one patient.

As a regular customer of the best-practices system, I can't see the system changing anytime soon. Doctors are trained to give every patient optimal care, as though they were the only patient in the world. This is fine as long as you live in a rich country with plenty of resources, but the system breaks down when the needs outstrip the resources. If that's the case, only a select few get optimal treatment, and everyone else gets no treated at all.

So that's the end-game of the best-practices system. As health care gets more expensive, fewer and fewer people will have access to it. It could happen because you don't have health insurance and the hospital won't admit you or because wait times are so long that people die before they get into the hospital.

There's no easy way out of this. Simple socializing medicine won't fix the problem, because the issue will still be too many patients and not enough resources, no matter how it's paid for.

The irony here is that the more medicine advances, the longer people live, and the greater their lifelong health care costs will be. In turn, this means that fewer and fewer people get healthcare at all, and more end up dying.

I cover this is in a video from June 2019 called The Medical Science Paradox: Why Longevity is Falling. My point there is that at some point, technical advances in medical science are going to stop saving total lives. A few chosen people may live longer and longer, at ever-greater expense, but overall longevity of the population may actually fall. Medicine may have already reached a steady state where its not improving society anymore. If you're interested in this topic, you might want to check that video out.


Written, recorded and edited by Glenn Campbell. For annotations, links and corrections, see the description on the video version of this podcast. You can also leave comments there.