Viewpoint: Honesty In Healthcare – A Little Bit Can Go A Long Way
"A foundation of trust is necessary for the best practice of medicine."
Honesty in Healthcare, part 1.
Background:
I favor free market solutions over continued expansion of governmental involvement in healthcare, and favor free market solutions over control of healthcare by giant monopoly-like corporations. I am skeptical of the idea of “government/private partnership.” Regulatory capture goes in both directions, although is typically defined as the corporations or groups capturing the government entities.
I’m not an absolutist or opposed to sincere debate, but I understand that (in general) the downsides of detailed laws and regulations are often underestimated, and that governmental “solutions” are actually tradeoffs. Like some other authors I admire, though, I also think that the subject of character and virtue seems intricately related to the entire subject of centralization vs decentralization; of planning by experts vs more individual liberty. Views on planned vs free markets represent differences in worldview and understanding of human nature. Check out Thomas Sowell’s Conflict of Visions and Lawrence Reed’s Are We Good Enough For Liberty?
Series On Honesty And Other Virtues In Healthcare.
I plan on this being the first of a series, as honesty (or lack thereof) alone is a big topic in healthcare. This is a more philosophical and less data-driven subject than some others that Jack Brown and I have written in Healthcare Viewpoints.
I feel strongly that we have a huge deficit of honesty in healthcare, although the practice of medicine has never been perfect in this regard. Here is a nuanced article on snake oil, which has been considered the classic medical scam.
Why We Have So Much Dishonesty In Healthcare.
Many readers have seen the dishonesty for themselves, as have I. Maybe this is related to the fact that medical care is increasingly delivered and run by large institutions, governmental and otherwise, which tend to operate off a complex set of rules, based on an unspecified and mixed moral foundation. It is individuals who are (or should be) responsible for having personal integrity; for trying to operate off a set of carefully cultivated internal values, hopefully including honesty. Perhaps too few people in large institutions take that responsibility personally. It’s nice when institutional rules and the values of the individuals working within them align, but they often don’t. It seems that within large institutions, their rules and values generally prevail over the values of those individuals working within them. To quote one of the business greats, Edwards Deming: “A bad system will beat a good person every time.” There is hope among many people for continually evolving and perfecting the rules, but I am downright pessimistic about that making people and systems more honest.
Another reason for problems in the area of honesty and virtue in healthcare may be that our society seems to have lost basic consensus as to what virtues are. We seem confused and fractured. One of my personal beliefs is that good relationships between individuals must be based on some degree of reciprocity, often verbalized as the ‘golden rule.’ If the care and consideration don’t go both ways most of the time, it doesn’t work very well. When we are one-on-one, it seems easier to hold each other accountable, or (importantly) decide not to deal with each other.
Lack of reliable excellence in healthcare:
I suspect that most of us, no matter the political or philosophical persuasion, believe that health care in the United States is something of a mess and not as good as it should be, in spite of incredible historical and current achievements. I like Billy Joel music, and one of my favorite Billy Joel songs is “Honesty.” The lyrics comment on how rare honesty can be in love relationships and how it can be the most important thing. Sadly, honesty seems to also be rare but important in healthcare today, and the song now makes me think of dishonesty in healthcare. I think that the lack of honesty is one of the most critical things about our lack of reliable excellence in healthcare. Honesty is one of the things I specifically seek when choosing a physician, along with indications of competence. However, I don’t expect it from giant healthcare systems, and enter them when necessary with some trepidation. I have always advised my own patients: ”Buyer beware, and seek excellence.” One traditional antidote for dishonesty in business dealings is competition; having plenty of other choices to go elsewhere. Healthcare has greatly consolidated, and we often have fewer choices than in the past.
In medicine, a traditional bulwark against unethical practice has been the Hippocratic Oath, and there are many versions in addition to the original (with significant differences between them).
It can be difficult to assess competence in medicine, especially since so many situations are complex and unique, and hidden from the public (operating room for example) and still subject to opinion, despite modern technology. An imperfect but important surrogate for demonstrated competence is trust, based on reputation, experience and training, rapport, outcome, etc. A foundation of trust is necessary for the best practice of medicine. Trust can be tested and strained when results are bad or emotions are high, which is a common thing in healthcare, due to its very nature. A foundation of trust is all the more important to pull us through those difficult times, and it should not to be taken for granted. Dishonesty, when discovered, kills trust. If not discovered, trust is betrayed.
I am going to give one example of dishonesty to start this series, with more to follow next month. This one is personal, and is a follow up to the Healthcare Viewpoints article I wrote in July, 2022. Once it was eventually acknowledged that I did have a second good faith estimate (lower than the first) issued by the hospital for a stress echo procedure, and that no additional services were performed, the hospital representative said that the “higher ups” would likely honor the estimate, although would add $400.00 to it. I heard this from two separate representatives. This is because the No Surprises Law provides for a dispute resolution process if the bill is more than $400.00 higher than the estimate. They never intended to honor their “good faith” estimate, because they knew the loopholes and intended to use them! I then politely asked the first representative what she thought of that, after saying that I thought it was not right. She took offense at the question and asked me to leave her office, which I did, after apologizing for offending her. I finally got the bill adjusted to the amount on the estimate, but only after I had my lawyer write a cover letter to my letter. To me, this representative was participating in a scam of sorts, and did not appear to have the self-honesty to admit it. Maybe I am being hard on her, but if none of us in large organizations accept the responsibility to speak the truth, things will likely get worse. Next month, I have other examples that I think are interesting and illustrative. Eventually, I will plan on discussing some remedies that are not giant legislation or more administrative rules. It’s a big problem, but when a lot of people begin to understand it, perhaps we can begin to make a big difference.