The crisis of trust in medicine: a personal story

When you get $9,000 to hammer, everything looks like a nail

This week, my mom called me to talk about a potential medical procedure.

This was not entirely a surprise.

My mom just turned 80, the golden age for American healthcare. What I mean is: she is old enough to go to doctors all the time, not so old the doctors can’t do anything. She’s in decent shape, meaning she doesn’t have cancer and can handle stairs. She went to London this spring. I think I’d sign for that at 80.

This week’s call was about something new, though.

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(Mom needs a new pair of Medicare copays!)

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I need cataract surgery. I went to a new ophthalmologist, he says I need it, he says it’s $5,000 to $9,000 each, I’m not sure why, I need to find out.

Mom, I said.

That seems like a big difference.

Hold on, I said.

You know my ophthalmologist retired, I don’t know why, she was only in her forties, she never said anything about this, this one -

Mom, I said. Are you having any problems? With your vision?

No.

Like at night?

No. I mean, sometimes when I walk through Times Square at night, it’s hard to see -

You get halos? Everyone gets halos in Times Square at night.¹ Anything else?

Not really, no.

Okay. Before you have eye surgery, I think you should make sure you need it. Like actual symptoms. Everyone has cataract clouding as they get older. And after all you have XXXX (another medical procedure) coming up too, you shouldn’t do this unless you need it. So you should ask him, what will happen if I don’t do it? Will it get worse in some irreversible way?

Yes… well, I’m seeing him again tomorrow.

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(First, do no harm. Or buy a new Range Rover? I can’t remember, it’s one or the other.)

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My mom called back the next day and said he didn’t just want to do the cataract surgery, he said she might need a procedure on her optic nerve.²

I am a very big fan of clinical medicine - that is, treating the patient’s symptoms - rather than blood test medicine.

And I am a very big fan of NOT having diagnostic procedures unless there is extremely strong evidence that they can find illnesses that can then be treated. In other words, unless having more information will affect your downstream choices in some way, what is the point of having more information.

And I am a very big fan of waiting to see if you recover on your own — though as you may recall that last one didn’t serve me particularly well when it came to my back and drop foot.

What I am not a big fan of is doctors who look at test results and see an excuse to do very expensive procedures on elderly people. That is to say, I am sure my mom has cataract clouding. This wasn’t fraud. Everyone has cataract clouding at 80. But the fact her cataracts are clouded doesn’t mean she needs surgery. She doesn’t drive at night and she has never complained about problems seeing.

So. She dumped him. All on her own — she didn’t need any more advice from me, hearing about the optic nerve was enough. Dr. Feelgood³ killed the golden goose, but no doubt he has a hundred more.

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(I don’t kill the geese… I just send you T-shirts! Get your Founding Member tee today!)

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She has an appointment with a new ophthalmologist, if this one also says she needs the surgery, okay, we will talk. But what if she hadn’t said anything about it to me? Presumably the surgery would already be scheduled. And presumably it would go fine, and my mom would have a few fewer halos at night, and Dr. Feelgood would be that much closer to his next trip to St. Barts, yay him.

But maybe not. Not every surgery goes perfectly — though it is the patient, not the doctor, who faces the risk. And even if it does, the cost is real, even if the system is now so large that even the most expensive drug or procedure is a rounding error.

In medicine, more than any other profession, we as patients must trust in the honor and integrity of our caregivers. They have a massive informational advantage even in elective surgery like this, much less for more serious and emotionally taxing situations like cancer treatments.

But healthcare - and American healthcare in particular - is filled with financial incentives that can distort the relationship between doctor and patient, and at worst lead physicians to exploit their patients.

I have no idea how to fix this problem, or even if it is fixable.

In the meantime, my best advice is to ask anyone who wants to cut you open every question you can imagine, including the most important: what will happen to me if I do NOT do this?

1. Putting aside the question of why my 80-year-old mother is in Times Square at night. (She goes to plays sometimes.)

2. I’m not sure what, we didn’t get into it.

3. Not his actual name.