Don’t Ask the Question If
You Don’t Want to Know the Answer
By
Leonard Zwelling
This is really good advice. It is often given to defense
attorneys about asking their clients whether or not “they did it.” In general,
it works for everyone. How about some examples?
In the early days of the Obama Administration, a stimulus
package was forced through Congress in an attempt to double clutch the languishing
economy into a higher gear after the Wall Street collapse of a few months
earlier. Among the funds made available were $1.1B for comparative effectiveness
research, a form of investigation that uses a number of techniques to establish
what actually works in real medical practice and what does not. Often CER uses
historical data from medical records to identify the likely “effectiveness” of
a medical intervention.
Since the use of historical data to answer CER questions was
fair game for applying for these funds, I got on a conference call from DC with
the Division Heads and suggested that MD Anderson plumb it’s historical data on
the treatment of primary prostate cancer to establish the best way to approach
these patients and whether or not clinical parameters measured at presentation (Gleason
score, stage, patient age) might predict which patients do best with which
treatment modalities—the various surgical approaches, the many radiation
approaches or no treatment at all. I was summarily dismissed which was too bad
because we still don’t know the answer despite it being listed among the 100
most important questions for which CER should be used by an Institute of
Medicine panel staffed by a close colleague. The best explanation I received as
to why no one was interested was from a high-ranking radiotherapy friend not
from Anderson who said, “don’t ask a question when no one wants to know the
answer.”
It was likely that if a specific modality was found to be
superior, the doctors plying the losing technology would be unhappy. Thus, why
ask the question? Essentially what I was told was, we aren’t going to change
what we do no matter what you find, so don’t bother asking.
While this may seem foolish, the same might be said of the
recent finding about using spiral CT scans of the chest in people with heavy
smoking histories to screen for early lung cancer. A $150M randomized federal study was
performed in this case and found a 20% reduction in lung cancer mortality among
the studied population screened with CTs as compared to those screened with
routine chest x-rays. This survival benefit was realized by only 88 people
among the 53,000 studied, and a new NEJM article puts the price tag for this at
$81,000 per quality adjusted life year gained among a population with a
self-induced disease. Hmmmm…now what? How much will your insurance premiums go
up to pay for this screening of the millions a small subset of whom might
benefit?
You get my drift. In the first case at least the Division
Heads knew they didn’t want to know the answer so why spend the money? In the
second case, anyone could have estimated the potential cost to the American
health care system of a successful spiral CT scan trial and realized the
opportunity cost of performing these scans on everyone that qualified (money
that could not be spent on smoking cessation or childhood vaccinations). Of
course, that would mean more income for people doing the screening and
responding to the results like all those chest surgeons chasing the many benign
nodules found on CT scan that never would have harmed anyone if they had never
been found. Thus, I am advocating that we use the wisdom of the Division Heads
more often and don’t ask a question when we are not prepared to respond to its
answer with meaningful action.
I believe that the Executive Vice Chancellor of Health
Affairs just asked a series of questions that he was not prepared to do
anything about when he received the answers he got after sending out the recent
faculty survey. If he is not prepared to take definitive action as a result of
this survey, my suggestion would have been not to bother everyone by asking
them to fill out the questionnaires.
But if his intent is to make the vital change needed to
move MD Anderson in a different, more constructive direction such that faculty
morale really improves and both productivity and attitudes brighten, then get
on with it. This is easy to do except it’s a lot like golf.
Golf is an easy game, it’s just hard to play. Well, Dr.
Greenberg…..the first tee is open. Fore?
