As Seen In: LinkedIn Pulse, Greg Sorensen, originally posted on June 23rd
While multiple countries across the globe struggle with limited access to proper healthcare, we in the U.S. currently have the opposite problem, what I call “Marshmallow Medicine.” We have an urgency to do something: Doctors and patients alike have come to expect immediate action at every appointment, often with little regard for whether that action is necessary.
This is the same impulse that Dr. Walter Mischel found in his famous self-control experiments in children at Stanford University in the 1960s. When given the choice between eating one marshmallow right away or waiting just 15 minutes and getting two, two-thirds of children aged 4-6 didn’t have the impulse control to wait. Our healthcare system seems to have an equivalent lack of impulse control—hence the term “Marshmallow Medicine.”
The rush to treat has long characterized how our healthcare system works and, worse, how we pay for it to work. The chain of overtreatment is usually prompted by an unexplained condition that propels our medical professionals into action. With no overtreatment penalties and very few incentives for watchful waiting, we as health practitioners have few barriers to taking immediate action.
This problem is often confused with other concepts, such as over-diagnosis. In fact, accurate readings of diagnostic tests provide crucial information that could help inform mature decision-making. How we use these tests is critical. When used wisely, these tests allow us to avoid overtreatment, the real heart of Marshmallow Medicine.
Last month (May 2015), a group of doctors in the U.K. published an article in the British Medical Journal urging physicians to stop the “overtreating” epidemic. The article hearkens back to the 2012 “Choosing Wisely Campaign,” an initiative to educate health professionals and their patients about avoiding unnecessary treatments and prescriptions. I agree wholeheartedly with their mission.
Take, for example, an elevated PSA value. When a patient presents with an elevated PSA and an enlarged prostate, there is a choice: to act or wait. In many cases, we physicians eagerly test, and when low-grade prostate cancer is confirmed, we treat aggressively, although such treatment may not always be warranted. Watchful waiting, which is less costly than active intervention, means active monitoring. By ignoring the option to retest, we are practicing Marshmallow Medicine.
Look for examples of Marshmallow Medicine and you will see them everywhere. After all, no hospital administrator is rewarded for keeping beds empty, and few health practices are rewarded for avoiding expensive tests. The system simply provides little incentive for even the most ethical practitioners to delay.
Of course, we cannot simply hope to avoid the marshmallow test. Unlike those children in the studies, not signing up for the experiment isn’t an option. In medicine, we are faced with questioning patients, and they seem to be demanding action. How do we avoid failing the marshmallow test?
First, we need to recognize and measure the problem, which, at its core, is arriving at the right diagnosis. The right diagnosis, even if it takes time, will then drive the correct actions. I know of no health provider in the U.S. that systematically tracks its diagnostic errors, even though they are much more common than other medical errors. We should reward health professionals that make early and accurate diagnoses and penalize poor performers.
Second, we need to recognize that diagnosis can be difficult. Unlike our existing system, which initiates payment bundles for treatment only after a diagnosis, we should incorporate diagnosis into the payment bundles themselves. Until we celebrate and highlight the importance of diagnostic excellence—even if it takes a while—little attention will be paid to getting it right the first time.
Finally, at a time when the Institute of Medicine estimates that $210 billion of our $3 trillion health system is spent on unnecessary care, we must better financially incentivize the right diagnosis—which may include a period of waiting—over quick intervention. The Affordable Care Act adjusts for other quality measures already; perhaps we should reduce payment for low-quality care or wrong diagnoses. It’s time to control the impulse to always “do something” and instead do a better job of stopping overtreatment. Let’s put an end to Marshmallow Medicine.
For more insights and opinions from Siemens’ Greg Sorensen, please follow him on LinkedIn here.