The Diagnostic Problem (Pt 3)

It was a few years ago that a physician wrote an article for the New York Times. A woman came in to see him. She had a knee injury, and had gone to the medical library and studied her kind of injury. It was clear that one kind of surgery had the best outcomes for her problem, and that the physician in whose office she was sitting had the best reputation for that kind of surgery. As soon as she had explained all this, the physician ordered her out of his office and said he would never accept her as his patient. He never saw her again, and said he would never accept anyone as a patient if that person had gone to a medical library and read about their condition.

Farook is, of course, convinced that he is taking his cousin to the best physician in Dubai, in fact, the best in the UAE, but he still wants extra assurance that this physician is prescribing the best treatment, not the treatment that will be most profitable to the physician. He didn't say so in so many words, but he had asked me to look over his cousin's medical records and go to the library.

I saw one major anomaly: the physician was prescribing anabolic steroids, and the library said anabolic steroids were very dangerous and ineffective for the condition Farook's cousin had. I tried to explain to Farook what I'd found. 'No time. We talk later.'

He asked me to come with him and his cousin one Monday.

Farook used to live about 500 meters away from me, and often called and said, 'You busy? Come with me, I wait you in front your building.'

Now he lives on the other side of Dubai, and his cousin lives in Sharjah, so he wanted me to come to his neighbourhood, a two hour drive.

When I got there, he said, 'Doctor office no see patients today. We take breakfast.'

I really didn't have time, so I said, 'I already had breakfast.' Farook was disappointed, so we had shisha for a couple of hours, then I went off to work.

The next day, I made the trip again, and Farook and his cousin met me and we went to the clinic.

We had to wait, since Farook had told me 9 am since the appointment was at 11 am, and he didn't want to be late.

Finally, the three of us were admitted to the inner sanctorum of the physician's consulting room.

Farook said, 'This my friend. He no speak Arabic and he not know any medicine, so he just sit here. Please talk Arabic.'

So the three spoke Arabic. The cousin wasn't allowed to say much, and I wasn't allowed to say anything.

After the usual 15 minute consultation, we left. Farook seemed happy with the results, whatever they were.

'Now we take big breakfast.'

'I've already eaten,' I said. I hadn't, and I was starving, but I also had a lot of work to do, and it was too late to spend another two or three hours having a leisurely brunch. Farook was very unhappy.

'You no take breakfast yesterday, and you no take breakfast today. I really want to take breakfast with you.'

And I really wanted to get to work, so I took my chauffeured limo to the office. (My private limo has my initials on it, Dubai RTA in big, bold letters. Since Arabic is written right to left, that's really Dubai At R.)

It was now clear that Farook was afraid the physician was not giving his cousin the cheapest and most effective treatment, but he didn't want to be booted out of the physician's consulting room like the New York lady, so he took me along as his rabbit's foot. He figured that the physician, seeing a Western face, would be afraid to prescribe the wrong thing. Farook (I assume, since it was all in Arabic) was being obsequious and agreeing wholeheartedly with whatever the physician recommended, and didn't want me to mention that I had been to the medical library, or give the slightest indication that anyone had checked up on the physician, but he hoped my Western face, sitting silently in a corner of the office, would convince the physician to diagnose correctly and prescribe that much sought (and often missed) cheapest and most effective treatment.

Whether Farook's latest scheme worked, I have no idea.

The Diagnostic Problem (pt 2)

I mentioned that repairpersons used to be studied regularly. People who take their vehicles or appliances or electronic gadgets to be repaired would like to think that the repairpersons are all competent and honest, but research by newspapers many years ago revealed that, while many were honest and competent, there were some who were incompetent and could not find the best repair, and some were dishonest, and always sold customers the most expensive repair.

This research was socially acceptable and cheap: there was usually no charge for the diagnosis and repair estimate.

Obviously, there are diagnosticians who diagnose other things than problems with vehicles, appliances, and electronic gadgets, but it is neither socially acceptable nor cheap to investigate to see if they are honest and competent. Like clerics under Thomas á Becket who insisted that only clerical discipline could be applied to clerics, and clerics were not subject to the secular legal authorities.

Today, clerics have been stripped of this immunity, but not physicians. The law agrees that only licensed physicians have the expertise to judge licensed physicians, so they must be responsible for disciplining their own profession, and they charge high fees for diagnosing problems, whether or not the patient allows them to perform their recommended procedure. So we have no empirical evidence that there is a single physician who is not scrupulously honest and competent, only the fact that they are human, and suffer the same moral hazard as the repairpersons who diagnose vehicles and gadgets and whose fallibilities have been repeatedly exposed.

Farook has a cousin who has had a medical problem for five years, and isn't getting any better, even though the physicians they have seen have assured them they are providing the very best medical care.

So Farook asked me to take his cousin's medical records and go to a medical library and do the necessary research.  Farook says he is convinced that many physicians prescribe the most expensive treatment rather than the most effective treatment, and wanted me to go check on what they were doing to his cousin.

I've taken some medical courses, but am not a physician, but I said I could at least go to the library and find out what I could to help.

The Diagnostic Problem (Pt 1)

When I was a lad, a regular newspaper article was about repair services. Sometimes appliance repair services, sometimes automotive repair services. The article could be repeated every few years as old, single proprietor repair shops closed and new ones opened.

In the jargon of economics, this is a common asymmetric information problem. The owner only knows that the device isn't working, but has no idea how it works or how to fix it. The repairperson is supposed to be knowledgeable, to know what's wrong and the cheapest way to fix it. The repairperson is also supposed to be honest, and to propose the cheapest solution to the problem.

The newspaper would take a car or a small appliance with a known problem, diagnosed by someone working for the newspaper who was an expert in repairing the thing being studied. It would be something that caused disastrous symptoms, like a TV that was blank, or a car that wouldn't run, but the cause was always very simple, something a competent repairman could fix for less than £1. Then the device would be sent to a large number of repair shops in the city where the newspaper was located, accompanied by someone who looked completely ignorant of the interior workings of the device.

Always, some repair shops would give the correct diagnosis and offer to fix it for less than £1, and always, some repair shops would try to convince the naïve person bringing the device in for repair that the repair would cost at least £100. In the case of small appliances, the repairman would point out that buying a new one from his shop would be cheaper than trying to repair the problem.

This is what is called the diagnostic problem, because the diagnostician knows what the problem is and the various ways to fix it, both cheap and expensive. Meanwhile, the owner has absolutely no idea of what the problem is or even roughly how much it should cost to fix it.

To be continued...