Skin in the game

The patient’s skin in the doctor’s game. The doctor’s skin in the system’s game.

The patient is someone whose life undergoes a sharp turn to a physically and psychologically taxing experience, especially in the context of serious disease or cancer diagnosis. All they want and expect from the healthcare system is to go back to their normal life with little or no damage.

The surgeon is someone who is trained to help patients out of their current experience with minimal damage. Surgeons have a reputation to protect and an ego to satisfy. They want excellent results with minimal or no complications. Surgeons also happen to be employed by the “system”.

The system provides regulations that will “hopefully“ safeguard the relationship between surgeon and patient. These are usually outcome measures against which a surgeon’s performance is assessed. For instance, in colorectal surgery, mortality, rare and anastomotic leak rates as will be discussed below.

The system has no feelings. Surgeons have “filtered” feelings which are kept in a coke like can the size of which differs between surgeons. Only patients have unfiltered feelings.

The surgeon has a vested interested in a successful outcome for the patient because it is simply a win-win for both in retrospect. But surgeons are also hampered by their outcome measures and so the numbers do count, especially if this goes as far as losing their reputation or livelihood in certain situations.

Here comes a problem frequently discussed in economics and rarely in medicine; The Agency Problem, when the interests of the agent/surgeon clashes with the interest of the client/patient.

The patients have their skin firmly in the game here. They are the ones who stand to lose their very lives or their quality of life, based on the extent of their disease and the extent to which the surgeon operates. The surgeon has his/her skin in the game too. Let’s take a stark and very clear example of anastomotic leak (leaky join) in the context of colorectal surgery. This is a most prominent outcome metric for surgeons, it is detrimental to their reputation, their ego, their numbers and their mental health. However, the system does not put a metric for stoma rate formation, i.e. not joining the patient and instead giving them a bag probably for life. Although this is probably indicated in many scenarios, there is no measure in place to protect the patient from the surgeon giving them a stoma they might have otherwise avoided.

The consent process

On the one hand, surgeons know a lot. They have the discretion and control over information transfer. They want to do well for the patients and themselves, but they do have their own conflict of interest. Patients knows nothing about their disease or know just a little. But even if they are highly knowledgeable people, let’s remember that at this moment in time, they are engulfed in their own survival battle with cancer and even the prospect of dying.

We are told the patient should be told what they want to know; Great! But what if they don’t know what the surgeon won’t tell them? Surgeons do not have to tell patients about their portfolio, what they do, and what they don't do. For instance, not every surgeon carries out the same range of operations, or has the same access to technology, that patients and society might expect. The information gap between surgeons and patients during the consent process remains large and needs to be objectively addressed.

When the surgeon talks about “risks” in the context of complications and final outcomes, the overall and implicit risk is for the patient. We do not tell patients about our own risks.

I remember a conversation with a patient with cancer when I explained the risk of anastomotic leak and the role of stoma formation to reduce this risk. It was the first time a patient replied to me saying “I will take a risk of even a 5-10% leak rate as long as you don’t give me a stoma”. My immediate reaction was revealing “what about me?” I said to myself. Consider this scenario; it all went well during surgery, and you made a low enough anastomosis that most colorectal surgeons would defunction i.e., give a stoma; would you take this patient’s acceptance of risk as a reason not to defunction?

Here are actually two competing not complimentary risk interests; the risk to patient and risk to the surgeon. Being a good doctor wanting to help people aside, the surgeon’s personal predicament is their complication rates and outcome measures imposed on them by their respective societies/regulators or even their own self standards. Although the surgeon shares these risks with the patient, he/she does not disclose the risks to themselves and what they might lose from a complication. Risk transfer is very real in these scenarios. The patient finds his/her skin in the doctor’s game. Since any metric is gameable then there is a very rare but real risk that the surgeon would give the patient stoma purely to bypass the anastomotic leak metric. After all we are not judged by our stoma formation rate. The surgeon of course would argue that many patients would choose a stoma and that the function would be very poor in the circumstances of a low anastomosis. That is all true, but how much time and effort are given to allow the patient to understand the true consequences and then decide with the doctor, and how could we disentangle the surgeon’s interests from the patient’s?

Solutions?

It would be a challenge to answer these subtle but real conflicts of interests between doctors and patients. I argued in The day the surgeon had a leak that decision making should be a holistic team’s decision not left solely for the individual surgeon and that the outcome measures should be adjusted to reduce the agency problem.

Another way to reduce the information gap is to produce a specific guide for each speciality in medicine/surgery based on previous knowledge of past patients as is detailed in The patient examines the doctor.