Wednesday, February 04, 2009

Trading off an argument from Scrubs

I was watching Scrubs (My New Role) last night & there was an exchange that I think should be a discussion point for everyone involved in medicine, though it wasn't the point the script writers really hammered on.

The setup is that a nurse was trying to get a doctor to change the antibiotic for a patient. The nurse's argument was that azithromycin required once daily dosing and would free her up for doing other things, where as the doctor's selection of clindamycin meant 4 times daily dosing. The doctor replied in a condescending way that she had gone to med school, the nurse hadn't, and therefore the script would stand as written.

Now, the theme of the episode was this sort of professional interaction -- where someone higher on the professional totem pole disrespects someone lower. An important issue, to be sure. But I think, especially in these days when we are more than ever concerned about the cost of healthcare & how to deliver effective healthcare economically, the specific argument deserves more attention.

Now, I'll confess I haven't gone to med school & I have no particular expertise in antibiotics, other than practical experience. For example, my wife is allergic to huge numbers, TNG broke out with Augmentin, doxycycline gives me a stomachache if I try to take it on an empty stomach & penicillin is mostly excreted, not metabolized & you'll notice this in the bathroom once it has cleared the infection from your nasal passages. But I can't reasonably discuss azithromycin vs clindamycin on actual facts, so I'll use them as proxies for some hypotheticals.

Suppose, for example, that there was absolutely no clinical difference between the two. They both had the same spectrum of treatable bacteria, the same risk of similar side effects, no contraindications in this patient and both had the same cost. Then clearly the nurse is right and the doctor wrong, as that once-a-day dosing frees a valuable resource (the nurse). In other words, under these conditions the drug choice for a patient is neutral for that patient but has important ramifications for other patients at the hospital.

But what about the less clear cases. For example, suppose all of the above conditions were met except equal cost; the once daily med is significantly more expensive (e.g. azithromycin before it went off patent). On the one hand, my argument still holds unless it is a huge cost difference -- several minutes of a nurses' time is worth quite a bit (like most hospitals, the one on Scrubs is portrayed as being cash strapped & short on nurses). However, that more convenient drug costs real money, whereas the nurse's saving is in opportunity cost: an accountant browsing the budget is likely to see the one but not the other even if both are real.

Now let's muddy the water further. Suppose they two drugs are clinically not precisely comparable but similar -- imagine if clindamycin is slightly broader spectrum or has a slightly lower risk of side effects. Now it becomes a really sticky wicket -- what additional risk to this patient is acceptable in order to reduce the risks to other patients (due to getting better nursing care).

That last one is the sort that really is troublesome. We never like explicitly to risk one person to help multiple others, but we are often less troubled when we do it implicitly. I won't claim to be an ethics expert, so I'll leave it at that. But I think these scenarios embody real situations which will be faced, such as sometimes an expensive drug is better than a cheaper one & (not to say this is always or even often true, just that it isn't always false). Or more generally: health care reform will be complex, because health care is complex.

1 comment:

Andrew Clegg said...

Congrats, you've just discovered health economics :-)

I used to work for a research centre that develops clinical and public-health guidelines for England and Wales, that take into account not just the clinical effectiveness, but also the cost-effectiveness of treatments. And the health economists I worked with really did have to factor in costs like nurse time into their models -- which were sometimes quite complex and used techniques I'd met in bioinformatics like decision trees or MCMC. A discussion about antibiotics almost exactly like this one came up on a project about meningitis I worked on (and wasn't unique).

There's no simple answer to this kind of thing, but these days it is all done in a rigorous and firmly evidence-based manner. The thing that frightens most people though is that in order to do the maths and work it out, you have to put a quality-adjusted value on a human life. Which is why, regardless of the interesting technical challenges, I wouldn't want to be a health economist...

Andrew.