On medicine

Taking care of our health has always been a major concern for most of us. As the economic condition improves, healthcare service becomes increasingly accessible. When the number of private hospital increases, you don't have to queue for hours at a public hospital (well, if you can pay for private service). You don't have to rely on health insurance to cover for the cost, or maybe your employer has bought extended insurance for you. And, as some of my friends who had been in other countries remarked, healthcare in Vietnam is really cheap, even by Vietnam living standard. Therefore, you rarely have to worry that your illness won't be treated. But with the availability of healthcare service, a new set of problems arises. You can be over-treated, treated incorrectly, or you might even be treated without you having any health problem. Here, I want to dig into these issues and point out the causes, with the hope of providing you some points to consider before you decide to go to a hospital or a health clinic, and before you decide to take any drug, undergo any treatment.

But before I start, there is some points which I want to clarify. First, I don't want to generalize to all health service providers, all doctors. There are certainly good, humble and prudent doctors. If you are one, please identify yourself. I would love to seek health advice from you. Second, my experience is limited to healthcare service in Vietnam. In developed countries, as what I read in several books, the situation might be better, but some issues still exist or in even worse form than those in Vietnam.

Now, lets go through the causes of what can be called a new "healthcare crisis" one by one.

The first problem to consider is the classic principal-agent problem. The principal is the one who delegates responsibility to someone else, the agent, to act in the principal's interest. The agent knows something that the principal doesn't, and use it to take advantage of the principal, and act in his interest instead. In this situation, you are the principal, who delegates part of the responsibility to take care of your health to your physician, who should consider your health his highest responsibility (well, at least for the duration of the visit). But it is usually not the case. The physician might prescribe some drugs or procedures that is unnecessary, or might even harm you, to gain a handsome amount of money, in the form of commission or operating fee. Even if it is not about money, the doctor might still do it to protect himself from being blamed, to keep his reputation. Which leads us to another problem: the dumb-principal problem, which exacerbate the previous one, to the detriment of the patient's health. In the dumb-principal problem, the same agent-issue occurs, but the principal is the one to be blamed, for his inability to create an environment in which the agent can serve the principal's interest. Let me use an example to illustrate this point. Let say I came to a doctor, feeling a bit unwell. After carefully examination, he concluded that I was suffering from a mild form of illness, and treatment was not required. So I went home, and the illness become severe afterward, for some unknown reasons. What would I do afterward? If I was like most people, I would blame the doctor for not doing anything. I wouldn't care that the chance of the illness become severe is one in a million, or that I was ill because of other reason that happened after the visit, or that, this is the crucial point, the doctor had made the best decision, to my best interest, with the information available at that time. Therefore, from the doctor's point of view, doing something is always better than not doing anything, regardless of the result, since he can avoid being blamed and losing his reputation, by replying: at least I tried. The one to blame is us - the dumb principal, when both our psychology and our culture prefer addition and intervention to omission, judge the quality of a decision based on the result, not by the information available at the time of decision. I will conclude the discussion of the first problem with an advice: before taking any drug or procedure suggested by a doctor, consider whether he has anything to gain from it, or anything to lose from not doing it.

The second problem is the limitation of knowledge. You might think that your doctor is an expert in his own field, who can cure most of the related illnesses, but in fact he doesn't. It is an undeniable truth that there are many conditions for which we don't have a cure. We don't have a cure for AIDS. We don't have a cure for every type of cancer. Why? Because the human body, a biological system, is extremely complex, with interdependency between different parts. Medicine and biology are not mechanics or physical science, just like the body, shaped by billions of years of evolution, is not a simple, artificial machine. We don't have the knowledge to cure all diseases efficiently and locally yet. Even if there is a cure, there is usually difficulty in execution, side effects, complications, and a lot of uncertainty in the outcome. At this point, you might say, yeah, admitted, but what is the point? The point is, your doctor usually doesn't admit his limitation, and doesn't present the problem to you in this way. Overconfidence is the biggest issue when knowledge is limited. This problem is especially acute in Vietnam, where the patients often don't have enough basic knowledge to question even the most questionable decision of a doctor. A doctor is then getting used to be in a high, authoritative position. So he doesn't inform your of the necessary stuff, the unknown or uncertain stuff, because he thinks it is not necessary, or maybe he doesn't even think of it. He prescribes drugs as if there is no side effect. He suggested procedures as if there is no complication. And don't think I'm exaggerating. Just think about the last time you visit a doctor. Did he tell you about the side effects, or just quickly write down all the drug that you need to buy? Did he, before prescribing a procedure, tell you about all the alternatives, the statistics related to each, including possibilities of complications, the time you need to recover, how your life will be changed afterward? Did he give you the time to calm your emotions, to think it through, to consult your family, who will inevitably be affected? Did he discuss with doctors in other departments, consider your body as a whole, not combination of independent parts to be treated independently, without any consideration of other parts? So what do you do to alleviate this problem? I think we should always have a plan, a list of questions to ask our physician. Never assume he knows everything and can cure everything. And take your time before making an important decision.

The last problem is the problem of information. Having a lot of data is not necessarily good for you. More data could mean more noise and less signal. To make good decisions, especially those concerning your well-being, you need signal, not noise. But in many cases, noise is what your get when you go to the hospital, particularly during some routine check-ups while you are felling perfectly well. Where does the noise come from? It comes from the variations in the measurements, and from incomplete information. Consider the first case with this example: your blood pressure. It varies according to many factors: time of the day, what you just eat, how you are currently feel, or just because of nothing at all. If you sample your blood pressure every hour, and then take drugs to increase it when it is low, then take drugs to decrease it when it is high, you will end up worse, not better. What you really need to do is, well, nothing at all. But this kind of interventionism is exactly what you get when you do regular check-up at hospitals. Consider the new, "advanced" HP bacteria test service, with all the drugs and treatments that follow. It is said that HP leads to inflammation, cancer and all the scary stuff. But it is also said that 70% of Vietnamese people have HP in their guts. What? 70%? Do 70% of Vietnamese people have cancer? I don't think so. We Vietnamese are not the cancerous race! People have lived with HP for years without any problems. The problem is whether you should know about it. I certainly think you shouldn't. But if you know about it, then you have to know enough about it. Not the kind of junk information in the Internet, somehow uttered in the same form by highly educated doctors. You need the statistics, not sheer possibilities. HP could lead to cancer, but what is the probability? I can say that eating could lead to cancer. Will you stop eating then? There are inherent risks in all living activities. The point is not to eliminate all the risks, regardless of the cost, but to make informed decisions, to avoid the high risk and live with the insignificant one. The same applies to medical decision-making: avoid regular check-up, ignore superficial claim, and choose intervention only when the condition is severe (wise words from Taleb, proved by several studies).

To summarize, all you need to do is being aware. Aware that the physician might not act in your best interest. Aware that there are many things he doesn't know, any might not tell you about. Aware that it is not wise to know about something, then try to act on it when the knowledge is insufficient or framed in a certain way. And, above all, aware that it is your responsibility to take care of your health. So think carefully, and trust nobody (including me).