The Magician’s Choice

The illusion of autonomy in healthcare

“Any color the customer wants, as long as it’s black.”

- Henry Ford

Friends, I’ve made a prediction.

But first, some context:

I believe that one engine behind the teleological crisis within medicine is a growing disassociation of authority from responsibility. Our wonderful administrators and support staff, with their fancy guidelines and protocols, have come to dictate more and more activity within the hospital walls. And yet, these people and policies will never face a patient harmed, comfort a loved one left behind, or stand before a judge.

It seems that having lost ground on everything from prescribing power to the white coat, the one part of doctoring left unplundered is this final responsibility. Doctors, in name and livelihood, answer for what happens: for the avoidable intervention; for the denied necessity; for other people’s mistakes.

As for our patients, modern medicine has become something of an amusement park ride: a thrilling experience with incredible technology…but everyone knows the car is on a track. After all, for most Americans, the system is mediated through insurance, which is itself mediated through our employers. Based on where you work, you get this insurance. And based on your insurance, you see this doctor. Need a test? You can use this lab, and this imaging center. Need some treatment? Well, you can fill prescriptions at this pharmacy, and you can have this surgery, at this hospital, maybe. For we un-wealthy citizens, “patient autonomy” is frequently little more than the right to just stay home.

Whether physician or patient, we all feel in our bones how many healthcare decisions are being made for us, instead of by us. And yet, our entire medical system – shared cultural assumptions, explicit professional ethics, codified legal principles – it all rests on those now-eroding foundations: patient autonomy and physician authority. But at the big shops, the corporate monoliths where doctors are employees and patients are profit, these grand old ideals have become like the stage patter of a master magician: fine-sounding misdirection.

That reminds me – my prediction! This trick really needs to be done in person, but I think you’ll get the point. So I made this prediction, and it’s written down here inside this sealed envelope, right here on the table, where I can’t touch it. You keep an eye on that envelope for me, alright? Keep me honest.

Now if you would, please imagine a standard deck of playing cards: 52 unique cards, standard suits and so on. We’ll start slow, just pick a color, either color, red or black. Red? Great, so we’ll keep the red cards. That means we have the hearts and diamonds left, so pick one of those suits, hearts or diamonds. You picked diamonds, ok perfect. Are you sure? Do you want to change your mind? No, you’re sticking with diamonds. Ok, then we’ll throw those diamonds away, leaving us with the hearts. Now, things aren’t split as evenly here, but I want you to pick between the number cards, that’s Ace to Ten, and the face cards, that’s Jack to King. The faces? Great, great, we’ll keep those faces. Now finally, the easiest decision of the day: guys or girls? The gentlemen! Alright, then we’ll kick those boys out of here, with leaves us with just one single card, the Queen of Hearts! Now I want to remind you, you had a free choice every step of the way, but it didn’t matter, because I knew the minute you walked into the room – I could smell it on you! – I knew that you would always pick the Queen of Hearts. Don’t believe me? Well, it’s right there in front of you. Open the envelope, you do it yourself so there’s no funny business. Open that envelope and show everyone what’s inside, that’s right: the Queen of Hearts!

Riotous applause, I’m sure. Thank you, thank you.

Now, I trust you followed along with that incredibly thumb-fingered example of the Magician’s Choice. It’s a basic technique in stage magic where an outcome is left undefined until after a choice is made by the spectator, which allows the magician to frame that decision in whichever way favors his predefined result. In the above card trick, each choice of the spectator inevitably leads to the Queen of Hearts. In an old childhood example, it’s a simple coin toss with “heads I win, tails you lose.” Or in a modern hospital, it’s a sophisticated web of influences that, for example, have so increased the utilization of advanced imaging that we’ve literally had to update the population incidence of certain brain tumors and aneurysms…

Now, the magician’s choice is just one type of what magician’s call a “force,” and there are many others. For example, riffling through a deck of cards until the spectator yells “stop!” – but in fact deliberately stopping at a specific card. This can also be done while flipping through the pages of a book. Or holding up a fanned set of playing cards very quickly and specifically arranged such that the spectator, when asked to pick a card “at random,” can only have seen one card very well, and will inevitably select it.

Forces are bread-and-butter magic techniques. Any magician will tell you: it’s not difficult to manufacture the illusion of free will.

So let’s bring it back to the hospital. Why does the ER order all those pan-scans? Why do primary services consult specialists willy-nilly? Why do those specialists offer so many procedures? How much happens automatically, behind the scenes, by unit-specific protocols, sometimes without the knowledge of the admitting physician? How many treatment plans are stopped dead because a non-physician was “uncomfortable” or “had a concern?” Why does it turn into a circus when the Joint Commission decides to stop by?

I tell you, “the patient’s best interest” is not the answer. No, friends, this is the logical result of corporatized medicine. That means doing more tests, even if you don’t need the results. That means senseless, tedious, burdensome documentation, even though no one will ever read it. That means generating so many algorithms and checklists that doctors find themselves thinking less, deciding little, and just signing off on all those templated orders. If this doesn’t sound like a dream job worth a decade of schooling and massive educational debt, you now understand why we’re facing a physician shortage. And what of our patients? Poked and prodded, herded and unheard, shuffled through an institution which views them as some abstract amalgam of risk, profit, and checkboxes.

One need hardly marvel to learn that older physicians are retiring early, medical students don’t intend to practice clinical medicine, and the public’s trust in doctors is at an historic low.

Ah, Progress!

But can we put the rabbit back into the hat? Is there another way to practice medicine at scale?

Well, yes…but unfortunately, it’s against the law. This new brand of smoke-and-mirrors medicine is the grim reality of the Affordable Care Act. Hospital ownership was stripped from physicians, and thus guaranteed to financiers. This decision, with other pro-corporate regulations, left doctors essentially no “choice” but to be employed, to follow someone else’s policies. And our poor patients have one and only one variety of hospital to “choose” from when seeking care: non-physician-owned. A magician’s choice indeed!

Speaking of patients, federal revenue streams were diverted away from patients, and directed toward institutions. This leaves the majority of non-ultra-wealthy patients with no realistic “choice” but to stay in-network, to receive covered treatment. At the price of patient autonomy, hospitals are protected from normal market forces of competition, price control, and public good.

The answer, of course, is to realize it’s all an illusion. When you pick the black cards and the magicians tries to take them away, call it out: “no! I wanted the black cards, why would you get rid of them?” Likewise, if healthcare is a priority for you, among so many societal ills (and you’re reading this, so I assume it is), then when you step into a ballot box later this year, ask yourself: who’s trying to put doctors back in charge? Who’s helping patients make decisions for their own health, with their own dollars?

Now truthfully, in many places, the ballot box is a magician’s choice of its own. But votes are counted, and can influence public opinion even if they can’t sway a given election. And if you’re reading this, you’re online, where everyone’s voice can be heard.

So make a real choice – speak up! Together, we can break the illusion. Together, we patients and physicians can re-instantiate that magic word: Autonomy.