The lady or the tiger?

In an effort to achieve organizational goals, physician executives expend tremendous time and energy attempting to change physician behavior. We encounter many obvious and not so obvious barriers in our quest.

In 1884, Frank Stockton published a short story called "The Lady or the Tiger." More than a hundred years have passed since then, but this tale still offers a timeless lesson about hidden agendas and individual behaviors.

Briefly, a semi-barbaric king practices his own unique system of justice. If a man is charged with a serious crime, he is ordered into a arena filled with spectators where he encounters two doors. The accused must open one of them.

Behind the first is a beautiful lady; if this door is chosen, they are married on the spot and allowed to live happily ever after in bliss and prosperity. But behind the other is a ferocious, hungry tiger waiting to make hash out of anyone who opens the door.

Fate decides which choice is made--and whether the accused is guilty or innocent.

The plot thickens when the king's daughter and a commoner fall in love. The king discovers the affair and tosses the lad into the arena, where the boy must choose his door.

Luckily, the king's daughter is sitting in the crowd and she has secretly discovered what waits behind each door. She signals the boy to pick the door on the right and he does so without hesitation.

What happens next? Has she served her own self-interest by sending him to the tiger, so that she won't have to bear the pain of watching him "live happily ever after" with another woman?

Or has she put her own self-interest aside and done what would seem logically best for her true love--that is, let him live and prosper with another woman?

We never find out. The story ends abruptly, leaving the reader to decide what emerges from the opened door.

Motives and motivations

This story raises some unpleasant issues about human nature and decision making. It forces us to examine how we weigh our own self-interest against the interest of others, especially those who we're supposed to love.

Ultimately, the story makes us ponder our motives for doing the things that we do. We wrestle with the same issues in medicine. Why do we do the things we do? And what motivates us to do them?

One thing seems certain--different things motivate different people.

For example, in the story the king is motivated by his perverse desire for justice--he certainly doesn't give a fig about the wishes of his daughter or the fate of the boy.

And surely the boy was originally motivated by his love for the princess--so much so that he risked his life to dare to love her." (But as he reaches for the door I'll bet he's hoping that the lady, not the tiger, emerges. Survival, not love, is likely the thing that motivates him now.)

Then there's the tiger, motivated to kill by hunger.

Like Stockton's short story, the medical system has its own unique set of characters, each with its own motivator. The five main characters include:

* Industry

* Third-party payers

* Regulatory agencies

* Patients

* Physicians

Although every player claims to be driven by the best interest of the patient, the real motivator is hardly elusive.

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Industry [right arrow] Profit

These folks also claim to care about the patient, but lawyers, device makers and pharmaceutical companies are in business to make a profit. If they don't, they're history. Everything else must be secondary.

Third-Party Payers [right arrow] Cost

No matter what third-party payers say about caring for the patient, it's all about cost. Whether it is an insurance company, Medicare or Medicaid, incoming funds are limited. For them, survival means that medical spending is minimized.

Regulatory Agencies [right arrow] Safety and Efficacy

The U.S. Food and Drug Administration, Joint Commission on Accreditation of Healthcare Organizations, public health departments and other regulators tell you that they care about the patient, but they focus so heavily on patient safety and medical efficacy that other factors pale in comparison. Does the FDA care what a drug will cost? Does JCAHO worry that their regulations and paperwork will increase provider stress and the cost of care? Do any of these regulatory agencies take into consideration the detrimental effects their decisions may have on health care asset allocation? I don't think so. They only care about their focus: safety and efficacy.

The Patient [right arrow] Personal Well-Being

The patient is concerned about ... the patient. It's assumed that patients want to get healthy and stay well. Unfortunately, the intense drive for personal well-being is often not in the best interest of the patient. The ill-informed consumer, and ironically the well-informed consumer who knows little about pathophysiology and who sits at the bottom of the informational dung heap, are easy victims to hype, profiteers and falsehoods. This accounts for the success of fad diets, sex stimulators, heart-healthy candy bars, enema therapies, copper bracelets, magnet therapy and several billion dollars of other health enhancers.

Physicians [right arrow] The Patient and Society

Luckily for everyone, physicians have been empowered with the ultimate fiduciary responsibility for the patient. Armed with knowledge, training, experience and an ethical commitment "to do no harm," the physician can sort through the motives of others and make decisions that benefit not only the patient, but our entire health care system.

Unfortunately, we also have to make a living doing it. As health care professionals, how well do we balance the interests of the patient (i.e. safe, cost-effective, highly efficacious care) against our own self-interest?

We recently had the opportunity to answer this question. Amazingly, we discovered an arena where a semi-barbaric king was practicing his own cruel brand of justice on a patient whose crime was to have ... claudication.

In front of the elderly gentleman were two doors. Behind one lurked every new, expensive, flashy, sexy, must-have product that industry could dream up for the treatment of claudication. Things like golden balloon catheters, shiny platinum stents, drugs made from unicorn horn and full-color ads in Ladies' Home Journal touting the "latest thing that Oprah takes."

The FDA confirmed the products to be safe and efficacious. Other bureaucrats layered on pages of regulations regarding their manufacture, use and disposal. The payers reluctantly approved their coverage under the pressure of industry and consumer demand (as long as the reimbursement was less than the cost of the technology, since the loss could be passed on to the hospital).

But there was a lot more than fancy therapies behind that door.

* There were sales reps bearing donuts and pens, proudly touting the latest technology to anyone with an ear and prescriptive authority.

* There was the patient's grand-daughter, who--after reading the articles in the Ladies' Home Journal--demanded the latest and the best and most expensive technology for her loved one.

* And, of course, there was a pack of carnivorous, salivating lawyers reminding everyone about the latest definitions of "standard of care."

What was behind the other door?

Not much except a bunch of boring, simple measures for the treatment of claudication. Things like a healthy diet, exercise, smoking cessation and an aspirin a day--things with low-cost and proven effectiveness. Things that constitute a sound choice for a minimally active, elderly gentleman with many co-morbidities.

Ahh, but there's a catch! Cheap, effective things rarely make anybody rich. After eight years of college and medical school, half a decade of indentured servitude as a resident and fellow, dozens of costly credentials, staggering loan payments, massive malpractice insurance premiums and other expenses too numerous to count, those who prescribe these cheap but effective therapies can ultimately expect to make peanuts for their efforts.

As we watched the patient ponder his choices, we noticed that his doctor was sitting in the stands next to us. The patient noticed the physician too, and was obviously relieved to see his trusted friend and advocate in the audience. We later learned that the doctor had secretly discovered which fate lay behind which door. It turns out the patient was also aware that the doctor had obtained this information.

The doctor leaned forward and subtly signaled for the man to pick the door on the right. His patient naturally followed the instruction.

We now leave it to you, dear reader, to figure out what emerged from that door.

By Thom Rooke, MD, and Alan S. Kaplan, MD, MMM, FACPE, CPE 

Thom W. Rooke, MD, FACC, is the Krehbiel professor of vascular medicine and head section of vascular medicine at Mayo Clinic. Rochester, N.Y. He can be reached at 507-266-7457 or Rooke. [e-mail]

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Alan S. Kaplan, MD, MMM, is vice president of medical affairs at Edward Hospital in Naperville, Ill. He can be reached at 630-527-3370 or [e-mail].