Alternative returns: On 'costs' and 'outcomes' in market-medicine

Despite significant improvements in the treatment of many pathologic processes witnessed over the past century, some particularly difficult medical problems persist, which are characterized by unclear underlying etiologies and less than desirable outcomes of treatment in spite of considerable intellectual and financial investment and escalating costs. Accordingly, physicians (as well as scientists, governmental officials, insurance companies, the media, ... etc.) have recently begun grappling with the following question: If our aim is to achieve the best outcome as measured by symptom relief/control and a return to functional activities; and if we are generally aware that the connections between assessment, diagnosis, treatment, and outcome for these problems are loose, at best; then why do a large proportion of health care providers continue to treat patients 'as-if' these connections were tight? In what follows, we hypothesize that the persistence and acceptance of this 'as-if' program is linked to its success in achieving outcomes that differ from those currently measured by physicians and patients and payers-and that physicians, patients, and citizens who understand these 'alternative outcomes' and their consequences should take the next step and consider the repercussions and the available options.