Posted on 02/22/2014 7:50:33 AM PST by Kaslin
People who worry about death panels are missing the forests for the trees. Yes, people with expensive-to-treat conditions may someday be denied life-saving treatment because of ObamaCare. But there is a far greater danger for ordinary mortals: government and its health insurance proxies telling doctors how to practice medicine.
In treating patients with various symptoms, doctors are increasingly pressured to follow guidelines or protocols. This "cookbook" approach to medicine is the opposite of personalized medicine — an approach which aims to tailor the therapy to the characteristics of the patient, including her genetic makeup.
Before criticizing it, let me say something good about the "cookbook" approach. I think a doctor would be foolish to ignore protocols. Being aware of how other professionals have treated conditions and what outcomes they have experienced is part of being on top of what is happening in the medical profession in general and the doctor's specialty in particular.
In MinuteClinics and in other walk-in primary care retail clinics around the country, nurses are doing a superb job of following computerized protocols. In fact they seem to follow best practices better than traditional primary care doctors. They also seem to pretty good at recognizing when a patient's condition is outside their area of expertise and referring that patient to a specialist or to an emergency room for more complex treatment.
But things will go wrong if the cookbook becomes a master rather than a servant; if it becomes a book of orders rather than a book of suggestions; and if complying with endless checklists takes valuable time away from patient care. Yet that is exactly what is happening in American medicine.
The cookbook that MinuteClinic nurses follow is a cookbook created in the marketplace for the purpose of meeting the needs of cash paying customers. MinuteClinic has an incentive to weigh costs against benefits in doing what it does. If a nurse has to type too much low-value information into her computer terminal, she will be able to see fewer patients and earn less revenue for the clinic. The cost of information overload will be judged not worth the benefit.
Contrast that with what is happening to doctors dealing with impersonal bureaucracies, which do not bear any of the costs they impose on doctors and their patients. Dr. Virginia McIvor, a pediatric physician at Harvard Medical School explains the problem as follows:
…[T]he quality police demand that for any child who comes in for a physical whose body-mass index is above the 85th percentile, I must comply with certain measures — what we call box checking. I first need to check a box stating that the child is overweight. Then I must acknowledge that I entered "overweight" in his problem list. Next, I need to check a box stating that diet and exercise counseling were provided. Finally, I need to be sure that the counseling is documented in the patient note. If this patient has asthma, I need to check more boxes for an asthma action plan, use of an asthma-controller medication, and flu-shot compliance.
When a healthy child visits, I must complete these tasks while reviewing more than 300 other preventative care measures such as safe storage of a gun, domestic violence, child-proofing the home, nutrition, exercise, school performance, safe sex, bullying, smoking, drinking, drugs, behavior problems, family health issues, sleep, development and whatever else is on a patient's or parent's mind. While primary-care providers are good at prioritizing and staying on time — patient satisfaction scores are another quality metric — the endless box checking and scoring takes precious time away from doctor-patient communication. Not one of my patients has lost a pound from my box checking.
In Priceless, I made the following observation:
Over all, health care is a field that can be described as a sea of mediocrity punctuated by islands of excellence. The islands always spring from the bottom up, never from the top down; they tend to be distributed randomly; they are invariably the result of the enthusiasm, leadership and entrepreneurial skills of a small number of people; and they are almost always penalized by the payment system.
Now if you think like an economist, you will say, "Why don't we reward, instead of punish, the islands of excellence and maybe we will get more of them?" But if you think like an engineer you will reject that idea as completely unacceptable. Instead you will want to 1) find out how medicine should be practiced, 2) find out what type of organization is needed for doctors to practice that way, so 3) you can then go tell everybody what to do.
Atul Gawande is the author of The Checklist Manifesto, in which he argues that doctors can improve the quality of medicine by following a checklist similar to the ones that have reduced airline accidents. Here is his explanation of how medicine should be practiced:
This can no longer be a profession of craftsmen individually brewing plans for whatever patient comes through the door. We have to be more like engineers building a mechanism whose parts actually fit together, whose workings are ever more finely tuned and tweaked forever better performance in providing aid and comfort to human beings.
Here is Karen Davis, explaining (in the context of health reform) how medical care should be organized:
The legislation also includes physician payment reforms that encourage physicians, hospitals and other providers to join together to form accountable care organizations [ACOs] to gain efficiencies and improve quality of care. Those that meet quality-of-care targets and reduce costs relative to a spending benchmark can share in the savings they generate for Medicare.
The Affordable Care Act (ObamaCare) was heavily influenced by the engineering model. Who, but a social engineer, would think you can control health care costs by running "pilot programs"? What's the purpose of a pilot program if not to find something that appears to work so that you can then order everybody else go copy it? Pilot programs are a prime example of the social engineer's fool's errand. And by the way, there is no evidence whatever that pay-for-performance schemes improve quality or reduce costs — either in this country or abroad — either in health care or in education.
Social engineers invariably believe that a plan devised by people at the top can work, even though everyone at the bottom has a self interest in defeating it. Implicitly, they assume that incentives don't matter. Or, if they do matter, they don't matter very much.
To the economist, by contrast, incentives are everything. Complex social systems display unpredictable spontaneous order, with all kinds of unintended consequences of purposeful action. To have the best chance of good social outcomes, people at the bottom must find that when they pursue their own interests they are meeting the needs of others. Perverse incentives almost always lead to perverse outcomes.
In the 20th century, country after country and regime after regime tried to impose an engineering model on society as a whole. Most of those experiments have thankfully come to a close. By the century's end, the vast majority of the world understood that the economic model, not the engineering model, is where our hopes should lie. Yet health care is still completely dominated by people who steadfastly resist the economic way of thinking.
Soooo WebMD does not make a good primary care physician? Who knew???
In my case, the doc refused to prescribe the antibiotics or run the tests and I ended up on doxycycline for eight months when I finally started to show more serious symptoms and they ran then the tests.
So in all three cases, tests showed that we were positive for Lyme disease, and in all three cases the physicians had botched the diagnosis. A good protocol could have prevented that. On the other hand a bad protocol could have denied us ever getting tested.
My point in saying this is that either proper protocols or physician discretion can be a good thing or a bad thing depending upon the type of case. Had I been the usual compliant patient, the latitude of physician discretion could have been debilitating or fatal. Had there been protocols in place denying testing at all the results would have been just as bad.
If you have the time both methods are recommended. Getting a second opinion from a craftsman couldn’t hurt too much.
Wait ‘till they find out you can’t sue the government!
There will be a dimunition of malpractice justice for deserving patients, and, consequently a drop in quality of care...that is, among the doctors who will buy into this system, which will be extremely diminutive.
The surgeons who finally came to visit asked me why I waited so long....
And MOST patients will not be seeing an MD anyway. Nurse practitioners will be the primary visit attending. Then maybe a Dr. And then, if he hasn’t had too many referrals that month, you might be referred to a specialist for your acute problems. Good luck to us under Obamacommiecare!
We are well on the way of educating all independent thought out of our medical students and residents.
Innovative approaches and individualized treatment based on understanding of pathophysiology, pharmacology, genomics, and psychosocial concerns will completely disappear in not very long.
Cookbook medicine works best in patients with straightforward conditions who are likely to get better on their own or with minimal intervention. Thus, many cookbook approaches wind up overtreating patients who need little or no treatment. The expensive and unnecessary emergency room care that is routinely delivered according to “metrics” is a good example.
Cookbook becomes less effective, and even injurious, as patients and their illnesses become more complex. A well-trained experienced physician who is trained to “split hairs” can usually tune through the static and deliver effective and focused treatment earlier, when it is likely to be more effective. This requires detailed analysis, careful analytic thought, and usually, approaches outside the algorithms that direct our modern trainees.
On a personal note, on a daily basis I receive faxes from insurance drug plans wanting to know the patient’s DIAGNOSIS. Now, some of these drugs are prescribed for only one reason, e.g. HIV/AIDS, so only a clueless moron would need a diagnosis code.
More importantly, it not necessary for a dispensing pharmacy to know the patient’s diagnosis: all they need is a legible prescription from a licensed physician. Adding a diagnosis code just makes it easier for a patient’s private information to be divulged by unauthorized database access or a malicious drone working for the insurance plan.
So far, good humor and politesse have ruled my responses to these requests: I write “You do not need this information to dispense this drug” in the space for “Diagnosis.”
I can forsee the day when I snap and enter, “None of your f***ing business!”
“Both my kids and I were (upon separate occasions) nearly condemned to denial of treatment for Lyme disease simply because the physicians involved did not believe that the Brucellosis bacterium was in our area. They showed the classic bulls-eye rash but the docs would not run the tests. A proper protocol would have saved me a ton of trouble in getting us to an infectious disease doc. When I finally did, his comment was, “Good job.” The tests showed that the kids were positive.
There is no substitute for a careful history and physical, critical thought, and asking for help when you are in over your head.
In my case, the doc refused to prescribe the antibiotics or run the tests and I ended up on doxycycline for eight months when I finally started to show more serious symptoms and they ran then the tests.
So in all three cases, tests showed that we were positive for Lyme disease, and in all three cases the physicians had botched the diagnosis. A good protocol could have prevented that. On the other hand a bad protocol could have denied us ever getting tested.
My point in saying this is that either proper protocols or physician discretion can be a good thing or a bad thing depending upon the type of case. Had I been the usual compliant patient, the latitude of physician discretion could have been debilitating or fatal. Had there been protocols in place denying testing at all the results would have been just as bad.”
I am glad that you and the kids were diagnosed and treated correctly. (BTW, the agent of Lyme is a Borrelia, not Brucella).
You are correct that the appropriateness of treatment is based on how well the algorithm is written. It is likely that the algorithm for a skin rash for a Nurse Practitioner in San Diego would likely be very different for one in White Plains, NY.
In San Diego, where there are very few cases of Lyme Disease reported annually, treatment for wasp or spider bite would likely be the protocol-directed “Correct” treatment. In White Plains, which lies in one of the most heavily Lyme-endemic counties in the Northeast, the protocol would likely (correctly) direct the NP to treat for Lyme Disease based on the appearance of the rash alone.
You are also correct that an early referral to an ID specialist would likely have unravelled the story earlier and saved you unnecessarily prolonged treatment.
We are trained to evaluate people based on history of travel, occupation, exposures in a way that you don’t get when people are following protocols. Medical diagnosis is very much a function of complex pattern-recognition, but you won’t see the pattern unless you take the time to get all the information. And, as I am wont to tell my students and residents, “When all else fails, LISTEN TO THE PATIENT!”
A few years ago, my friend’s daughter drove cross-country from her Connecticut home to California. By the time she reached Las Vegas, she had a peculiar blistering rash behind the knee. She was given steroids for a spider bite. She texted a photo to me, and it was clearly a typical rash of Lyme, which often blisters behind the knee.
I phoned in an Rx for doxycycline, and obtained a confirmatory blood test (positive) when she arrived in California.
Now, if the Las Vegas ER doc had trained in the Northeast, he might have made the diagnosis. But based on his experience, the low prevalence of Lyme Disease in Nevada, and the ER prorocol there, the correct diagnosis was missed.
This was fifteen years ago. Memory failed. Brucellosis is a tick borne disease, as is human monocytic erlichiosis.
Now, if the Las Vegas ER doc had trained in the Northeast, he might have made the diagnosis. But based on his experience, the low prevalence of Lyme Disease in Nevada, and the ER prorocol there, the correct diagnosis was missed.
We have Western black legged ticks here in California, which are an ixodid capable of transmitting Lyme. At the time, there had been only four documented cases here, but that more likely means there were many that had gone undiagnosed.
We are trained to evaluate people based on history of travel, occupation, exposures in a way that you don’t get when people are following protocols.
I think expert systems in the hands of a nurse practitioner with specialist backup have a real future. Nurse practitioners equipped with such tools probably have better diagnostic capability available now than were available to physicians twenty years ago. With the broad availability of antibody detection sticks, that point of service detection capability could be amplified considerably.
The vast bulk of cases physicians see are either obvious (an injury) or fairly routine. Hence, teaching the NP when to punt will be a real challenge.
Medical diagnosis is very much a function of complex pattern-recognition, but you won’t see the pattern unless you take the time to get all the information. And, as I am wont to tell my students and residents, “When all else fails, LISTEN TO THE PATIENT!”
Learning how to ask questions and engage the patient to search and evaluate his or her experience so as to deliver relative or quantifiable distinctions are equally subtle. In terms of pattern recognition, teaching the physician to reconstruct a progression of symptoms by which to make such distinctions is still an art-form. As you know, it is not at all uncommon for a tick bite to fail to show the classic rash.
In a completely different vein, I think medical science is so distorted by a legal environment that presumes anything is treatable as long as it comes from a government-sanctioned therapy that we have blown off totally broad spectrum treatments with a very solid history. There is such a thing as 'do something as long as it is not harmful' as opposed to 'do nothing unless you know for certain what you are treating.' There are a LOT of pathologies out there about which we have little to no idea.
Case in point, I think viruses as inducing immune system disorders are behind a host of 'treatable' diseases, particularly cascading consequences of inflammation, such as causes of heart disease (for example as aggravated by oral gingivitis), rheumatoid arthritis, consequences of apnea, and kidney disease. I believe I have such a malady, possibly analogous to Wegener's granulomatosis. My gums were going bad. My fingers were so painful I couldn't negotiate buttons. My nose was bleeding. All of those symptoms were stopped cold and reversed to a degree by sublingual colloidal silver. It's not gone, but life is at least functional again to the degree that I'm back to climbing trees with a chainsaw. It sure as hell beats the prognosis of a lifetime course of methotrexate and cortisone shots.
Thanks for the thoughtful post.
The cookbook approach is being pushed within psychology (mainly by academics who shouldn’t be allowed alone in a room with anyone). It is sooooooooooooo wrong and inadequate for the nuances of mental health treatment.
I like WebMD. Sure, it can't replace physician services, but it still provides decent information. A patient who wants to learn more about his/her diagnosis can find out more about it at websites like WebMD, Mayo Clinic, etc.
The twin ideas of state medical licensure and psychological disorder as a disease were guaranteed to produce such a result. To it we have added state control of morality, with the state having a direct interest in immorality as a means to increase demand for police powers. It is a terrible feedback loop.
"Don't worry, scrote. There are plenty of 'tards out there living really kick-ass lives. My first wife was 'tarded. She's a pilot now."
I've seen way too much of doctors dealing with the effects rather than the causes. It's why I avoid doctors; they've done so much harm to so many people not treating these underlying causes.
Does it take a nurse to put low value information into a computer terminal? / rhetorical question
LOL!
I beg your pardon, but this is not the case. A pharmacist's mandate includes dispensing the correct drug for the patient's disease, and the pharmacist is both ethically and legally liable if a drug is dispensed for an inappropriate indication. They may not ask all the time, but if they do they generally have a good reason.
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