Posts Tagged 'Evidence Based Medicine'

Decision Support, Professionalism and the Lost Art of Healing

Health care in the United States is struggling to redefine itself. We have been spending twice what other countries spend on health care, yet our citizens are less healthy. We now have legislation to create more or less universal insurance coverage, and we are about to embark on a technology-driven quest for quality and uniformity. At the same time, Americans are increasingly turning to alternative health care practitioners, mostly at their own expense, because the health care system is not meeting their needs.

In the three decades since I entered this profession the typical role of physicians has changed dramatically. In the 1980’s most doctors were self-employed and received payment directly from their patients. Now most doctors are employees who receive their salaries from organizations that collect payment from insurance companies on behalf of the patients.

With this arrangement patients have lost the power that came with directly paying doctors for their services. Doctors now have to answer not only to their patients, but also to their own employers and to the insurance companies, whose profits are carved from the difference between insurance premiums collected and medical care delivered.

Medicine has until now been considered one of the three learned professions along with Law and Theology. These three professions are said to require advanced learning and high principles. Physicians, lawyers and clergy study and interpret their material. They sometimes find themselves in a position where they are forced to disagree with others of similar training, who draw different conclusions from the same text.

It is very tempting to think that there is only one right way to do things in medicine. After all, medicine is a science, and we spend a lot of money on doctors, tests and treatments. For those who remember, Marxism was also touted as a science, yet the planned economies of the world collapsed because their scientific theory created systems that were too large and rigid to manage effectively, let alone meet the needs of their customers.

Every day I read about medical errors that only computers could avoid and alleged epidemics of unprofessional conduct, negligence and incompetence among physicians. The solution is made to seem obvious: Change the role of physicians from intellectually independent professionals to generic health care providers. Put them in front of computers that offer “Decision Support”, which is jargon for suggesting to them what to do, and then measure their compliance with the computer’s suggestions.

Even the New England Journal of Medicine recently printed an article that suggested that computers could make unnecessary the “master diagnosticians of past eras”.

Is it any wonder that so many hard-working, decent doctors are dissatisfied with their careers? Is it any wonder that the primary care specialties are having recruitment problems?

Doctors will happily do the right thing, if we show them what the right thing is, President Obama inferred after the United States Public Health Service recommended cutting back on mammography screenings.

This is an example of where we, unfortunately, stand with “Evidence-Based Medicine” (EBM) in the United States today. The mammography recommendations were changed, not because the evidence changed, but because the task force looked at the data differently.

“Evidence Based Medicine”, in my opinion, requires individual physicians to continue to act as professionals, read the literature and expert opinions with a discerning eye, look for bias and ultimately help individual patients with unique situations take the best action.

The proponents of uniformity, today’s capitalists or yesterday’s Marxists, have both failed to understand the art in what we do. Health care is like food, wine or music. The ingredients, even the recipes, may look similar, but the interpretation and delivery makes it what it is. Two different doctors can deliver the same care in theory but get different clinical results and different patient satisfaction. And two patients with the same stage of a disease may respond differently to the same treatment.

In 1996 Nobel Prize winner Bernard Lown wrote “The Lost Art of Healing”. It is still missing in many places.

No matter how technologically advanced medicine gets, and no matter what financial or administrative pressures doctors are subjected to, ours is a healing profession. Our duty is to maintain our professionalism and use our scientific training, never forgetting that patients come to us to be healed or comforted. Even our Evidence-Based treatments are sometimes only marginally better than placebo, for example antidepressants. A therapeutic relationship between doctor and patient can sometimes do more for a patient’s health than a hastily delivered, computer-generated prescription.

Physicians need to take pride in their work and act like doctors, not health care drones, who blindly and mindlessly toil for the big health care machine.

Quality or Conformity?

Yesterday I received something in the mail about how I might be judged by certain “Quality Indicators”, such as my patients’ mammography rate. This struck me as very odd, since just a few weeks ago the U.S. Public Health Service Taskforce reversed their longstanding recommendation that all women should have annual mammograms from age 40.

This is a striking example of how yesterday’s truths are tomorrow’s fallacies in modern medicine. A doctor who orders annual mammograms this month could be viewed as practicing poor quality medicine, even though the same behavior might have earned him or her bonus payments and honorable mentions last month.  

I think it is time we speak honestly about what the agenda really is here. If we, or those who pay us or regulate us, choose quality indicators that are not based on solid scientific principles, but instead on expert opinions that could – and do – change at any moment, we are not measuring quality at all. What we are measuring and rewarding in that case is conformity. How fast and how consistently today’s physicians can implement new guidelines is certainly easier to measure than how well their patients are feeling.

We aren’t measuring how often doctors make the correct diagnosis on the first visit or how well they handle difficult clinical situations. We aren’t measuring how often we are able to reassure or comfort another human being who would otherwise keep circling within the health care system at great expense in search of peace of mind.

No, the things we measure are only the underpinnings of quality in health care. It is fine to measure doctors’ compliance with official guidelines, but we need to look well beyond such low hanging fruit if we want to be serious about quality. 

Frankly, there are ways we can let our office staff, our disease registries or Electronic Medical Records handle a lot of the housekeeping items people think of as quality indicators. The quality measures of physicians’ work would then reflect how we practice the art and science of medicine. We need to look more to clinical results (outcomes) and appropriateness of care.

Just like in school, we can strive to master the subject or just pass the test. If we just want to pass the test, we can change the subject when our patients bare their souls to us, fumble with the chart or peer into the EMR and start talking about tetanus shots and cholesterol and mammograms (or perhaps why we won’t order a mammogram), or we can push the paper chart or computer screen aside, look them straight in the eyes and say:

“We’ll let the system catch up with you about those things. Tell me what’s bothering you…”


Osler said “Listen to your patient, he is telling you the diagnosis”. Duvefelt says “Listen to your patient, he is telling you what kind of doctor he needs you to be”.

BOOKS BY HANS DUVEFELT, MD

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