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A Prescription for the Healers

I hope readers take the time to read David Leonhardt’s terrific Sunday New York Times Magazine piece on Intermountain Healthcare. It is a great introduction to the changes that organized medicine must adopt to deliver team- and evidence-based care. (I wish we used the term evidence informed treatment, which brings fewer connotations of cookie-cutter care.)

This transition requires changes in the way doctors and hospitals are paid. It also requires changing medical professional culture to embrace a team approach. Many doctors have been socialized to believe in a model in which what matters most resides in the head of individual physicians. Jerome Groopman’s otherwise wonderful How Doctors Think expresses this mindset right in its title. Groopman provides a beautiful account of how doctors effectively diagnose conditions and how their heuristics can go astray. As Darshak Sanghavi notes in Slate, Groopman provides less guidance regarding how we could create systems that make patients less vulnerable to the mistakes or inattention of fallible human beings. (It’s too bad Groopman declined to be interviewed for Leonhardt’s piece, which has a nice little section on these issues.)

The change in medical culture will be tough, not least because there is so much to admire in the traditional medical model. Unfortunately, there is just too much evidence that it frequently produces bad care. More clinical intelligence and compassion reside in a well-deployed team of people than can reside with any single person, no matter how committed and well-trained that person might be.

Betsy McCaughey published a recent Wall Street Journal op-ed, in which she quoted 16 doctors she convened for an anti-reform discussion panel. If one reads the transcript, one finds the expected bias and exaggeration. One also finds more interesting genuine push-back against CER and team models of care. Here, for example, is heart specialist Mark Fields:

I think that the guidelines are a fundamental assault on physician autonomy and there will be in the future guideline doctors and they will be real doctors. Or there will be nurses who will follow guidelines. I think the guidelines in a way are written for nurses or other allied health personnel because we’re giving them sort of an outline or framework but they don’t have the depth of training to be able to figure out when to apply them and when not to, when it’s good, when it’s bad. Only physicians really have that training that involves physiology and biochemistry and all that stuff.

There is something admirable in Fields’ stance. Doctors want to take responsibility for the human beings they treat, and they don’t want bureaucrats to impose checklist care. Fields’ attitude--certainly including the casual condescension towards non-physicians--is widely shared in the medical community. Our poor use of non-physicians, for example, is one reason care is uncoordinated and overly costly.

Docs such as Field seem blind to the ways doctors’ great professional autonomy can and does undermine the quality of care provided to millions of people. Within the past several years, my wife’s heart infection was misdiagnosed and my brother-in-law’s common genetic disorder was overlooked by smart and caring physicians. These diagnoses were not especially difficult. They were both missed by fallible human beings operating in systems that lacked structures to minimize the probability of misdiagnosis and that had even less in-place to identify missteps after they occurred. A checklist might have helped in both cases.

Health policy debate is now dominated by the political heavy lifting required to pass health reform. The long success of these efforts will depend on the willingness and ability of American medicine to emulate the unsexy but valuable best-practices exemplified by Intermountain. It won’t be simple or easy, and it won’t have the obvious ideological handles that command public attention. It has to be done.