Friday, March 14, 2008
Slate.com's Darshak Sanghavi has a brief article on a way to improve the quality of health care - have the doctor focus on the patient's treatment rather than on the diagnosis. He writes,
. . . . The real trouble is that doctors—somewhat paradoxically—are simply not focused on actually treating disease.
A key indicator of this problem emerged last October, when a team of researchers led by Rita Mangione-Smith reviewed children's medical records from 12 major American cities and found that fewer than half of children got the correct medical care during doctor visits. The researchers asked basic questions such as these: Did doctors properly inform mothers to continue feeding infants who had diarrhea? Was HIV testing offered to all adolescents diagnosed with a sexually transmitted disease? Was a follow-up visit scheduled after a child's medication changed for chronic asthma? These were all simple things doctors should have been doing yet weren't. (A similar study of adult quality of care was published in 2003 with similar results.). . . .
There are at least two explanations. First, clinical training in primary care—including pediatrics, internal medicine, and family practice—excessively focuses on the diagnostic hunt rather than the more routine rounds of treatment that follow. It's tempting to think that most doctors are detectives nailing baffling diagnoses, like Hugh Laurie's character on House. In part, this view of medicine accounts for the success of Jerome Groopman's book How Doctors Think, which explores how wrong diagnoses occur. In almost every educational venue—from morning teaching sessions for residents to the weekly case conference featured in the New England Journal of Medicine—medical trainees spend hours learning about how to diagnose rare ailments. And then, abruptly, discussion ends, as though treatment were an afterthought.
The not-so-subtle subtext: Medicine is about the exciting search for a diagnosis, and any old doctor can write a prescription once the real work is done. This same bias pervades insurance rules. To be paid at the appropriate level, physicians must exhaustively document all sorts of irrelevant diagnostic data—such as a rectal exam in toddlers seen for a comprehensive asthma evaluation—rather than the rationale for the treatment they prescribe.
On a separate but related front, medical education today fixates on acquiring knowledge that is largely unrelated to patient care. Consider the college prerequisites to attend medical school (for example, physics and organic chemistry) and the morass of molecular biology, anatomy lessons, and pharmacology that follows and must be committed to memory. Of course, a general foundation is important. However, the sheer abundance crowds out an important—in fact, the only—skill that matters in treating a patient: how to critically appraise published clinical trials. Few doctors ever read them. In effect, medicine has become a priesthood of practitioners who never review or learn to interpret the Bible to minister to their flock; they instead rely on secondhand wisdom. Or, worse, on Google. . . . .
Even if perfect treatment guidelines were to appear magically, it takes a lot of work to teach doctors to follow them. Consider ear infections in children, which are vastly overtreated with powerful antibiotics. In 2000, a group of Boston researchers created an ambitious three-year program (using sociological methods used by missionaries to score religious converts) to educate local pediatricians about proper ear-infection treatment. They explained how to talk to patients, control symptoms without antibiotics, and create educational handouts for patients. They taught doctors what they should have learned in medical school and, as reported in Pediatrics this year, substantially cut antibiotic use. The only sticking point is that it all took a big investment of time and money.
Treatment neglect has big consequences beyond ear infections. Medical errors may claim almost 100,000 lives each year, often from basic skills like poor handwriting on prescriptions. In her book, Overtreated, Shannon Brownlee explains how ignoring treatment has led to odd discrepancies in medical care; for example, some towns in Vermont had tenfold higher rates of pediatric tonsillectomy than others, despite having the same kinds of patients.
Refocusing doctors on actual treatment, instead of pointy-headed diagnostic puzzles, will take serious effort. In the meantime, patients should ask a simple question: "Can you describe the evidence for my treatment?" For better or worse, the answer will tell you a lot about the care you're getting.