Clashing visions on medical care practice prove to be hurdle

Clashing visions of how physicians should practice medicine in the 21st century bubble beneath the surface of nearly every controversial issue in delivery system reform.

On the one side is what Press Ganey chief medical officer Dr. Thomas H. Lee in a recent essay in JAMA Internal Medicine called a “last-century perspective. It reflects a time when patient outcomes were considered unmeasurable and when the idea of team care meant everyone following the orders of whichever physician was in charge.”

This approach put heroic practitioners at the center of the diagnosis, treatment and healing process. It posited that the best therapy for any patient should be discerned and delivered by someone with years of training and experience and, hopefully, a personal relationship with the individual in need of care.

In a practice environment where knowledge and technology evolved slowly and medical evidence in the form of clinical trials and outcomes data was scant, that approach offered comfort to physicians and patients alike. If things turned out poorly, both the healer and the family at least came away thinking they had tried their best.

However, the rapidly evolving protocols of population health medicine and coordinated care challenge that century-old model. They do so both on the medical science and on methods of practice.

Today, much more is known about what works in medicine, how well it works, and how well it compares to alternative approaches, both in terms of outcomes and costs. This advancing medical knowledge presents practitioners with the choice of making judgments based on their own experiences or following scientifically derived clinical practice guidelines and protocols.

Most physicians, even those who are most vociferous in their complaints about “cookbook” medicine, say they adhere to the science in all but the exceptional cases. But do they really?

Medical science remains a sphere where technology developers can make claims based on minimal or poorly designed trials about their latest drug, heart implant or radiation delivery system. Most providers—and this includes hospitals as well as physicians—still operate under the misaligned incentives of fee-for-service medicine. The opportunity for pseudo-knowledge and self-interest to cloud judgment is ever-present.

There also is a growing recognition that many medical technologies, even when approved by regulators and incorporated into guidelines, have trade-offs that may reduce or even eliminate their medical value. A cancer-screening test may turn up some early tumors. But if it simultaneously generates numerous false positives that lead to unnecessary treatments with their own downsides, the effort to catch disease early may in fact wind up causing more harm than it prevents.

Patient preferences and growing financial responsibilities also play a greater role in determining the medical decisions made by physicians and hospitals. Given the option, most patients will choose watchful waiting or palliation to treatments that have serious side effects or offer little likelihood of a long-term cure.

No matter what technology gets chosen, physicians and hospitals practicing 21st century medicine will have to confront process issues as they strive to achieve the higher overall quality that leads to better outcomes. There's no question that adhering to well-defined surgical procedures or immediately administering an aspirin to heart attack patients will reduce unnecessary complications and mortality. The issue is how to achieve 100% compliance with proven standards like those.

The old model is stood on its head here, too. To achieve superior performance, the once-unquestionable physician leader must give way to the team. She must adhere to standard protocols for procedures and administer therapeutic approaches that the scientific evidence—which may come just as often from registries and outcomes databases as from clinical trials—suggests will lead to the best outcomes for the greatest number.

In this brave new world, variation in care is the enemy of quality—not the wise choice of an experienced clinician. Standardization is the surest path to achieving the best outcomes. It is analogous to the wise investor picking an index fund over the stock-picking money manager who once had a good year.

In his essay, Lee pushed back against those who argue that “improving value” is just the latest code word for rationing care. Stinting on care “in ways that hurt outcomes is not improving value,” he wrote. “Improving outcomes without raising costs is improving value. So is reducing costs without compromising outcomes.”

The biggest hurdle on the road to increasing the value of what Americans spend on healthcare is ensuring that clinicians, provider organizations, payers and the public understand the difference.

Follow Merrill Goozner on Twitter: @MHgoozner