Monday, January 03, 2005

Good Old-Fashioned Doctoring

I was amazed to see this in the main-stream business media, of all places. In his 2005 predictions for the pharmaceutical industry, Matthew Herper wrote:

Medicine needs to be reorganized more than it needs any scientific breakthrough. The problem is no longer inventing new lifesaving drugs or devices, but getting them to the right patients. Armies of specialists prescribe tons of pricey pills but fail to deliver basic medical care. Patients don't get drugs that could save them, and medical errors crop up with alarming frequency. New computer systems could help. But what we really need is good, old-fashioned doctoring--the kind that takes the time to take care of the whole patient.

Does this mean that the folks in various big health care organizations are going to introspect about how health care (dis)organization and (mis)governance has gotten in the way of primary care and generalism, which is what I think he means to promote?


Egan said...

Good question Roy.

We are cursed by our own blessings. I would hypothesize that there is a sigmoidal relationship (like pO2 and oxygen saturation) between costly "advances" in medicine and survival/QOL. In other words, there are diminishing returns for the increasingly expensive medical technologies. The more desirable portion of the curve derives its slope to the basics: public sewage, sanitary peripartal care, and immunizations. After that we spend a lot for very little (the plateau portion of the curve).

Evidence based approaches have a tendency to be interpreted by medical colleges, journals and institutions, I would argue, as black and white. If it is statistically significant then it becomes interpreted as "must do". I don't hear about NNT (numbers need to treat) enough. Cost-benefit analyses seem to get a back seat to the all powerful P-value. The result is that many a 50+ year old races to the gastroenterologist for a colonoscopy (at a premium price and not without risks) for an arguable "P-value" driven reason.

I feel that the pace of new knowledge accumulation is too fast for the maladaptive healthcare system to handle. A 6 figure cost for a "discovery" becomes a "right" for every American to have access to. The medical-legal pressure to practice defensive medicine only increases. Decreasing reimbursements for cognitive specialists only drives a decreasing [time with doc]/[medical complexity] ratio. The latter in turn drives extreme, and costly, reactions to "bad news". The net result is out of control healthcare costs.

I yearn for the day when there were 3 antibiotics, a couple of antihypertensives, a few tricyclics, plain films only, in-office Hematocrits and UAs, etc. No options, little costs....and not a heck of a lot less in terms of overal life span!



Lee Green MD MPH said...

I don't yearn for the days when choices were few and simple (well, not too much, anyway!), but I do yearn for having time with patients commensurate with the cognitive workload. Studies of physician-patient interaction don't show that we have less time per patient than we used to, but they fail to investigate why it feels as though we do. When I started practicing family medicine there were two beta blockers, one CCB, no ACE, fewer cephalosporins than grains of sand on a beach... the number of options available and the number of decisions per unit time were much fewer than today. It's not that we have less time per patient, but that we have so many more tasks per patient. Patient visits have to get longer if more stuff is squeezed in, or stuff gets squeezed out. What's been squeezed out is doctoring.