That old holism/reductionism thing . . .

My friend Dena Rifkin, who recently completed a fellowship at Our Glorious Institution before moving to San Diego (I guess she wanted to go to Sea World, I dunno) has an essay in the NYT that I commend to your attention.

There has been a multifaceted movement underway for some time now to have doctors, practices, hospitals and whatever kind of institution or subset thereof document adherence to practice guidelines, process of care indicators, and/or outcomes. These efforts may be framed in terms of patient safety, evidence based medicine, realignment of incentives from volume to performance, or some mashup of the above. As I have noted here, or at least I meant to at some point, these sorts of schemes are essential if we're going to have meaningful payment reform that reins in wasteful and even harmful overtreatment, while making cost-effective and preventive care happen when it's supposed to, and gets us all something closer to our money's worth for our health care dollar.

In my own words, Dena's caveat is analogous to the much-decried problem of teaching to the test in education. Teachers who concentrate on maximizing students' ability to check the right boxes on a standardized test, because that's how their own performance of that of their school are assessed, may not be teaching critical thinking, appreciation of the arts and humanities, or promoting emotional intelligence and the diverse talents and interests of their individual students. Doctors who focus on the checklist may end up failing to treat patients as people, failing to listen and respond humanely, and might even make diagnostic errors because they don't take an adequate history or appreciate people's social context.

Some of my physician colleagues here complain about a lesser but still noteworthy problem, that having to document process of care indicators forces them to go through some ridiculous ceremonies that probably don't really harm patients, but aren't the best use of anybody's time. And then there are people with serious co-morbidities that make some process indicators simply absurd. Should you really get docked for failing to meet the cholesterol control target of somebody with terminal cancer? The way these things work now, you just might.

These are genuine concerns. It is important to have a standard metric, for both educational and medical excellence. We need to have accountability and comparability in both fields. But both fields also combine art and science, and deal with the extremely complex entities call human beings who cannot possibly be properly served by focusing on a one-page list of prescriptions and targets. Somehow we need to find an approach compatible with both the reductionist and holistic goals of the enterprise. I don't have a magical answer, but I do honor both sides.