Tuesday, August 07, 2012
Medicine's dirty little secret
It's revealed here by Atul Gawande, although he somewhat buries the lede. Here it is:
Nobody's in charge. Every physician and surgeon is a kingdom unto himself or herself. Doctors do not have bosses, and they are essentially accountable to no-one. This remains true even as they migrate from independent or small group practices to salaried positions with large, integrated medical systems.
The result is that it takes literally decades, and sometimes forever, for evidence about best practices to be generally implemented. Even within a single hospital, as Gawande tells us, every surgeon has a particular way of doing things, even if there is good evidence that says they're all doing something wrong.
This total disorganization also extends to medical education. In medical school, each department has an inherited number of "contact hours" they get with students, and each course director uses that sinecure to teach whatever and however she or he wants to do it. The dean has nothing to say about it. In the second two years, the students are assigned to follow particular doctors around, and when they graduate, as resident they have preceptors. These people, again, teach whatever they want to teach, and model whatever practices and behaviors they happen to engage in. Nobody has anything to tell them about it.
As a result, my colleagues and I who study health services policy and practice, and clinical researchers who learn all the latest and best ways of treating disease, can publish as much compelling research as we can possibly produce, but if anybody pays attention to it we're lucky, and we're luckier still if it changes the way anybody does anything. We figure it will get out there gradually, like a bucket of paint diffusing in a lake, but that's all we can hope for.
Gawande envisions a day when medicine is organized like a business, with protocols that are enforced by people who are actually in charge. You'd think this would maybe appeal to conservatives, because he isn't saying the government should do it. He's saying big companies should swallow up lots of hospitals and practices and put their managers in charge. The government will just keep 'em honest. This may well be a good idea but it's going to set off a serious shit storm. We'll see.