Map of life expectancy at birth from Global Education Project.

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.


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Anonymous said...

The good Swiss ppl have voted many times against

a) heists or proposed changes by insurance cos. (Health care all by private insurance cos. in CH, though you’d need a lot of footnotes on that.)
b) moves towards a more ‘socialistic’ health care system, such as premiums in function of income, or variants of ‘single payer’ etc.

Superficially, the reasons are not hard to see. Having high risk individuals pay more is - refused. Changing the system and having high income ppl pay more is - refused. Etc. On each vote, you can see why the NO, and in fact predict the outcome easily. One might also just say that ppl don’t like change, are scared of ‘new rules’, etc. Part of the answer also lies in the fact that the tax payer chips in for far more than he knows, as the State subsidises payments to the insurance cos. for the poor, and this is generally not bruited about. (heh, ‘cause it’s weird.)

A more deeper reason is that both from the right and the left, the state authorities or the corps, family associations etc. etc. many of the proposals imply or seem to lead to more ‘managed’ care (managed care just refused a few months ago), more strictures, more rules, more procedures, and loss of choosing your own doctor/specialist or being able to change (The last has already been lost for many but it is voluntary in return for a reduction of premiums.) At the heart, proposals seems to negate the dr-patient relation and patient choice as to med. therapy.

I recall when my son was 14 (and that is a kind of age-majority here) being allowed to sit in the back - it was understood i would not speak - while a specialist and a consultant outlined his choices for a minor but somewhat scary / ugly / mildly handicapping thing. The choices were, a) we do nothing for a long while and wait and see, this pathology can evolve in different ways, there is no pressing med need to act, if>.... then>.....b) we apply therapy X, which is more aggressive than therapy Y which you have already had, X has a 55% success rate, c) we operate which will work but be painful - longish in recovery etc., and may have minor but inalterable neg. results (e.g. weakness, loss of feeling, etc.)

It was his choice. I am sure that there is a best ‘protocol’, statistically, for what he had.

But these are the kinds of choices ppl here do not want to give up.

(He chose the op and it went perfectly.)


Rx247 Blog said...

I doubt that many of our patients would want to hear their doctors talk about the role of luck in medicine, but is true, that’s our dirty little secret.

Dr. McKenzie

Generic Medications said...

In the lexicon of luck, there are times when a prepared mind puts disparate information together to arrive at a diagnosis. A case in point: While filling in for a colleague, I saw a patient with anasarca. He had a minimally elevated transaminase and, in leafing through his chart, I spotted an ultrasound suggesting intrinsic liver disease. Lo and behold, his hepatitis B and C panels were positive. My suspicion immediately turned to chronic hepatitis. Perhaps this comes under the heading of educated luck.

Consider, too, the dumb luck of the incidental finding—when you order an imaging test for pneumonia and find the treatable (but unrelated) cancer or aneurysm.

Best regards,
Dr. Robinson