Stranger in a strange land

I find myself a stranger in a strange land, or (more prosaically) a square peg being forced into a round hole.



My nearly 40 years as a primary care physician have been dedicated to forming and maintaining trusting and collaborative long-term relationships with patients,  in order to help them with their health care. This involves teaching about the natural and pathologic processes at work and the medical evidence pertinent to their lives, trying to understand their circumstances and values, and working with them to find solutions tailored to them as individuals.

The medical world I find myself in is less and less supportive of this approach.  It has become an industry rather than a profession. The product being sold is neither neither individualized care nor patient outcomes, but interventions like office visits and tests, measured not in patient benefit but in wRVUs that are converted into revenue streams. Third parties (payors, government, reviewers) are the consumers, and patients (now called covered lives) have become a raw material. My front office staff actually now wears Walmart style badges that say Customer Service. WTF? The definition of excellent care is no longer related to the needs or desires of the patient, but is increasingly determined by outside agencies using panels of experts. A friend recently told me she left medicine because she realized that the term ‘care’ no longer referred to how physicians felt about their patients, but had become a label for the visits, tests, and treatments they sold. Instead of caring, we sell care.

Some examples of the contrast between these two visions:

• Evidence for the life-saving benefits of routine mammograms in normal risk asymptomatic women is so shaky and inconsistent that the different professional societies that appoint themselves as agents of truth make different recommendations about who should undergo mammograms and how often (see guidelines by the American Cancer Society and the US Preventive Services Task Force) while the most recent and most robust published trial calls into question whether or not mammograms actually save lives. My approach is to explain the data, make the patient aware of the recommendations, be honest about the controversy and uncertainties, answer her questions, and help her make her own best individual decision based on a combination of the evidence and her values and preferences. A fairly typical approach is to have a committee pick one of the existing recommendations as its institutional policy and quality goal, and then expect its clinicians to convince their patients that this is The Answer. They enforce this with the financial pressure of salary cuts if patients make their own decisions.
• Pneumococcal vaccine for patients over 65 became a standard recommendation in 1997 and most government and private Quality Initiatives consider it a ‘benchmark’ indicator of quality of care. However, more recent evaluation of the data strongly suggests that it is of no value in preventing hospitalization or mortality from pneumonia, and of minimal value in preventing invasive pneumococcal disease. My approach is to tell patients that we have a vaccine that may or may not reduce their risk of a very serious and sometimes fatal illness, discuss the numbers and answer their questions, and help them decide what they want to do. Quality programs take the stance that we are sure enough of the benefit of pneumococcal vaccine that patients should be told to have the vaccine, and institutions and physicians should be penalized financially if patients decide otherwise.
• Similar discrepancies between a patient-centered, best-evidence guided approach and modern medicine’s paternalistic industrial management approach are seen with the use of A1c targets for diabetes, BP targets for both the diagnosis and treatment of hypertension, BMI screening and treatment for the overweight (not just the obese), and lipid targets in diabetes and hyperlipidemia.
• Protocols and policies are steadily replacing individual patient-centered decision making in the approach to pain, the treatment of attention deficit,  the pre-operative evaluation of patients undergoing bariatric surgery, even the use of medications for depression.

While it often feels to me as if medicine has lost its way, a better explanation is that medicine is struggling to evolve from a non-scientific calling dedicated to caring for individual patients into a patient-centered, evidence-guided, and technology-supported calling dedicated to caring for both individual patients and society as a whole - but is currently mired in an ugly adolescent phase where evidence has replaced the paternalistic physician as the new autocrat. Physicians are being transformed from skilled artisans into compliant line workers. Patients are more likely to be on the menu than at the table when decisions are made.

There was a similar transition in furniture making from the era of artisans through an industrial phase, to the current era. Up until the early 1800s and the industrial revolution,  furniture was made by individual artisans. There was a wide range of skill and quality, and fine furniture from the likes of Sheraton, Chippendale or Hepplewhite was available only to the rich and powerful. (High quality pieces remain beautiful and functional to this day. Poor quality furniture, if it survived, is now valued as ‘folk art’ rather than as quality furniture.) Serviceable, cheap and uniform furniture - and the middle class market that desired it - first became available in the early and mid 1800s with the Industrial Revolution. This standardized and widely available product would never be called excellent. It was - and is - mediocre, meaning average or of only moderate quality. (The goal of the Golden Mean was originally called ‘golden mediocrity.’) Since WW2 we have seen first a growth of ‘hobbyists’ and now a plethora of truly fine artisans, using modern technology and materials to create furniture of the same caliber as the old masters.  A Google search for fine furniture in Maine gives 1.8 million hits and there are hundreds of high quality furniture artisans within an hour’s drive of my house in central Maine. Standardized and mass-produced furniture is better than no furniture or furniture made by the untrained with poor materials, but the value is that it is available, not that it is excellent.

My point is that excellence is not defined or created by standardized processes, by design consensus, or by the elimination of variability; the opposite is true. Standardization and the elimination of variability make things average,  predictable and consistent - but also mediocre rather than excellent. Excellence requires individual attention and demands variation based on the craftsman, the materials available, the purpose of the piece, and the preferences of the purchaser.

This is just as true in medicine as it is in furniture making. 

Excellence in medicine is NOT based on a universal set of one-size-fits-all targets or guidelines. Excellence will not be achieved by replacing the paternalism of individual physicians with the paternalism of groups of physicians whose opinions about the conflicting and constantly changing evidence are called guidelines and are imposed on institutions, physicians and patients alike. Excellence is based on the formation of trusting long term relationships, which requires time and honesty. In the setting of these relationships, clinicians can work with their patients to achieve excellent outcomes by knowing both the medical science and their patients well, by sharing information and providing education, by soliciting and answering questions, by finding and applying the best pertinent evidence (which is often in conflict with published guidelines), and by helping patients make good personally suitable decisions.

I am an optimist. I believe that better times are ahead. Unfortunately, I am also a realist and therefore think they are quite a ways down the road. Physicians like Bertalan Mesko, Lawrence and Lincoln Weed,  and Eric Topol clearly envision a time when the availability of data and the use of technology will be used to encourage individualized but data-informed and therefore high-quality medicine, rather than the homogenized and therefore mediocre (standardized and average) medicine that is currently the stated goal. 

In the meantime, I will continue doing what I have always done. I will use the technology at my disposal and the best evidence I can find (and guidelines ONLY to the extent that they are current and applicable) to help patients understand what is happening with their health and what their choices are. Using the trust and comfort of long-term and honest relationships, I will do my best to help my patients make decisions that serve them well. 

I understand that this will sometimes put me in conflict with institutions and with powerful forces in main stream medicine. I have been called disloyal and disruptive, and will likely continue to be marginalized (and occasionally punished) for my advocacy on behalf of the patient as an individual. I am a square peg, and proud of it. Regardless of who signs my pay check, I work with and for my patients.  When I can’t do that, it will be time to find another way to spend my days.