Last year the New York Times reported that the aviation industry had become so safe that one could fly every day for 123,000 years before dying in an aviation crash. I wish we could say the same for the U.S. health care system. Nationally, problems with health care quality (doing too much, doing the wrong things, and doing too little when indicated) are pretty clear. The bigger problem is that progress has been painfully slow.
I once heard a great lecture given by Dr. Brent James, the renowned health care quality expert from Intermountain Health Care in Utah. In his talk, Dr. James described health care's "dysfunctions," one of which was a glaring lack of consistency in the practice of medicine. His main point was that health care – still today – remains a "craft" business with little standardization of even basic processes. He reflected on this point in a communication with health writer Paul Levy a few years ago:
The term of art that is usually used to describe the present state... is "the craft of medicine." It's the idea that every physician (or nurse, or technician, or administrator, etc.) is a personal expert, relying primarily on their personal commitment to excellence. In a very real sense, every physician occupies his/her own universe, with its own reality, truths, physical constants. As a physician I might say to a colleague, "What works for you, works for you. What works for me, works for me."
Efforts to reduce variation in care and to stop prescribing un-indicated interventions have met a lot of resistance. Doctors are truly convinced (although the literature may suggest otherwise) that individualized interventions embody the patient-focused art of medical practice. Standardized care, even for simple conditions, is "cookbook medicine" and efforts to impose restrictions on medical practice interfere with a sacrosanct "doctor-patient relationship."
This approach partly explains the massive variations in clinical practice that we see nationally. But it also contributes to a lot of unnecessary and un-indicated medicine, all which is not without harm. There have been efforts to address unnecessary health care. Choosing Wisely is an initiative sponsored by the American Board of Internal Medicine. The campaign is supposed to reduce unnecessary medical interventions by publicizing the top five most overused interventions, (such as antibiotics for coughs and colds and unneeded X-rays for routine back pain) in nearly every specialty. A lot of the interventions on the list continue to be widely used (to the tune of $5 billion per year) even though they have been well studied and found to be pretty resoundingly discredited.
In response, there have been squeals of protest from some physicians. A letter to the editor notes: "The present Choosing Wisely campaign has fundamental flaws – not because it is medically wrong but because it attempts to replace choice and good judgment with a rigid set of rules that undoubtedly will have many exceptions. Based on what we have seen so far, we suspect that Choosing Wisely is much more about saving money than improving patient care. We also predict it will be used by the unknowing or unscrupulous to further interfere with the doctor-patient relationship."
There is a critical point to be made about Choosing Wisely and other campaigns, such as the World Health Organization's and the U.S. Centers for Disease Control's campaigns to improve provider hand washing: all expect consumers to carry the water when it comes to ensuring health care appropriateness.
Choosing Wisely is promoting itself as a means to "spark conversations between providers and patients." It has partnered with Consumer Reports to disseminate the list of overused and un-indicated interventions to patients. Clearly it's hoping that patients will confront doctors about unnecessary procedures and care. The CDC, for its part, is distributing "patient empowerment" materials which ask patients to confront caregivers who don't wash their hands. It's a bad turn of events when health care quality programs need to work around physicians by asking patients to "engage in dialogue" with their health care providers to avoid dirty hands and unnecessary care.
And there's the rub: As much as we can argue that patient engagement with their own health care decisions is progress, asking patients to keep doctors honest about the most basic medical practices is less a form of patient centered medicine than a tacit failure of physician professionalism (and to an even greater degree a failure of medical management).
I can't imagine how we got to a point where responsibility for appropriate and safe health care practice has fallen to patients, some who are supposed to supervise their own care on the basis of handouts from the CDC and Choosing Wisely (available here by the way...).
Reflecting back on the aviation industry: Imagine, for a moment, if we expected passengers to "have a dialogue" with airline pilots prior to a flight. Is this something we'd consider admirably "passenger-centered?"
This post originally appeared on Dr. Munk's blog, Considering American Healthcare, on August 27, 2014.