Improving Medical Care
Friday, April 13, 2007
I recently had a thoughtful exchange on Slate with Darshak Sanghavi, a pediatric cardiologist. In it, we discussed how to improve the current state of medical care and how to better patient treatment. Our views differed in that I am in favor of improving the system primarily by honing the individual doctor's skills and my peer argues standardization of the medical process. It was a very productive conversation and I wanted to take the time to expand on some of the ideas here.The state of medical care is that there is going to be less and less time to do an imperfect science. While common things can be standardized, and implementation of certain routine practices may improve care, it is critical to remember that many diseases are not "standard," because there is considerable variation among individuals whose biology is, by nature, variable. That means that one microbe can act very differently in different people, that a blocked coronary artery can produce classic symptoms like crushing chest pain radiating down the arm but in another person be very atypical, presenting nausea or indigestion. Prototypes and guidelines are always worth referring to, but all care cannot fit into one format.
Beyond my discussion with Darshak, I worry that we may be deluding ourselves about what constitutes outstanding performance by physicians. The current metrics measure the simplest processes and procedures, so that scoring high may give us a false sense of reassurance. There is an art to medicine that involves creative thinking, self doubt, self questioning, and engaged dialog with a patient and his family, drawing out key information and weighing its importance. I am not sure how this can be "measured," but I do believe that it can be better taught and modeled. I know that there are many times when I fall into cognitive traps and still have a long way to go to improve "performance" after some 35 years in medicine.
The question remains, who is a good doctor, and, moreover, who is the right doctor for any individual? The best answer that I have found for myself and my family is a doctor who thinks with us, explains clearly what is in her mind, how she arrived at her working diagnosis, and why the offered treatment makes sense for us as individuals. She may refer to guidelines and "best practices," but clearly takes into account the spectrum of human biology and customizes our care to fit both our clinical needs as well as our emotional, social, and psychological dimensions.
