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Wednesday, May 6, 2015

Reducing variability in healthcare delivery--maybe not such a great idea

I just got back from the annual meeting of the American College of Physicians, an organization of internal medicine physicians with about 140,000 members. In the annual meetings organizational things take place, such as recognition of particularly hard working members and a kind of graduation ceremony in which members who have achieved a certain level of accomplishment are advanced to fellowship. Mostly, though, the tens of thousands who attend are there to go to lectures and discussions by doctors who know things that we all want to know.

It is possible when attending these meetings to get a general idea of what the leadership in internal medicine thinks is important or acceptable. This year one of the themes seemed to be "reduction of variability." Only one talk actually used those words, but many of the speakers mentioned that they were encouraged to present the "party line" meaning published guidelines by specialty organizations within the ACP. Guidelines are carefully built recommendations for managing various conditions, from diabetes to urinary tract infections, and are extremely helpful in swaying our practice away from things that don't work and toward things that do. They were never intended to be the last and final word.

The one talk that actually used the verbiage "reducing variability" was also addressing the Choosing Wisely campaign. A few years ago the American Board of Internal Medicine championed an initiative to reduce the number of wasteful and useless things physicians did in caring for patients. The idea was that specialty groups would point out the tests or treatments that were being done that really didn't make sense. There are lists now of what not to do (like a head CT scan for a fainting spell or an x-ray for uncomplicated back pain without "red flag" symptoms or antibiotics for the common cold). These lists will help doctors to feel supported when practicing good medicine. They are also an attempt to reduce variability by presenting a unified approach to common problems. I would have liked to see the talk about Choosing Wisely and reducing variability, but for some reason it required an advanced reservation.

I am actually a big fan of Choosing Wisely, since I think that many physicians do more testing and treatment than really makes sense, thus wasting their patients' time and money and cluttering their consciousness with useless and excessive data. But I am not entirely on board with reducing variability.

When I go to a lecture at the ACP meeting, what I hope for is to hear a physician speak who has immense experience in the practice of medicine and who will tell me what he or she does that works well. Sometimes there are controlled trials to support their practice but sometimes their subtle and individualized approaches are not amenable to controlled trials. This is as it should be: much of medicine is an art, and amazing and committed physicians are among us and we can learn a great deal from them. Sometimes different great teachers practice differently from one another. Doing things differently often means that thinking and innovation is going on and that people are not simply acting like sheep.

I heard one speaker, who seemed quite good at what she did, speak of the research regarding her field. She presented data to show that a certain medication worked no better than placebo for treating the condition in question. She said that when her patients asked about using the medication, she told them that they could try it but that it would work no better than a placebo. But she was wrong. The study showed that on average, for a group of patients the medication worked no better than placebo. But for some patients it, of course, worked significantly better than placebo and for some it worked less well. In saying this she made the assumption that there was no variability among patients and that her patient would have the same results as the average patient in the study. Because of this interpretation, those patients of hers who might have benefited from the treatment were probably unlikely to try it.

Because our patients are individuals and not groups of average subjects there should be some variability in how we practice. Because there are more ways than one of doing a job well, we should continue to rejoice in our variability, while striving not to do things that are clearly stupid. It is right that what we do as physicians should be informed by clinical trials and controlled studies, but we should not be convinced by them to ignore the individuality of both physiology and goals of the patient who sits in front of us.


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