Wednesday, November 17, 2004

If Doctor Doesn’t Know Best, Then What?

It hasn’t been so long ago that a good patient was one who followed doctor’s orders. Doctor knew best.

Whether doctor always knew best can be debated, but the belief that he did has been a bedrock assumption underpinning the organization and operation of the health care system. The doctor, without external interference, decided what was to be done for the patient and it was then the responsibility of the rest of the health care system to see that it got done and that it got paid for.

Now the magazine AARP, in the lead article of its November/December 2004 issue, urges its readers not to accept uncritically the decisions of cardiologists who tell them that they need to have heart surgery as treatment for their clogged arteries. The article reports “neither bypass nor angiography has been shown to prevent heart attacks.” It suggests that these procedures are appropriate in only a limited number of cases – many fewer than are now being done. Patients who are advised by their doctors to have them are urged to seek a second opinion and are given a three-step formula to use in evaluating the advice received.

Of course, this sort of thing has appeared in the media before. But seeing it in AARP brings its implications sharply to mind. AARP claims the largest circulation of any American magazine and is aimed at the seniors who are the main users of these two procedures.

If we can no longer assume that doctor knows best, then who should decide what should be done for patients? The patients themselves? Insurance companies? The government? Provider organizations like hospitals and large group practices?

These are important questions. Any serious thinking about redesigning the health care system has to address them.

Leaving these matters up to individual patients doesn’t seem very practical. Attempts by managed care companies to do it set off a public revolt.

So as a practical matter we are left with provider organizations. Actually, there has already been movement in that direction. Clinical protocols and care pathways are examples. These standardized approaches to the treatment of particular conditions represent institutional rather than individual decisions about what is to be done for patients. To the extent that they are based on evidence and followed in a disciplined way, they result in better outcomes and lower cost.

Unfortunately, all if this is happening in a rather haphazard way. It needs more strategic thought and the process of doing it needs to be speeded up.

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