Hospitals can be dangerous and inefficient; therefore it is easy to connect with Atul Gawande’s recent New Yorker essay “BigMed” suggesting that the streamlined, production processes found at the Cheesecake Factory can and likely will be applied to healthcare. Yet hospital care should not be confused with the full spectrum of healthcare. One must make the distinction between the cognitive process of medical diagnosis occurring in exam rooms, with the procedural basis of surgical care and hospital recovery. While Dr. Gawande has provided a wonderful revealing portrait of cost-effective, fast, food preparation and delivery at the Cheesecake Factory, he has focused on the process of creating the meal, not the process of deciding what meal to make. Successful surgery, for the wrong diagnosis, is a problem. If we are to solve some of healthcare’s largest failings we should focus on what happens as physicians try to address their patient’s problems, diagnose and make decisions, at the table of medicine called the exam room.
Consider the continuum of the patient encounter, from first symptoms, through diagnosis and therapy at a restaurant called Med. At Med I spend all of my shifts with my patrons at my tables. This is an unusual restaurant since the patrons are never sure of what they want to eat and appear every 20 minutes with ever changing lists of unique groups of ingredients to share with me. There are varying ingredients and thousands of meals that can be created. The patrons know the ingredients, but not the meal that they would like to eat. From memory I respond to the customers list of ingredients and ask many questions, take the pulse and other vital signs of the customer, order blood samples, radiographic studies and then decide for the patron which meal their ingredients add up to. All from memory. At Med, restaurant patrons also ask for foods and “food tests” they have seen on television all purported to be risk free. Further complicating the process is my customer is not out for a fun and relaxing evening, they are in small booths in skimpy, open at the back gowns, often anxious and uncertain if they will be harmed or poisoned by my foods, or simply receive a meal they do not want. Some are in pain and some are depressed, while other customers are totally unrealistic about the meal that is to be delivered. You see at Restaurant Med, where patrons only can speak to their wait staff about ingredients, and demand the modern but unhelpful ovens they heard about from friends and the media, it is really difficult to create meals that patrons thoroughly enjoy.
An appendectomy should be consistently performed and priced, but how do we consistently perform and price considering the ambiguity inherent in diagnosis itself? Unlike a restaurant, where customers choose a meal by ordering a meal, at restaurant Med some higher force gives an unfortunate person an undifferentiated and undiagnosed problem that needs and deserves an answer. As it turns out, none of the patrons really want to be eating at restaurant Med, as they always receive a meal they did not ask for.
Patients do not choose their diagnoses from menus; doctors must discover and diagnose them.
If your waiter tries to memorize all the orders at all the tables, you might get the wrong meal, and if your server is in a hurry, thai dipping sauce might be spilled on your new silk blouse. Likewise if physicians are in a rush, they might not take a thorough history, perform a complete physical exam, or have an accurate and thorough list of diagnostic possibilities, ultimately resulting in the wrong diagnosis. If your physician believes he or she can memorize all the questions, tied to all the possible diagnoses you also might receive the wrong diagnosis. With that wrong diagnosis you might end up in a hospital more efficient than the Cheesecake Factory with doctors efficiently ordering unnecessary tests, and performing wrong surgeries for the wrong diagnosis all with the ease and speed of the best assembly line on the planet.
Diagnostic and patient management error caused by cognitive mistakes in the exam room are all too often overlooked and unmentioned in the discussion of repairing our broken healthcare system. There are over a billion outpatient visits in the US each year, and numerous studies have shown 15-20% of these visits have an inaccurate diagnosis. Autopsy data proves this, malpractice insurers know this, and policy makers avoid it. Add diagnostic error in the emergency room and walk-in clinics to error in the out-patient offices of medicine and you have more than 200 million errors. If we are to resolve some of healthcare’s deepest woes we need to address diagnostic errors and the decision-making occurring at the restaurant table of medicine, the exam room. A bright light needs to be shined on the simple fact that there is too much to know, to ask and to apply during a 15 minute encounter unless the patient has the simplest of medical questions or problems. Medical informaticists, researchers and innovative companies are focusing on this essential limitation of medical decision-making by designing information systems to be used by physicians at the point of care, during the patient encounter. Problem oriented systems can also be designed for use by patients in advance of the visit, and the future holds home-based information coordinated with professional clinical decision support. These new information tools are beginning to take the guessing out of which ingredients (symptoms) relate to the meals that the patient ultimately receives (diagnosis and treatment). If medical care is truly to be driven back to primary care we need to arm the waiters of medicine with purposefully designed tools and training to resolve ambiguity, aid diagnosis and inform therapy in the exam room.
Art Papier MD
Art Papier MD is CEO of Logical Images the developer of www.visualdx.com a clinical decision support system, Associate Professor of Dermatology and Medical Informatics at the University of Rochester College of Medicine, and a Director of the Society To Improve Diagnosis In Medicine (SIDM) http://www.improvediagnosis.org/
Monday’s New Yorker has a story, Personal Best, by Atul Gawande. It’s about coaching, and the seemingly novel idea that doctors might engage coaches – individuals with relevant expertise and experience — to help them improve their usual work, i.e. how they practice medicine.
Dr. Gawande is a surgeon, now of eight years according to his article. His specialty is endocrine surgery – when he operates it’s most often on problematic glands like the thyroid, parathyroid or appendix. Results, and complications, are tracked. For a while after he completed his training he got better and better, in comparison to nation stats, by his accounting. And then things leveled off.
The surgeon-writer considered how coaches can help individuals get better at whatever they do, like playing a sport or singing. He writes:
The coaching model is different from the traditional conception of pedagogy, where there’s a presumption that, after a certain point, the student no longer needs instruction. You graduate. You’re done. You can go the rest of the way yourself…
He wonders about how this might apply in medicine: Read more »
*This blog post was originally published at Medical Lessons*
Recently, I had a conversation with Shannon Brownlee (the widely respected science journalist and acting director of the Health Policy Program at the New America Foundation) about whether men should continue to have access to the PSA test for prostate cancer screening, despite the overwhelming evidence that it extends few, if any, lives and harms many more men than it benefits. She felt that if patients could be provided with truly unbiased information and appropriate decision aids, they should still be able to choose to have the test (and have it covered by medical insurance). Believing that one of the most important roles of doctors is to prevent patients from making bad decisions, I disagreed.
After reading Your Medical Mind, the new book by Harvard oncologist and New Yorker columnist Jerome Groopman, I think he would probably side with Brownlee’s point of view. Groopman, whose authoring credits include the 2007 bestseller How Doctors Think, and wife Pamela Hartzband, MD have written a kind of sequel to that book that could have easily been titled How Patients Think. Drawing on interviews with dozens of patients about a wide variety of medical decisions – from starting a cholesterol-lowering drug, to having knee surgery, to accepting or refusing heroic end-of-life interventions – the authors Read more »
*This blog post was originally published at Common Sense Family Doctor*
Everyone is reading Atul Gawande’s article in the New Yorker about health care costs. But I think most people misunderstand Gawande’s major point.
Everyone’s At It
The conventional wisdom on Gawande’s piece is this: our problems are caused by bad incentives in our health care system. They encourage doctors to overprescribe care. McAllen, Texas is the poster child of this problem. If we can change the economic incentives, doctors will behave better. They will follow medical evidence, not their bottom lines, and from this will emerge a rational, affordable system.
This isn’t what Gawande is saying.
Gawande went to McAllen expecting to see a microcosm of the American health care system. As expected, he found excessive, even abusive spending, and a culture that encouraged both. But he also found that in nearby El Paso, Texas, medicine wasn’t practiced this way, nor in most other places in the country. And so he came up with a surprising insight. Yes, McAllen is a reflection of what can happen based on the incentives in the system. But if every incentive works this way, why is McAllen such an outlier?
Gawande concluded it had to do with the “culture” of medicine in each community. Most doctors go into medicine to help patients. In Gawande’s visit to McAllen, he heard stories that money had become more important than quality care. What Gawande realized was how important this question of “culture” was to how McAllen became McAllen. It made him think of places that had a completely different culture, like the Mayo Clinic.
The doctors of the Mayo Clinic decided, some decades ago, to put medicine first:
The core tenet of the Mayo Clinic is “The needs of the patient come first” — not the convenience of the doctors, not their revenues. The doctors and the nurses, and even the janitors, sat in meetings almost weekly, working on ideas to make the service and the care better, not to get more money out of patients. . . . Mayo promoted leaders who focused first on what was best for patients, and then on how to make this financially feasible.
Gawande couldn’t believe how much time doctors at the Mayo clinic spent with each patient, and how readily they could interact with colleagues on difficult problems. While it is true, the Mayo Clinic has financial arrangements that make this easier, it is the culture of patient care that dominates, not questions of pay:
No one there actually intends to do fewer expensive scans and procedures than is done elsewhere in the country. The aim is to raise quality and to help doctors and other staff members work as a team. But almost by happenstance, the result has been lower costs.
“When doctors put their heads together in a room, when they share expertise, you get more thinking and less testing,” [Denis] Cortes [CEO of the Mayo Clinic] told me
And this is where Gawande is being misunderstood.
The “cost conundrum” that Gawande talks about is not about how to cut costs, or how to change who pays for health care and how much. It’s deeper than that. Gawande’s point is that we have been fixated for so long on the question of money in health care that we are starting to forget about medicine. By focusing on ever more clever ways to pay doctors, we have systematically undervalued everything that makes for high quality medicine. Things like time with your patient, thinking about his or her problems, consulting with colleagues, and coming up with sound advice.
We discount what he calls the “astonishing” accomplishments of the Mayo Clinic on this score. And instead of designing health care reform around ways to help more hospitals become like the Mayo Clinic, we choose instead to think about money, to focus our attention on how to cut costs in places like McAllen.
Politically, it makes sense – it’s convenient to have a poster child like McAllen to explain why one reform plan or another should become law. But the pity is that in this important time of reform we’re not talking about trying to put the needs of the patients first – to put medicine back in the center of health care. The pity is that in spite of the fact that everyone’s reading Gawande’s article, his most important insight is being misunderstood.
If we continue to be focused on money over medicine, we will lose the “war over the culture of medicine – the war over whether our country’s anchor model with be Mayo or McAllen.”
*This blog post was originally published at See First Blog*