Monday, August 31, 2009

Health Reform: Setting the Record Right and Getting the Facts Straight

I’m becoming a fan of Jerome Groopman, MD, a Harvard Medical School professor and a staff writer for the New Yorker.

I quoted from his book How Doctors Think (2007) for setting the record straight on the usefulness of clinical algorithms, in my own book, Obama, Doctors, and Health Reform,

Clinical algorithms can be useful for run-of-the-mill diagnosis and treatment – distinguishing strep throat from viral pharyngitis, for example. But they quickly fall apart when a doctors needs to think outside their boxes, when symptoms are vague, or multiple and confusing or when test results are inexact. In such cases – the kinds of cases where we most need a discerning doctor – algorithms discourage physicians from thinking independently and creatively. Instead of expanding a doctor’s thinking, they constrain it.”

“Similarly, a movement is afoot to base all treatment decisions strictly on statistically proven data. This so-called evidence-based medicine is rapidly becoming the cannon… But today’s rigid reliance on evidence-based medicine risks having the doctor chooses care passively, solely on the numbers. Statistics can’t substitute for the human being before you; statistics embody averages, not individuals.”

Another Expression of Thanks

Now I would like to thank him and his co-author, Pamela Hartzband, MD, for getting the facts straight on a number of facts often bandied about by critics of American doctors and the U.S. Health system in the Wall Street Journal,” Fact From Fiction on Health Care,” Here is what they say in part, and I quote.

Consider these myths and mantras of the current debate.”

• “Americans only receive 55% of recommended care. This would be a frightening statistic, if it were true. It is not. Yet it was presented as fact to the Senate Health and Finance Committees, which are writing reform bills, in March 2009 by the Agency for Healthcare Research and Quality (the federal body that sets priorities to improve the nation's health care). The statistic comes from a flawed study published in 2003 by the Rand Corporation. “

• “The World Health Organization ranks the U.S. 37th In the world in quality. This is another frightening statistic. It is also not accurate. Yet the head of the National Committee for Quality Assurance, a powerful organization influencing both the government and private insurers in defining quality of care, has stated this as fact. In fact, the World Health Organization ranks the U.S. No. 1 among all countries in ‘responsiveness.’ Responsiveness has two components: respect for persons (including dignity, confidentiality and autonomy of individuals and families to make decisions about their own care), and client orientation (including prompt attention, access to social support networks during care, quality of basic amenities and choice of provider)”.

• “We need to implement ‘best practices.’ Mr. Obama and his advisers believe in implementing "best practices" that physicians and hospitals should follow. A federal commission would identify these practices. There are domains of medicine where a patient has no control and depends on the physician and the hospital to provide best practices. Strict protocols have been developed to prevent infections during procedures and to reduce the risk of surgical mishaps. There are also emergency situations like a patient arriving in the midst of a heart attack where standardized advanced treatments save many lives.

“But once we leave safety measures and emergency therapies where patients have scant say, what is ‘the right thing’? Data from clinical studies provide averages from populations and may not apply to individual patients. Clinical studies routinely exclude patients with more than one medical condition and often the elderly or people on multiple medications.

“Conclusions about what works and what doesn't work change much too quickly for policy makers to dictate clinical practice. With respect to "best practices," prudent doctors think, not just follow, and informed patients consider and then choose, not just comply.”

• “No government bureaucrat will come between you and your doctor. The president has repeatedly stated this in town-hall meetings. But his proposal to provide financial incentives to ‘allow doctors to do the right thing’ could undermine this promise. If doctors and hospitals are rewarded for complying with government mandated treatment measures or penalized if they do not comply, clearly federal bureaucrats are directing health decisions."

“Private insurers are already doing this, and both physicians and patients are chafing at their arbitrary intervention. As Congress works to extend coverage and contain costs, any legislation must clearly codify the promise to preserve for Americans the principle of control over their health-care decisions.”

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