OP-ED

Medicine in Denial

“Any system of care that depends on the personal knowledge and analytic capabilities of physicians cannot be trusted.”

Finally, I’ve come across a really spot-on analysis of what ails healthcare, and some proposals that have serious potential to improve healthcare for people like my patients. Come to think of it, implementing these proposals would surely improve care for all patients.

The analysis, and the proposed fixes, are detailed by Dr. Lawrence Weed and his son Lincoln Weed, in their book “Medicine in Denial.” (The quote above is from this book.)

The book is a little long, but for those who are interested in leveraging technology to make healthcare more consistent and more patient-centered, I’d say it’s a must-read and must-discuss. (I’m a bit surprised that this book doesn’t seem to have many reviews, and that Dr. Weed’s ideas are not more often cited by those advocating for digital health and patient empowerment.) In particular, the Weeds’ book provides:

  1. An excellent description and analysis of two huge fundamental problems in healthcare. One is the way we persist in relying on fallible physician minds to manage the process of evaluating, diagnosing, and managing medical problems. The other is our lack of standards for consistently documenting and organizing information related to our evaluation and management of patients. Both lead to idiosyncratic, disorganized healthcare that generally serves patients poorly, especially those who are medically complex or have multiple chronic conditions.
  2. A proposed method of using computers and technology to consistently connect patient data to medical knowledge, leading to better diagnosis and medical management.
  3. A proposed method of reorganizing of medical records and clinical data. This “problem-oriented medical record” would provide a fundamental level of organization and transparency to the practice of medicine, and would allow better management of multiple problems over time.
  4. A vision of healthcare focused on empowering patients, and on enabling healthcare to be tailored to each patient’s needs, rather than driven by provider idiosyncracy or the blunt tools of evidence-based (aka population-based) medicine.

The book also covers several other topics, such as related problems in medical education and credentialing, and redefining competence in medicine. But the points above are the ones that resonated most deeply with me and my frustrations with the healthcare system.

“The concept of a physician as we know it is not viable”

The Weeds point out the obvious: there exists far too much medical information for the human brain to keep it all in mind, and apply it in a consistent and thorough fashion during a medical encounter.

This creates serious problems when it comes to the core medical work of diagnosis and providing treatment recommendations. To being with, when a patient comes to a physician with a complaint, the physician invariably does not collect enough data. (Just take a look at any UpToDate topic – or JAMA clinical review article — on evaluating a common complaint, and ask yourself if clinicians usually inquire about everything they should. We don’t.) Instead, clinicians ask questions somewhat idiosyncratically, depending on factors such as their initial hunch, their specialty habits, etc.

Next, physicians do a highly imperfect job of matching the patient’s data – i.e. the positive and negative findings – with medical knowledge. This results in a diagnostic conclusion that is often wrong, or in a differential which is incomplete.

As the Weeds point out, a patient with a medical concern can go see three different doctors and emerge with three different diagnoses. And of course, just as clinicians are idiosyncratic in their diagnostic processes, they are also idiosyncratic in how they recommend further evaluation, or in prescribing a management plan.

Doctors will call this “clinical judgement,” but the Weeds consider this unacceptable human-generated variation in medical practice, and I have to say that I agree with them.

To make matters even worse, not only are clinicians applying idiosyncratic human processes to diagnosis and management, but they then go on to document their findings and thought-processes in spotty idiosyncratic ways. This leaves the patient without a good record of his or her medical findings, and makes it difficult for subsequent clinicians – or the patient, for that matter — to reliably build upon the efforts of the initial clinician.

In short, the Weeds argue that medicine is plagued by a culture of severe, pervasive disorder. We are not orderly in how we evaluate patients, we are not orderly in how we match their data to our existing knowledge base, and we are not orderly in how we document our clinical processes and data.

The Weeds attribute much of this to medicine’s habit of valorizing the individual physician’s intellect and autonomy. Because of this, we persist in organizing healthcare around the efforts of fallible physician minds. The authors declare that the profession of medicine is in terrible denial.

I found myself agreeing, yet again, with them.

The computer-assisted alternative

To counter the existing sorry state of affairs, the Weeds propose a “standardization of inputs,” and argue that clinical judgement should be applied after we use computers and technology to complete two key tasks. The first task is to reliably identify and collect the necessary information from patients, via standardized questionnaires that are tailored to the complaint in question. The second is to use a “knowledge coupler” to analyze the patient’s responses and propose a list of diagnostic possibilities.

Only then should clinical judgement really enter the picture, and according to the Weeds, this should be applied in order to tailor the next clinical steps to the patient’s preferences and individual circumstances. (Hear hear! I like it.)

Presumably the reflexive response of many physicians will be to decry this as cookbook medicine.

Is it? Having been dismayed by the spotty clinical work that many physicians produce under today’s usual rushed outpatient conditions, I’m not sure a little cookbook structure is such a bad thing. As the Weeds point out, the purpose is to start with a solid, consistent foundation, and *then* proceed to individualizing:

“Decision-making must begin with a simple, mechanical process of association between data and knowledge, conducted without reliance on the practitioner’s mind. Thereafter, the processes of care must remain highly organized and explicit. Care would become highly standardized at the front end, and medical decisions at the back end would become highly individualized – precisely the opposite of the status quo, where physicians have broad discretion during the intial patient encounter but are expected to conform to standardized, “evidence-based” guidelines in their ultimate decisions.”

Being a junkie for order and completeness, I found myself quite attracted to the concept of standardizing inputs and applying a knowledge coupler before bringing in a physician’s clinical judgement. (The Weeds call this the “combinatorial” approach, as compared to the now predominant “judgemental” approach, which relies almost entirely on clinical judgment.)

How fantastic would it be if my elderly patients complaining of falls could have worked through a nice thorough questionnaire and computer-assisted differential, all before I even sat down to hold their hand. And it would be even better if such digital assistance would enable the non-geriatricians to identify orthostasis and medication side-effects as source of falls in the elderly.

But is it actually feasible to apply questionnaires and knowledge coupling to most older patients? I couldn’t help thinking that it would take my patients a long time to go through the questionnaires, and that they would probably need someone’s assistance.

The Weeds do address likely objections to the combinatorial approach. They point out that “comprehensive does not mean exhaustive” (but actually it does, when it comes to geriatrics). They also note that even if a standardized initial data collection is time-consuming, this should be considered time well-spent if it leads to better quality diagnosis and management. (On this I agree.)

Still, I couldn’t help but wonder if detailed data collection might not be more overwhelming for patients and providers than they admit. It certainly would’ve helped if the Weeds had provided an actual example of a sample questionnaire for one or more common complaints in an older adult.

For example, for shortness of breath, I presume an older person with history of CHF, CAD and COPD will require a more detailed questionnaire than a young adult with no significant past medical history. What would such a questionnaire actually look like? And how long would it take to complete?

In short, I found myself easily persuaded by the theoretical case for a technology-assisted combinatorial approach, rather than today’s terribly error-prone judgmental approach. But I was left uncertain as to how feasible it actually would be to implement in the case of complex elderly patients.

[Part Two of this commentary will be published next week, and will address some of the other key concepts discussed in “Medicine in Denial.” In the meantime, comments and reactions to the ideas described are very welcome.]

Leslie Kernisan, MD, MPH, has been practicing geriatrics since 2006, and is board-certified in Internal Medicine and in Geriatric Medicine. She blogs at GeriTech.

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Mark Freemanplaton20NathanaelMFreemanKeith Berndtson, MD Recent comment authors
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Nathanael
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Nathanael

This is a good article. The “cookbook” structure which Weed & Wed describes is exactly what doctors do when searching for drug side-effects and interactions: they search the PDR, cross-referencing all drugs taken with all described symptons. This is the beginning of the clinical analysis, and avoids the very common problem where physicians only think of a short list of possibilities. This should be done for ALL possible diagnoses, not just for the diagnoses of “this was caused by a drug”. However, to do that, first someone has to *create* a database of medical information in a standardized format, similar… Read more »

Keith Berndtson, MD
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Keith Berndtson, MD

Dr. Freeman’s succinct comment contains some of the richest wisdom I’ve seen on the subject of IT-driven population health vs. the care of individuals – especially the growing number whose conditions are too complex to pigeonhole into tidy diagnostic categories. Technology has not reached the level at which it might assist physicians in their care of uniquely complex individuals. It can assist population health management, but that’s a different charge that can be left to public health functionaries. Honestly, Dr. Kernisan, well-intentioned as it may be, your analysis is as spotty and idiosyncratic as the class of physicians you dismiss… Read more »

kerry pay
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kerry pay

P. S. My father was a pharmacist as well as V.P. sales Eli Lilly so I grew up discussing healthcare in American from 1960 til he died in 1976 at 59 of second heart attack. I have to tell doctors what they need to look at because none of them have every asked me the correct questions. I would gladly fill out a questionaire, but all my doctors I have found were unable to write or listen to what I was telling them which was extremely detailed with massive notes to give them so they would put on their thinking… Read more »

kerry pay
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kerry pay

I totally agree wil all that she is right on! I had to diagnose my own illness because after looking at all my medical records from every doctor I have seen since my surgery in 2000 for sciatica where my surgeon made a very big mistake and damaged my leg nerve permanently. Surgery was to have been 4 hrs but became 8 hrs and stopped at 10 p.m. started at 2 p.m. He had a morning surgery at another hospital. When I woke 24 hrs later massive pain and unable to feel or move my leg. Wasn’t able to be… Read more »

Dr P
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Dr P

How much have you cost us the taxpayers? Do us a favor and leave this country.

Nathanael
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Nathanael

Do us a favor, Dr. Criminal, and check yourself into prison, rather than insulting one of the people who’s been victimized by criminal doctors.

Dr P
Guest
Dr P

The prison will be full from all of the criminals in the Obama administration for Benghazi, IRS and Wire Tapping SCANDALS. I am sure that you and all of your friends are “victiims”. Most victims are actually just losers like you Nathantard.

Dr P
Guest
Dr P

As soon as the words “patient questionaire” come up more than once i`n any discussion you can usually dismiss the entire discussion. Patient questionaires are basically useless unless the physician is asking the questions in a face-to-face encounter. The Weeds are out of touch…maybe the Weeds have been smoking too much weed.

peter bailey, MD, MBS
Guest
peter bailey, MD, MBS

Reminds me of quote concerning democracy: “it is the worst form of government, except for all the others”. Demonstrating that an alternative “system” would be feasible & cost-effective to design and deploy would be the first mandatory step. Otherwise, the costs and risks are enormous. In any event, a top-down complete reshaping of health care in the USA is not possible – see “Obamacare”. Two other points: 1. An old mentor of mine told me that patients go to the doctor for two reasons only – they are either scared or in pain. They don’t go to fill out a… Read more »

Leslie Kernisan, MD MPH
Guest

Agree that many patients may have trouble completing a long questionnaire. I certainly don’t like questionnaires, but there are probably ways to make it more manageable/appealing to patients.

However I think you’re underestimating the cognitive errors that all humans make when it comes to complex problem solving. Kahneman’s thinking fast and slow is another long book that is very good; addresses this issue in depth.

MFreeman
Guest
MFreeman

Cognitive errors occur when there is TOO much input of data. A history is taken for a reason. There are clues as to why certain things are highlighted in the medical record, for example. If I were to have 10 extra pieces of data for every visit (which EHR necessarily requires), I will necessarily spend less time on the items which matter. Too much theory and too little clinical experience. In addition, with regard to questionnaires, they have other inherent negatives. the best information includes the nuances and qualifying information one gets in gathering data as a PHYSICIAN talking to… Read more »

Nathanael
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Nathanael

Clinical experience is great for those few physicians who are able to learn.

For the rest of the crowd, they’d do better by doing a full-text search of a book like the PDR with all possible diagnoses in it, looking for the keywords matching the patient’s complaints.

This is NOT a statement in favor of EHR (which are garbage) or in favor of questionnaires (which are questionable). The benefit of computers is in creating databases similar to the PDR.

Mark Freeman
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Mark Freeman

Nathanael, only a brief response is necessary. Your premise that most doctors don’t learn is ridiculous and ignorant. The rest of your comments are no more enlightened. Enough said.

Nathanael
Guest
Nathanael

Briliant comment, Dr. Bailey. “: 1. An old mentor of mine told me that patients go to the doctor for two reasons only – they are either scared or in pain.” Yep. “2. It is the perverse incentives that largely drive the behavior of doctors in bad ways. It is not that they can not usually figure stuff out, it is that it is in their own interest to do so as expeditiously as possible. ” The thing is, there’s no point in paying doctors if they don’t bother to figure stuff out. I guess there’s still a point in… Read more »

Shirie Leng, MD
Guest

Wait a minute. You’re saying that doctors don’t gather enough data, come to the right diagnosis, or treat the correct thing. That patient care is fragmented by physicians “idiosyncracies”. Really? What do we do then? Enter data in a computer and do what it says? My 4 year old can do that. Doctors have their quirks, but so do patients. A computerized system such as the Weeds describe assumes that all patients and diseases are the same. This is patently not true. Medicine is not an exact science. This drives techies crazy.

Peter1
Guest
Peter1

“Medicine is not an exact science.”

Only because docs don’t have all the information.

Leslie Kernisan, MD MPH
Guest

Actually the Weeds do a very good job of explaining why patients are all individual and require individualized care. However they believe we should start with a solid, systematic foundation of data gathering.

You should read the book; I really can’t do it justice here although I’m going to try to address the part about individualizing care in an upcoming post.

Nathanael
Guest
Nathanael

Medicine isn’t a science at all.

But it *could* be a science, if the data which is collected in medical research and in clinical practice was actually present in a searchable database. It still wouldn’t be an exact science… but it would be a lot more like biology and a lot less like witch-doctoring.

D'cm
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D'cm

The force that would cause the tipping point to where this technology would become available and accepted is a political one. When our legislators mandate and reward quality care we will see minds open to this approach. I would emphasize the mandate as the doctors that need this technological support the most will most likely be the last to adopt it. Of course, imagining our current congress even considering doing something that would benefit all at the expense of the status quo leaves us ROFL.

ent doctors in pune
Guest

Recent technology like computer helps to keep the data and history of patient to connect patient to medical knowledge, but better diagnosis and prescription is in hand of doctors which most important.

Peter1
Guest
Peter1

I wonder how a computer will do much more than a good MD. Input data and get what – multiple choice possibilities because the body only has a few symptoms to show for a multitude of causes? Then who picks which possible to explore? I have consistently been misdiagnosed for simple stuff and treated inappropriately, but not harmfully, only to find a cause/treatment down the road of self diagnosis and analysis of what my body is doing and reacting. If computers (like IBM’s “Watson”) can spit out a single correct diagnosis then humans are going to be required to input… Read more »

Leslie Kernisan, MD MPH
Guest

Think computer + clinician, not computer instead of clinician.

Clinicians miss things and make cognitive errors all the time.

MFreeman
Guest
MFreeman

A good role for technology is the patient owning his/her own SD card or other storage device with personal health data to be updated at provider offices, hospitals, etc (as is done in Europe). If we had that in 5 years, that would be a good use of technology.

The human mind (that of a physician) requires some control of the organization of data. To have a computer structure how that process flows risks making a very competent physician less efficient and less effective.

Nathanael
Guest
Nathanael

“Input data and get what – multiple choice possibilities because the body only has a few symptoms to show for a multitude of causes? Yes. That’s a major improvement over the current situation, where a doctor can typically think of two possibilities, and if it isn’t one of those two, the doctor is rude and dismissive to the patient, and wastes the patient’s time and money. Most doctors don’t even consider vitamin deficiencies as a cause of anything, for example, yet there’s a giant literature on this subject. ” Then who picks which possible to explore?” *That* is where clinical… Read more »

art r
Guest
art r

I was astounded to read a website describing the body’s maintainance of sodium concentration by increasing/decreasing urine production. Instead of advising how to use salt to deal with frequency of urination–(behavior)– it gave every reader a tool to work with. Even established the need for salt intake, made uncertain by the cardiologists. I think physiology trumps solutions, and in its absence only outcome data is useful.

Jason T
Guest
Jason T

Can somebody show me a real study instead of hypotheticals that a questionnaire is just as good at diagnosing, say, pneumonia as a physician is?

I still havent seen a single (even small) study validating this approach.

Leslie Kernisan, MD MPH
Guest

It’s not about physician vs questionnaire. It’s about how we physicians could do a much better and consistent job evaluating pneumonia-like symptoms if patients always started by completing a questionnaire.

Deb Verran
Guest

What this is really about but is not put into explicit terms is knowledge management and an understanding that the sub systems within healthcare now need to become ‘learning organizations’.

The information overload is real, as well as the tendency for doctors to deal with the problem by ‘satisficing’ also now being clear. Organizations need to understand how to both address and manage this problem. Technology can be of a great help but needs to be integrated into a framework of knowledge management across the organization. Anything less is doomed to fail-and there are many examples of this in healthcare.

MFreeman
Guest
MFreeman

Learning organizations? The day medicine is managed by organizational decisionmaking is a dark day indeed. Don’t be too hasty to empower a “framework of knowledge management across the organization.” The “organization” won’t have a good bedside manner and probably won’t satisfy the widow when the patient dies. This sterilization of the whole process makes me think of the movie Coma from the 70s. Be wary of a beneficent health care “organization.”

Deb Verran
Guest

Organizational learning is about ensuring that the same mistakes are not repeated due to lack of knowledge or poor access to information. It is about enabling and empowering healthcare workers(and not a throwback to some movie).

When one looks at incidents or near misses particularly in acute health care it is often lack of the correct information or inability to act on what is available that leads to problems.

Have you seen the study where a large percentage of radiologists missed the image of a gorilla superimposed on a CT scan image?

pcb
Guest
pcb

color me skeptical. We have tons of decision support in our EMR. Much of it is worthless. All DM patients should be on ACE, regardless of +/- proteinuria or baseline BP, all BMI over 25 shold be counseled on wt loss (a joke for a large segment of healthy lean men), every possible “interaction” comes up when prescribing any medicine, hardly any of which are clinically important. I could go on and on….. Decent care can come from algorithms, computer driven type stuff. Excellent care will come from wise clinicians. What we need are more wise clinicians, and producing more… Read more »

Leslie Kernisan, MD MPH
Guest

It’s really important to not confuse the Weeds’ idea with decision-support as we now know it. Right now, if we access decision-support, we do it fairly late in the encounter, after we’ve made decisions about what data to collect from patient/chart. The Weeds are proposing a very methodical data collection, followed by knowledge coupling. And then we are supposed to get going as physicians.

I do agree that we need more wise clinicians though…

Nathanael
Guest
Nathanael

I see exactly what you’re saying, Dr. Kernisan. I have believed for about a decade that the role of computers is to provide a big searchable database which can generate all possibilities — because the doctor is *never* going to be able to come up with all the possibilities out of his head. The physician’s job is then to winnow the possibilities down, by consultation with the patient. (In contrast, the “EMR” systems do the exact opposite, interfering at a late stage, but not providing the critical, openminded list of all possibilities.) I’ve noticed that modern medicine in the US… Read more »

platon20
Guest
platon20

LOL this would be hilarious!

Coming in with a headache?

OK, lets see that means you need a CBC, ESR, CRP, SLE panel, urine tox screen, CMP, brain MRI, neck MRI, cerebral angiogram, and a brain biopsy to boot! All at the discout price to you of only $20,000! Where should we start?

MFreeman
Guest
MFreeman

pcb, this is PRECISELY the current crisis of caregivers. More than the learning and acceptance of software programs that dogs providers, it is the mandates and intrusion of common sense incorporated into the process (which is rampant today) which makes this job nearly impossible. Much harder than even 3 years ago. What pcb says is exactly my experience on a daily basis. Every medicine I refill prompts me for interactions with alcohol, for example. Significant or useful drug interaction prompts are certainly ignored because EVERY refill prompts about various interactions (which will never be read). Screening is poorly constructed and… Read more »

Nathanael
Guest
Nathanael

Computers are being used for what they shouldn’t be used for…. while not being used for what they should be used for.

The full drug interaction list is a very useful tool. It seems to be the first thing most doctors search when a patient reports a new symptom. But it’s looney to print it out for every refill.

Mark Freeman
Guest
Mark Freeman

Until these problems are addressed, the current course is causing active damage to the quality of care. Every caregiver I run into has the same experience. The constant drug interaction warnings only serve for liability protection for the EHR vendor (there is no evidence that this encumberance will go away). We are seeing less patients due to unbelievable inefficiencies forced upon us. I really think few have a clue about the reality here outside of those of us who actually do the work. Our work demands consistent precision. At present, EHR makes my work LESS precise. Hang out with a… Read more »

Ron Hammerle
Guest

THCB’s headline is misleading and unduly singles out “doctors” from the broader “medicine” the Weeds and their publishers took care to define. Other respondents (above) appropriately include medical software companies and technologists whose “reform” initiatives have often created as many problems as they profess to solve.

Leslie Kernisan, MD MPH
Guest

Don’t tell the THCB editors, but I don’t disagree with you. My original working title for the post was “How to really leverage technology to improve healthcare for patients.” Which is what I think the Weed’s book is really about.