It has been suggested that to improve quality in healthcare we must reduce variability in how diseases are diagnosed and treated.
It has been inferred that clinical outcomes would improve exponentially if doctors would only follow established guidelines instead of their own whims.
I take that to mean if doctors didn’t think for themselves so much, the health of our nation would be better. I take that to mean that we may be overqualified for the simple work of delivering “evidence based care”.
That is the fantasy of the non-clinician creators of our new medical world order.
Doctors spend all these years learning biology, biochemistry and physics. We learn about anatomy, physiology and pathology. Eventually we study diseases. Then we learn how to practice what we were taught. Finally, more than a decade after we started, do we earn the right to practice independently, only to become the obedient instruments of a healthcare system that demands conformity and disciplines those who put their training to use by questioning politically motivated health policies and overly simplistic clinical guidelines.
Let me count the ways…
Let us look at how simple it is to deliver evidence based care for, say, a healthy 65 year old woman, new to Medicare:
If I personally had met this woman at the beginning of my career, I would have been under pressure from many authorities to get her started on postmenopausal estrogen if she wasn’t already on it. It was only 15 short years ago that the Women’s Health Study stopped their estrogen trial because of finding out about breast cancer and cardiovascular risk increases. The experts and the guidelines had told us her risk for heart attack would decrease; a complete reversal of marching orders.
But now we know better.
The highly promoted “Welcome to Medicare” visit tells us to perform a baseline EKG. The US Public Health Service Taskforce on Prevention (USPSTF) tells us that’s a waste of time.
Medicare tells us to screen her for cognitive impairment. The USPSTF tells us not to.
Medicare requires us to do a simple vision screen. The USPSTF tells us not to.
All primary care practices now ask screening questions about illicit drug use. The USPSTF tells us not to.
The USPSTF and the American Cancer Society tell us not to suggest a clinical breast exam or Self Breast Examinations. The National Comprehensive Cancer Network tells us to recommend both. Our sample patient should have mammograms biannually according to USPSTF and the Cancer Society, annually according to the NCCN, the Mayo Clinic and many others.
Our sample patient has a blood pressure of 138/86. Our current guideline, JNC 8, says she’s okay, CMS declares her prehypertensive and the SPRINT study suggests starting antihypertensive medication for people with her blood pressure if they have additional risk factors, but they didn’t study people exactly like her, so we don’t quite know what the best course of action is.
If she happens to have had two fasting blood sugars between 115 and 125, she is only a prediabetic in this country, but a full blown diabetic across the border in Canada.
Such a precise science, medicine! Just follow the guidelines…
So what’s a primary care doctor to do for this particular female patient – who isn’t even sick? This ought to be a pretty straightforward scenario. It would be different if she came to us with multiple medical problems.
Hans Duevefelt, MD is a Swedish-American physician. He practices in Maine.