Should Doctors Think?

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.

Just think.


Hans Duevefelt, MD is a Swedish-American physician. He practices in Maine.

Categories: Uncategorized

18 replies »

  1. I suspect we are in agreement, but are using a different connotation for “guidelines.” We have general intents (guides) to promote patient well-being based on the best evidence we have. We promote individualized guidelines advising good diet, exercise, stress management, etc. I suspect we agree that the application of single-disease based guidelines across a patient population brings net harm to individuals due to the inescapable, unintended, adverse consequences. The key to a healthier population is the facilitation of health and well-being of each, unique individual starting with self.
    I’m predicting that most, if not all, health plans will not allow for this and will migrate to models that use P4P primarily as a tool to preserve their $$ and control. Along with that will be narrowed networks of less skilled health professionals, and limited formularies, etc. Out-of-pocket patient expenses will grow as fast as the increase in hassles to do the reporting and collect payment.
    Individuals valuing quality will be turning more toward models of direct, private contracting.

  2. Wise words. We need a serious discussion about population or public health versus personalized care, precision medicine. Can you do both at the same time?

  3. Love the post. Don’t agree with statement, few to none deny guidelines are good starting points. I think it just the opposite; most don’t like them or think they have value for the “individuals” we care for. We may be lost in the idea of “population” health. This cannot be achieved to any level of satisfaction if we continue to think we can treat “averages” of the population. Also, the population health idea is 180 degrees contrary to personalized medicine. The goal of care is that every individual knows their best information about harms and benefits of competing options for care, and then decides. Population health will be best when variable individualistic choices are made by individuals, and then summed. No guideline is helpful; all are unethical if they are aimed at all. In fact, perhaps they are “controls” denying a return to a profession of medicine. Physicians that follow without a patient’s choice are abdicating their responsibility in my view, and by abdication, are following rather than leading. The only guide a physician needs is to inform, guide the patient, but let the patient be the decision maker. We need variation in decisions based on variations in people, not guides directed against the personalized benefit of an individual.

  4. If the desired outcome is a performance metric defined by other than patients and their clinicians that has a net-negative effect on patients due to unanticipated adverse consequences… why not?

  5. ” The problem is that when they become the basis for payment”

    Didn’t we also complain about payments based upon outcomes?

  6. Few to none are denying the usefulness of guidelines as starting points. The problem is that when they become the basis for payment the net effect is harmful to patients and clinicians http://www.vox.com/the-big-idea/2017/1/25/14375776/pay-for-performance-doctors-bonuses?_lrsc=a2f0ea13-a43a-449d-a94d-4853a22d6147
    The imposed rigidity-inflexibility creates patient safety issues and burns out clinicians (now >50%) creating even more risk for patients.
    The UK,is a little more than a decade ahead of the US with implementing pay-for-performance via their Quality Outcome Foundation (QOF). They have learned a lot about how to implement guidelines in primary care- http://blogs.bmj.com/bmj/2015/08/12/neal-maskrey-what-will-replace-qof/
    The US is on track to decimate primary care creating a humanitarian crises similar to what is now being experienced in the UK. The net effect will be Reverse-Triple Aim. Increasingly, those who value quality will be forced to opt-out or engage in civil disobedience.

  7. A few problems:
    1) Conflicting/competing guidelines.
    2) Outdated guidelines.
    3) Some people equate quality to conformity with random guidelines.
    4) Medicine is moving toward individualization.
    5) Primary care touches on many, many issues in every conversation with patients, and we have to choose our battles due to time constraints and patients’ ability or willingness to tackle many changes at the same time.
    6) Maybe the purpose of healthcare is to support patients in making their own choices, and maybe guidelines are merely a conversation point if that’s the case…

  8. Using guidelines does require thinking. While they will generally apply to most people you need to understand your patient and the guidelines well enough to know when you should depart from them. If you cannot explain, at least to yourself, why you aren’t following them, then you are probably not acting based upon the best standards found in the literature.

    I dont know about primary care, but I do know that on the inpatient side guidelines have frequently improved outcomes. Having participated in taking over and fixing some failing hospitals, the absence of practicing according to any guidelines sure leads to chaos and bad outcomes, especially in the ICU.

  9. Paul, it’s almost impossible for primary care physicians to function in the way most of us want. I have watched my formerly excellent colleagues change the way they practice medicine or retire. We are losing history, the history one generation transfers to the next and this is having devastating effects on how physicians relate to patients.

  10. That’s why doctors SHOULD think. And that’s why quality isn’t the same as conformity.

  11. It is a guideline frenzy out there. Very little of it prospectively analyzed. Very little of it cross validated. The science is extremely sloppy, as is the peer review that validates it. We should not be subjecting patients to this chaos so that the “publish or perish” crowd can litter the clinical environment. Medicine is a custom job…every patient…every time. Guidelines should be an aid, not a bludgeon.

  12. Here is my problem: how to find a primary care doctor who thinks….and is willing to hear my Hadler inspired questions and preferences (forget the psa test, don’t practice defensive medicine, please don’t spend most of the visit clicking and scrolling on the EHR screen, etc.).

    My 65 year old primary care doc retired, and the younger generation of docs seem to accept all this top down control and guidelines that lead to way too much testing and a proliferation of diagnoses.

    Unfortunately I can’t move to Maine to see Dr. Duevefelt.

  13. Thanks. I don’t know how you as a pediatrician feel about this, but since immunizations are becoming more or less mandatory, are you having informed discussions with parents and patients about the shots? Or should they just be handled by the Public Health immunization police?

  14. “to ‘manage human uncertainty’ that brings such personal and professional satisfaction to the ‘practice’ of medicine.”

    Exactly. Primary care is messy and full of uncertainty. That’s when you have to think, because there are no protocols for the intersections of multiple diseases, social factors, belief systems and expectations.

  15. There are somewhat more than 7 Billion people on this planet, each person genetically different and each with an individually, unique temperament. After sifting through what is known during about 1/3 of my encounters, a fairly predictable and definable plan was apparent and clearly acceptable to the person. The next 1/3 of the encounters, the basics for a plan could be defined but with less predictable outcome or sensibly considered patient concurrence. The last 1/3 of the encounters often closed with a final question, “What do you think is going on here?” Now…there are all sorts of constraints that apply to the following discussion. But it usually ended with a reasonably sensible plan and the usual iterative deductive and inductive processes of health care in a shambles.
    The 1/3 rule may be arbitrary from visit to visit since you really are unable to, real-time, know where you are within the knowledge spectrum at any given point in time. It is the basis for the commitment to ‘manage human uncertainty’ that brings such personal and professional satisfaction to the ‘practice’ of medicine. And, it is the one attribute of healthcare that physicians newly exiting their post-graduate training are the least prepared to endure.
    P.S.: The UN projects a world-wide population of more than 10 Billion by 2050, each person with an individually unique temperament and, with the exception of a few persons with a maternal connection who share an identical genetic template, each genetically different. The basis for this blog site will be gone way before then.

  16. Awesome post! We are no longer being paid to think. We are paid to hand out prescriptions and nag people to come in for preventive visits. Something a robot could do.

  17. Just get back to your EHR computer screen and stop the complaining!
    (just kidding)…..excellent post!

  18. Select your own personal health plan based on best algorithms, as they may consider personal docs more as quaint anachronisms?

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