When doctors are freed from commercial pressure, how well do they perform? We've grown accustomed to scapegoating pharmaceutical companies for health-care ills—consider movies like The Constant Gardener and the recent New York Times Magazine exposé by a psychiatrist paid by drug makers. The implication is that if left alone by money-grubbing drug companies and health insurers, physicians make the right decisions on behalf of their patients.
Not so fast. It turns out that improving the quality of health care has only a little to do with drug companies. Their influence is a symptom of a deeper underlying pathology. The real trouble is that doctors—somewhat paradoxically—are simply not focused on actually treating disease.
A key indicator of this problem emerged last October, when a team of researchers led by Rita Mangione-Smith reviewed children's medical records from 12 major American cities and found that fewer than half of children got the correct medical care during doctor visits. The researchers asked basic questions such as these: Did doctors properly inform mothers to continue feeding infants who had diarrhea? Was HIV testing offered to all adolescents diagnosed with a sexually transmitted disease? Was a follow-up visit scheduled after a child's medication changed for chronic asthma? These were all simple things doctors should have been doing yet weren't. (A similar study of adult quality of care was published in 2003 with similar results.)
This seems absurd. Physicians are some of the most hypereducated professionals around, with eight years of higher education, followed by three to 10 years of residency and subspecialty training over thousands of hours. They also must pass some of the most exacting and complex licensing exams ever written, including at least four separate tests requiring weeks of dedicated study to achieve board certification. And yet, according to studies like Mangione-Smith's, most doctors in practice don't pass muster in administering optimal care for elementary conditions like infant diarrhea. What is going on?
There are at least two explanations. First, clinical training in primary care—including pediatrics, internal medicine, and family practice—excessively focuses on the diagnostic hunt rather than the more routine rounds of treatment that follow. It's tempting to think that most doctors are detectives nailing baffling diagnoses, like Hugh Laurie's character on House. In part, this view of medicine accounts for the success of Jerome Groopman's book How Doctors Think, which explores how wrong diagnoses occur. In almost every educational venue—from morning teaching sessions for residents to the weekly case conference featured in the New England Journal of Medicine—medical trainees spend hours learning about how to diagnose rare ailments. And then, abruptly, discussion ends, as though treatment were an afterthought.
The not-so-subtle subtext: Medicine is about the exciting search for a diagnosis, and any old doctor can write a prescription once the real work is done. This same bias pervades insurance rules. To be paid at the appropriate level, physicians must exhaustively document all sorts of irrelevant diagnostic data—such as a rectal exam in toddlers seen for a comprehensive asthma evaluation—rather than the rationale for the treatment they prescribe.
On a separate but related front, medical education today fixates on acquiring knowledge that is largely unrelated to patient care. Consider the college prerequisites to attend medical school (for example, physics and organic chemistry) and the morass of molecular biology, anatomy lessons, and pharmacology that follows and must be committed to memory. Of course, a general foundation is important. However, the sheer abundance crowds out an important—in fact, the only—skill that matters in treating a patient: how to critically appraise published clinical trials. Few doctors ever read them. In effect, medicine has become a priesthood of practitioners who never review or learn to interpret the Bible to minister to their flock; they instead rely on secondhand wisdom. Or, worse, on Google.
That is why, for example, the average internist can describe the branching patterns of the major coronary arteries but not the primary clinical trials assessing how much, if at all, various cholesterol-lowering agents cut heart-attack risks. Or, for that matter, whether the trials were soundly conducted. Yet in real practice, diagnostic puzzles are rare, and knowing the molecular basis of an illness does little good. Instead, children see pediatricians for ear infections, diarrhea, and attention-deficit disorders. Adults see internists for high blood pressure, diabetes, and chronic pulmonary disease. Filling the training vacuum, an unregulated, for-profit industry of information peddlers is emerging to interpret clinical trials and guide treatment.
These groups essentially write CliffsNotes for doctors, and their influence on medical care cannot be overstated, though it's largely invisible to consumers. The most widely used service is UpToDate.com, a private-equity-backed, subscription-only Web site that, according to some research, is accessed by half the clinicians at hospitals affiliated with Harvard Medical School at least five times a week. Eighty-seven percent of U.S. teaching hospitals subscribe to it. On the site are thousands of recipelike entries on everything from toddler ear infections to drug therapy for heart failure. UpToDate.com has become the cookbook for medical treatment. No professional primary-care medical association, like the American Medical Association or American Academy of Pediatrics, has created anything like it.
To its credit, this site is subscriber-funded and refuses advertising, unlike rival sites like Medscape and eMedicine. But there's no guarantee it'll stay that way, especially if it is sold or goes public. And while the overall quality of information is quite good, the treatment guidelines tend to favor medications over modifying behavior and lifestyle, are not vetted by any government or other professional association, rely a lot on the personal views of the one or two authors of each recipe, and rarely include any cost-benefit analysis. Fundamentally, by neglecting treatment, doctors have outsourced it to private contractors who don't answer to any authority. (This is why drug companies can launch misleading marketing campaigns without a unified voice arguing on the side of the data.)
Even if perfect treatment guidelines were to appear magically, it takes a lot of work to teach doctors to follow them. Consider ear infections in children, which are vastly overtreated with powerful antibiotics. In 2000, a group of Boston researchers created an ambitious three-year program (using sociological methods used by missionaries to score religious converts) to educate local pediatricians about proper ear-infection treatment. They explained how to talk to patients, control symptoms without antibiotics, and create educational handouts for patients. They taught doctors what they should have learned in medical school and, as reported in Pediatrics this year, substantially cut antibiotic use. The only sticking point is that it all took a big investment of time and money.
Treatment neglect has big consequences beyond ear infections. Medical errors may claim almost 100,000 lives each year, often from basic skills like poor handwriting on prescriptions. In her book, Overtreated, Shannon Brownlee explains how ignoring treatment has led to odd discrepancies in medical care; for example, some towns in Vermont had tenfold higher rates of pediatric tonsillectomy than others, despite having the same kinds of patients.
Refocusing doctors on actual treatment, instead of pointy-headed diagnostic puzzles, will take serious effort. In the meantime, patients should ask a simple question: "Can you describe the evidence for my treatment?" For better or worse, the answer will tell you a lot about the care you're getting.
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