Saturday, February 13, 2010

Inspiration Needed

I have been remiss in updating this blog recently, and partly it has been my tendency to wait until I see something that truly inspires me or at least amuses me enough to write about.  There has certainly been nothing in the health care debate that is either inspiring or amusing and there have not been any blockbuster scientific studies that I have read that have really caused me to sit up and take notice.  But I did receive an email from a faithful reader who asked me whether I thought it would be likely for former President Bill Clinton to have had the same care under the health care reform approaches being put forth by our Congress.  That inspired me.

What Happened to Bill?

For those of you who have not been reading the news, President Clinton has stents placed in two of his coronary arteries this past week after having chest pain.  He is a patient with known coronary artery disease who underwent bypass surgery in 2004.  According to new reports, he developed chest pain and was taken to the hospital where the procedure was done.  He was discharged twenty four hours later in good spirits and presumably in good health.  Had he not had the procedure, one can confidently predict he would have had a heart attack.

Was His Care Different and Would Reform Have Made it Different?

The short answer is that I do not believe that his care was any different than anyone else’s care at Columbia Presbyterian Hospital in New York except that I believe that the attending physician, and not the physician in training, preformed the procedure and that is often not the case in a teaching hospital such as Presbyterian.  I also don’t believe that any of the health proposals on the table would have made an immediate difference in the care he received.  Over time the proposals did put into place mechanisms that could change this approach based on cost/benefit/risk analysis.

So far, the Blog isn’t even Interesting let along Inspiring!

Yet the question made me think about other factors.  President Clinton does have excellent care and has a physician who he can call, hear he has chest pain, know him well enough to understand the possibility of a heart attack, and immediately arrange for the needed, correct care.  That is the part that seems to be to be different under today’s health care and could even get more different in a number of the proposals being made.  In today’s world of medicine for the average person, their contact with the doctor is very short and relatively impersonal.  There is no time taken to really know a patient when you are seeing twenty to thirty patients a day.  Of course there is a small number of people who the average doctors knows well, and a small number of doctors who know all their patients well, but those exceptions are on the tail end of this bell curve.  That is bad now and could conceivably get worse as we move towards a world in which physicians are incented and even rewarded for doing their work quickly and as close to a median norm as they can be. 

Personal Attention as a Vice or a Virtue

While we need to foster more evidence based medicine, more use of electronic information systems and more normative behavior among doctors, we also have to remember that medicine ultimately is personal and caring.  While I want my doctor to know the right thing to do in a situation and I want him to stick with practice guidelines and best practice standards, I also want him or her to understand that best practices are all based on statistical probabilities and that there are always people who are not in the center of the probability curve but two  standard deviations away.  A good doctor will have the judgment to ignore best practice when a patient who does not fit the norm appears.  I fear that the virtue of following “best practice” will turn out to be great for 80 – 90% of patients and potentially deadly for the rest.  Best practice medicine can easily become lowest common denominator medicine.  The present proposals, and even many of today’s approaches make the virtues of following the cookbook of best practice so overwhelming that it becomes a vice.  The moment that a physician is afraid to do the right thing for a patient because it doesn’t fit the normative notion of “best practice”. is the moment our system becomes dangerous for some of us.

Back to Bill

I don’t believe that will ever be a problem for our former President.  I have not been able to determine if President Clinton was told to call 911 and get an ambulance and then be first seen in the emergency room although I doubt it even though every protocol I know for the “best practice” of dealing with acute chest pain in a person with known coronary artery disease would call for that approach.  Under our new incentives, will his physicians be punished with lower payments or even black marks against him or her for licensure or future contracting?  Under a new system, will President Clinton have been required to first have a stress test before going straight to the angiography suite as the costs of angiography are grappled with?  I don’t know the answers and only hope that my family’s care will always be the kind of personal care that the President received.

One Last Word

I love getting questions as they do inspire me so please send them.