Tuesday, August 13, 2013

Review, Quality Control and Arrogance

In 2002, I had an 80% right coronary artery narrowing that resulted in my having an angioplasty and a stent placement.   I thought of my procedure when I first read of the coronary artery stent placement performed on former President Bush and when I subsequently read the Washington Post opinion piece entitled President Bush’s Unnecessary Heart Surgery” written by Drs. Vinod Prasad and Adam Cifu.   While I understand the authors concern that people who are asymptomatic will mistakenly interpret President Bush’s stress test and subsequent stent placement as meaning that this sort of approach should be taken for everyone, I am even more concerned about their strong statements that the former President’s care was wrong.   In their zeal to prevent unnecessary and potentially dangerous care, the article crossed a line by proclaiming judgments on medical care based on limited facts and incomplete information.    They presented as absolutes, decisions made daily by caring physicians and informed patients that are often more nuanced than they appear.  Medicine exists in the realm of uncertainty and consists of the constant balancing of risks and benefits for individuals.  Within this realm of uncertainty there still must be quality control to protect the public from dangerous and unnecessary care since doctors are human and make mistakes.  However, there is a difference between careful and thoughtful quality control and Monday morning quarterbacking.  There are four major factors that cause me to pause before I make the kinds of absolute statements that are made in this article.  These same factors also cause me to hesitate before endorsing many of the decisions that insurance carriers and regulators can be too quick to make about payment for services and quality of medical providers. These factors are:
Facts Change:
Back to my angioplasty and stent in 2002.  At that time, I had what was considered to be the correct standard of care.  The cardiology department at the Harvard teaching hospital where my procedure was done was steeped in the academic studies that rigorously followed the facts in the medical literature.  Today the facts are different as pointed out by Drs. Prasad and Cifu because as more information and different studies are done, facts change.  In an article published in the October 2012 issue of the American Journal of Medicine, Dr. Joseph Alpert points this out quite eloquently.  He states in the article entitled, What Is True Today Is Often Not True Tomorrow”,In fact, it is likely that many of our current medical beliefs will turn out to be untrue or only half true as a result of information obtained through subsequent scientific investigation.”
Populations Change:
When studies are done, the population is often defined in one way; however as more facts become available, certain subpopulations are defined that do not necessarily follow the lessons learned from the broader population.  Thus, as an example, women with breast cancer as a population do not benefit from removing the unaffected breast.  The smaller subpopulations of women with breast cancer who are positive for the BRCA gene however do benefit. 
Context Matters:
If someone cannot afford medication, then prescribing a medication that they will not take is not good care, even if the care pathway says it is.  Context is any factor that may make the “correct” approach or therapy not be applicable.  Every few months, I get the obligatory letter from my health plan saying that I should be on an ACE inhibitor due to my history of heart disease.  With my history, taking an ACE inhibitor every day is a good idea and is a part of many care guidelines and standards.  The health plan does not see my context which is that I don’t tolerate ACE inhibitors because they cause me to cough.   Context can be medical issues, social issues, even religious issues.  When I was in practice I cared for a number of people who were Jehovah’s Witnesses.  As part of their religious beliefs they often refused blood transfusions which, as a gastroenterologist treating them for bleeding from their GI tract caused me to modify my approach in order to respect their religious belief.  I found that they could be treated successfully even while being sensitive to their culture and their beliefs, however, the treatment often was not in keeping with the standard care approaches.  Context can be related to issues of culture or simply related to issues of communication and trust.  Dr. Saul Weiner and his group at the University of Illinois have studied context in medical care and have found that care quality is compromised and care outcomes are worse if doctors and nurses do not actively ask about contextual issues and change their approach based on the answers to those questions.
We don’t know the context of the former President’s procedure (although I suspect it was not a financial issue).
Real, Pertinent Information is Often Limited Outside of the Patient and Caregiver:
Perhaps the most intelligent statement made in the Washington Post piece by Prasad and Cifu is “Few facts are known about the case”.  In the case of the former President, we don’t have all the facts about what was said between doctor and patient.  We don’t know if President Bush had mild jaw pain that was considered to possibly be atypical cardiac pain during the long bike ride that was noted.  We don’t know if his ability to do other activities had been affected in small ways that his physician believed to be a warning sign.  The fact is that both media reports, and also the claims data that health plans depend on, are very limited and usually do not include the small clues that may lead a physician and patient in partnership to decide on a specific course of action.  Even electronic medical records may not have all the necessary facts.  It is the height of arrogance to think that through media reports we have enough information to make these types of statements.   We also can be misguided if we make payment decisions and judgments on the quality of care a physician is providing for an individual patient solely on claims data. 
I think there is another way.  I think there is a way to encourage good individualized medical care without the second guessing that is becoming even more prevalent in medicine, insurance and in public policy.  There is a way to include context in care pathways and guidelines; to develop quality systems that review patient physician interactions based both on outcomes (and right now the former President’s outcome looks pretty good) and on the process of individualized care.  That will require more communication and integration within medicine, that goes beyond system integration and back to physicians and nurses actually talking to one another and talking more with their patients.  It will also require that we acknowledge that medicine is really about uncertainty and that includes uncertainty about applying the ever evolving science of pathophysiology to the individual patient to maximize the value to that patient.  It will require a rethinking of our belief that every person fits neatly into a care guideline or insurance medical policy and that claims data can adjudicate every medical interaction easily.  It will require less arrogance and more cooperation and coordination in the pursuit of the best result for every patient.