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The Cookbooking of Medicine

Posted by MDViews on September 1, 2009

  I’ve been in practice (out of residency) for more than 27 years, a doctor for 31 years and doing clinical medicine (since a 3rd year medical student) for 33 years. (Goodness, I’m old!) I’ve dealt with cranky ward clerks, primadonna nurses, obtuse administrators, incompetent MD peers, powerful insurance companies, government bureaucracy, employee conflicts, good financial times and bad financial times. I’ve even survived two lawsuits. But the cookbooking of medicine is the most fraudulent, intrusive, problematic and dangerous paradigm to come down the pike yet. I’ve written about it and submitted it hoping to get it published. It wasn’t. So I’ll contribute it here, my blog. If you are a young doctor, you may think I’m nuts, because it may be all you have known. If you are an older MD, you’ll probably understand. If you are not in medicine, you may be appalled. Most people to whom I tell this story–can’t believe it. But true it is. Hope you enjoy the read.

 

 

 

The Cookbooking of Medicine

 

Standards. Protocols. Evidence-based medicine (EBM). Pay for performance. Best practices. Buzzwords all—these terms describe the new direction of medicine in the 21st century.

 

As you read this, groups of doctors along with administrators, bureaucrats, nurses and lawyers gather at corporate headquarters, medical schools, insurance companies and government buildings to set standards of care every doctor should follow. Such groups base these standards on “best practices” or “evidence-based medicine”, a consensus of opinion on what the best care should be for any and all illnesses. Such a system sounds so good, so wonderful—what could possibly be wrong with encouraging all doctors to practice the best medicine possible?

 

Well, plenty, it seems to me, as one who deals with it everyday.

 

For example, 26 year old Mrs. Johnson (name changed), a missionary home on furlough, presents for her annual exam. She and her husband were virginal until married and have remained faithful to each other. As the doctor does her pap smear, a test for cervix cancer, she also swabs her cervix for Chlamydia and gonorrhea, two STD’s.

 

The doctor knows her chances of having Chlamydia and gonorrhea are exactly zero, but has to meet a quota of screening 80% of all women up to age 27 for Chlamydia and gonorrhea or she will not get her bonus, or “pay for performance”. So, knowing the test will be negative, she does it anyway. Why does this rule exist? Because most research done on STD’s occurs in inner city hospitals where the rates are very high, not on missionaries home on furlough. The doctor, wanting her “pay for performance” performs an unnecessary test.

 

For diabetics, doctors may order unnecessary tests or prescribe unnecessary medicines to capture pay-for-performance. Worse, early diabetes does not qualify for treatment, even if the doctor, looking at the big picture, deems treatment appropriate. So, the doctor may deny care he or she may judge necessary, since the protocol won’t allow it.

 

Welcome to the world of cookbook medicine, where one-size-fits-all. A world in which your doctor receives money, “pay for performance,” for following “guidelines” or “best practices.” Such a system removes the doctor’s judgment about what is best for you and substitutes corporate or government guidelines regarding what is best for a group.

 

Doctors, me included, always want the best for our patients. But how does one determine what is best? Even the best studies can be in error. Two of the largest and best studies of regarding postmenopausal hormone therapy came to opposite conclusions regarding the risk of heart disease. Does a study on an inner-city population translate to a well-to-do suburban population? Do studies on one race translate to all races? Does a study based on thousands of people necessarily translate to the individual patient in the exam room? Individuals vary by sex, physical characteristics, mental capacity, emotional make-up, cultural differences, values, ethnicity and side effects to medicines just to name a few variations a doctor sees. Is what may be good for a majority the best for you in your situation? Are you really unique? Could politics influence these protocols, say, to save money? Or further a politically correct “treatment”, such as euthanasia?

 

For me every encounter, every crisis, every illness, every life-threatening emergency is unique to my one patient at that particular time in her life. I collate all the information I have about…everything—her needs, her social situation, her illness, how it affects her life as she lives it, her fears, her exam and her history; then decide what the best treatment would be for her. Such a process is antithetical to the cookbook.

 

When I speak with those in charge of the protocols, they always say the doctor must still use his or her best judgment even if such judgment conflicts with the guidelines, but that really isn’t true, in my experience. The leap from a guideline to a protocol to a rule is short. When I’ve gone against protocols, administration demands explanations, threatens discipline and docks my pay if I don’t measure up. Soon the heavy hand of the protocol dictates what you can and can’t do regardless of your judgment.

 

As we go down the path of more central control of medicine where doctors are told what constitutes disease, illness, and appropriate treatment, your doctor will become more and more a technician, doling out care, tests and medicines based on the whim of government bureaucrats or corporate panels. I fear the protocol, the best practice prescripts, the machinations and rules which stand between you and your doctor will plow the furrow for the seeds of health care rationing and denial of care.

 

 

 

 

5 Responses to “The Cookbooking of Medicine”

  1. MDViews said

    I’m sorry about your experience, but glad your daughter finally received the correct treatment. Thank you for writing.

    Matt Anderson

  2. Melanie said

    This comes as no surprise. It sums up what we experienced last year when our then 13 month old daughter was hospitalized for an abscessed lymph node. We are Canadians who were vacationing in Florida, and our only experience with health care was the Canadian one, so found ourselves with a very rude awakening. This first eye opener was prior to our daughter getting sick and that was the consumerization (is that a real word?)of health care. It was shocking to see HUGE billboards ADVERTISING hospital services. What????
    Anyways, the first hospital refused to treat our daughter siting she needed to go to Miami Children’s for the “best possible” care. They were the “pediatric experts”. The ER doctor also gave me quite a scare as he laid out the worst case scenario for our daughter.
    I called our BC Health Line (a free service for residents of British Columbia where we can talk to a nurse any time of day or night), the nurse calmed me down – assured me that while my daughter did indeed need treatment ASAP she was not going to die and advised me to get a second opinion and gave me some practical things I could do for my daughter in the mean time.
    We were able to see a local pediatrician who also refused to treat our daughter and advised us to head to Miami Children’s. He gave the same lip service as the ER doctor. We asked if he could hospitalize her locally, put her on IV antibiotics and reassess whether the 2 1/2 hour trip to Miami was necessary. He refused – if her prognosis worsened, he did not want to be liable for getting in the way of her receiving “the best possible” care. We offered to sign a liability waver. No go.
    We went to Miami. She was admitted and saw a whole string of specialists and had several diagnostic tests. We got the distinct impression that the doctors were not treating her based on what was actually happening to her and in their judgment was a reasonable course of action based on HER symptoms. But rather, they were treating based on the worst possible thing that could happen to her. For two reasons, liability (Miami is “sue city” apparently) and profit.
    Long story short, after a battery of tests and repeated poking and prodding by several doctors our daughter was put on IV antibiotics. Why couldn’t they have done that at the first hospital????? That was exactly what we asked the first pediatrician to do!!!!
    Next, the ENT wanted to surgically drain the abscess which would require her being anesthetized and hospitalized for and additional 3 days. After 48 hours on anti-biotics, the infection was minimized, the abscess came to a head and with our flights home booked for the day after the ENT wanted to do surgery and three other children to care for, we refused the surgery and chose to take her home (against medical advice) and have her treatment followed up here in Canada.
    Upon arrival at home, I took her to the local hospital where an ENT froze the abscess locally popped it with a poke from a scalpel bandaged it and sent us on our way with a new prescription for oral anti-biotics and instructions to follow-up with our family physician in a week. That whole visit was 2 hours. WHY did the ENT in Miami say she needed surgery and to be hospitalized for 3 more days????? Because “best practice” required him to treat based on the “worst case scenario”? Because the hospital could profit from our extended stay?
    Anyways, all this to say your article sums up some of the reasons for what we experienced very well.

  3. Patrick said

    Thanks, sir! Especially for such a quick response! I really appreciate it, and look forward to reading your upcoming article. I haven’t made it to my clinical years yet, but I guess I’ll see what opportunities the Lord will provide. Thanks again for giving me some things to think about in trying to figure out how to choose a specialty and stuff.

  4. MDViews said

    Thank you for your post. Encouragement is a good thing and I certainly appreciate it.

    Would I go into OB/GYN again had I known all I know now? In a heartbeat! I love medicine in general and OB/GYN in particular. I’ve shared in so many, too many to count, tears of joy as a newborn takes its first cry. I see tears of joy when I do the first ultrasound at 8 weeks and mom and dad see a tiny heartbeat, little legs and arms. Then, the baby wiggles. Oh, my! What a moment! I’ve helped patients through cancer surgery. I’ve seen more than a few die. I’ve helped women with pain so severe their marriage was on the rocks and had them thank me later because they could finally be intimate with their husband. I’ve talked some woman out of abortion. I’ve had to do hysterectomies at 3:00am on women with post partum hemorrhages when their lives hung in the balance. I’ve seen babies grow and deliver babies from those I delivered. I’ve had infertility patients hug me in spontaneous joy when their pregnancy test turned positive. I’ve prayed with patients innumerable times when in crisis or prior to surgery. One patient even asked me to pray just before I was about to make the incision for a cesarean. So, the whole OR stopped while I prayed out loud!

    I could go on and on.

    Are there downsides to OB/GYN? Of course, but every specialty has downsides. In OB/GYN, the hours are long, the call can be hard, some problems have no fix and malpractice lawsuits ever loom as a possibility. For men in OB/GYN, women prefer women (except for surgery), but my schedule remains busy, even with 3 women partners. I find I have to work harder than they do to get and keep a patient following.

    I’ve written an article entitiled, “The Joy of Doctoring,” which I’ll post in the future.

    Thanks for a good, serious question.

    Matt Anderson

  5. Patrick said

    Thanks so much for this post! It’s a real eye-opener to say the least.

    Also, thanks for your weblog as a whole, which I’ve been happily checking out and of course have added to my RSS feed. I really appreciate the fact that you’re not only a doctor but also a godly, evangelical, and Reformed Christian striving to apply your faith to your work!

    By the way, could I please ask you a personal question? Of course, if you’d rather not respond (publicly), I understand; please no need to do so. My question is: I was wondering if you’d consider doing OB/GYN again if you could do things over knowing what you know today? Or would you have chosen another specialty? I was wondering because I’m a current med student and so have been thinking about which specialties to enter in the future if God willing I make it through and graduate.

    Thanks again!

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