The common thought among health reformers is that we spend too much on care, and the additional care patients receive doesn’t necessarily help them.
What inevitably follows is a discussion on how to streamline care, yet maintain quality. To that end, most hospitals and emergency rooms are using algorithm-based care based on the best available evidence. Where doctors actually had to hand write admission orders, they are now checked off – like a menu at a restaurant.
But sometimes diagnosis requires more nuance. How do you know, for instance, that the patient really has pneumonia as you’re running down the pneumonia checklist? That’s a question that Stanford physician Abraham Verghese asks as well:
Indeed, the push for efficiency and “quality” has every hospital touting “pathways” and “algorithms” for the treatment of pneumonia. And with the focus on “outcomes” research we will probably be saddled with more pathways and algorithms. It is commonplace to see patients being wheeled down the “pneumonia” pathway and meeting all the quality and other metrics that measure a hospital’s efficiency, only for me to disagree with the label of pneumonia. Diagnosis matters. Patients would concur, even if we seem to have forgotten.
But in a difficult financial environment, hospitals are making business decisions to emphasize efficiency and cut costs. And that sometimes impedes diagnosis, like a decision to move a microbiology lab off-site.
So let’s slow down before completely embracing algorithm-based medicine, or as Dr. Verghese writes, “Let’s give ourselves a chance at precise diagnosis before we treat. That means good specimens, hand carried, examined by the people who care for the patient.”
Indeed.
Similar Posts:
- How should patients decide which hospitals are best for them?
- Hospitals can deliver low cost, high quality care
- Is an efficient physician necessarily a good doctor?
{ 3 comments }
Agree, check and recheck before diving into the treatment.
It happens with stroke pathways too. How often does a stroke nurse ask me ‘did patient x have a TIA?’ It is such a simple question, but it isn’t always clear. I may never know if patient ‘X’ had a TIA. Indeed, I may feel that partial simple seizure or migraine phenomenon is more likely, with TIA being a distant third. Yet the stroke pathways, with request for my signature, keep showing up the chart. It is surprising to me how easy patients, administrators, and even nurses feel diagnosis is.
The title is right on track, but the text that follows is nearly meaningless to me. Taking care of patients follows an algorithm of thought and process. This is the foundation of medical practice. In fact, one of the best texts in surgical practice is “Surgical Decision Making” by Robert McIntyre, Gregory Van Stiegmann, Ben Eiseman. This book is, in practice, a series of algorithms that include thought processes and pathways that organize the surgeon’s ability to better sift through what could otherwise be complicated decisions.
In other words, many physicians focus on the ubiquitous negative visceral reaction to the idea of “cook-book” medicine. The truth is, good medical practice is based on logical algorithms applied to individuals with specific problems. Local practices can appropriately influence these logical algorithms, thus making them difficult (if not impossible) to apply broadly. This, in turn, is one of the reasons why negative perceptions continue to surround algorithms and pathways. Pathways need to consider the local factors that can influence the usefulness or appropriateness of their application.
In my opinion, we need to get the argument on track. Pathways and algorithms can be very good for patient care, and in fact, if adopted widely can help us better identify how well we are treating our patients. Without standards of care broadly applied and tracked, we continue to struggle with understanding what is truly good care, and what isn’t.
JF Sucher, MD
Comments on this entry are closed.