Six years ago I wrote a column titled “Five Great Lies of Medicine” (OT, 2/25/08 issue). It included the infamous statements by some surgical oncologists to the patient or family that, “We got it all.” That and four other “lies” expressed a need to be more specifically honest to patients and family members—saying, for example, something like, “We got all we could see and detect. But we know that microscopic parts of the cancer often remain and threaten to grow and re-emerge, so additional therapy may be necessary.”
On the other hand, there are also “truths” in medicine that we rarely talk about—i.e., things that are common knowledge among medical professionals but are often not recognized or clearly understood by the public. We may not wish to focus on these truths because of fear that patients may lose confidence in us and in our ability to provide excellent care. And certainly a discussion of these generic, almost philosophical, issues is usually not appropriate when one is in the process of laying out the options to a patient, when confidence in your abilities is a key factor in the patient's sense of being in good hands. But recognizing these truths with humility is good for both the caregiver and the recipient of care. Here are three:
There is no reliable, public mechanism for choosing a skillful doctor.
It is not easy for the average person to choose a personal physician based on his or her professional skills, experience, or results. Virtually any M.D. can obtain and maintain a license to practice medicine. Medical licenses are very rarely revoked, and then only for committing a felony, writing excessive drug prescriptions, or defrauding Medicare.
There is no formal and ongoing assessment of the quality of care provided. In most states, doctors are required to obtain a number of Continuing Medical Education credits, a means of trying to force them to update their education. But these are often based on attendance at medical meetings and taking online courses on topics such as the law of prescribing narcotics, sexual harassment in the workplace, or reviews of some aspect of medicine. Certificates on his office wall from prestigious medical schools, hospitals, or training programs are not very meaningful in assessing the quality of his care.
So how does a patient choose a doctor? Often it is based on advice from a friend or family member, referral by one's primary care doctor, reading an article in the press, or location at a convenient neighborhood hospital. One may also go online to consult doctor evaluations for a fee, which are often based on some unknown number of patient satisfaction surveys.
The latter are a pet peeve of mine; very early in my career I learned that patient satisfaction was unreliable as a measure of the quality of medical care. Some of the worst doctors I worked with as a resident were adored by their patients.
Even when a relative or friend asks me where I would go for care of a medical problem, I often base my recommendation on generic information about an institution or a doctor I have come to know and trust; this may be a bit better than the other reasons, but it still doesn't get to the core issue, because I have no data on the quality of that physician's care, only a sense of it.
Some of the measures in place today deal mostly with process measures, which are useful. But if I am likely to have a major operation by a surgical oncologist, although I don't care about his processes very much, I do care about his results. We need national, objective, transparent measures by which we can at least get a notion of the quality of care provided by physicians and hospitals.
Doctors and other caregivers make mistakes.
Okay, this is obvious since doctors are human. But it is possible to reduce mistakes considerably. As has been much noted recently, the commercial airlines are the model for dealing with error. There is oversight by federal and local agencies of pilot performance, recurring tests in flight simulators, medical exams to assess the continued ability of the pilot to perform from a physical and psychological point of view, and a careful review of his flight performance, looking for early signs of poor judgment or performance. And there is an age limit for piloting a commercial airplane.
An easier and often overlooked point about reducing medical mistakes is that many of them are due not to incompetence, but rather, to a faulty system of care. It has been shown repeatedly that errors are reduced significantly by process measures such as the routine use of checklists, patient I.D. bracelets, and practice standards where appropriate—e.g., the use of agreed-upon regimens of antibiotics or chemotherapy for specific conditions.
Some doctors balk at the use of guidelines or protocols, calling it “cook-book medicine.” But standard approaches to standard situations reduce the likelihood of error or antibiotic-resistant bacteria and dosage errors. Adhering to standards also has the side benefit of being able to learn about the effectiveness or side effects of a particular regimen instead of having numerous, one-off variations.
The quality of a physician's care is often inversely proportional to the elapsed time since his or her training.
This is sad but true. Studies have shown that the quality of care stays relatively steady for five to 10 years after training but declines thereafter in many cases. Studying the medical literature gradually declines to reviewing only the abstracts, then reviewing only the table of contents, and then (if print issues are received) just putting the journal on top of the pile of unread journals, never to be opened.
The same is true of medical meetings, with a gradual decline in the frequency of attendance and, even when present, hearing fewer and fewer presentations.
There are many exceptions, of course, but on average this trend holds. (I must fess up that, to some degree, this describes my trend as well. I still read specific abstracts and occasionally entire articles, but much less than I used to. My excuse: I stopped having direct care of patients 20 years ago because I took on an administrative position that left little time available to my patients.)
Declining study of journals and engagement in medical meetings can lead to excessive dependence on one's own anecdotal experience. Medicine changes rapidly, and keeping up is not easy. Once physicians are confident and feel they are doing a good job, the urge to learn more may decline. This is human nature in action.
What often prevents catastrophe is the salvation provided by good judgment. Over time many, if not most, doctors develop increasingly good medical judgment about when and when not to operate, radiate, or treat at all; and they learn from earlier mistakes, either their own or those of colleagues.
To some degree, good judgment can make up for being a bit less up to date, and it certainly can convince a doctor that he or she doesn't know enough about the problem, and then use good judgment by referring the patient to another doctor.
Hear Joe Simone on BBC Radio!
Joe Simone was recently interviewed by the BBC radio program “Soul Music,” following up about his 5/10/12OTcolumn about Peggy Lee's song “Is That All There Is?,” written by Jerry Leiber and Mike Stoller. Hear him talk about why this devastating song about disillusionment inspires him nonetheless: http://www.bbc.co.uk/programmes/b01qgr4h