Six years ago, I wrote a column titled, “Five Great Lies of Medicine.” I wrote an updated and expanded version of that column, which published last month (Oncology Times, 10/10/16 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 with the patient and the family; for example, “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.” Or something like that.
Several years ago, I also wrote a column, “Three Great Truths of Medicine,” because there are also “truths” in medicine we rarely talk about. By that, I mean common knowledge among medical professionals that is 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, when and if such a discussion of these generic, almost philosophical, issues may not be 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 a few.
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 MD 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 laws for 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 to a subspecialist by one's primary care doctor;
- reading an article in the press; or
- choosing someone 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 an unreliable measure of the quality of medical care. Some of the worst doctors (quacks) 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 from experience or anecdotal evidence. Some of the standards 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, I don't care about his processes very much, but I do care about his results. We need national, objective, transparent measures by which we can get a notion, at least, of the quality of care provided by physicians and hospitals.
Doctors and other caregivers make mistakes.
This is obvious since doctors are human. But it is possible to reduce errors considerably. The commercial airlines are the model for dealing with pilot error. There is oversight by federal and local agencies, recurring tests of performance 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 approach to reducing medical mistakes is that many of them are not due to incompetence, but 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 ID bracelets, and practice standards where appropriate (e.g., the use of an agreed upon regimens of antibiotics or chemotherapy for specific conditions). Some doctors balk at the use of guidelines or protocols as “cookbook medicine.” But standard approaches to standard situations reduce the likelihood of error, antibiotic-resistant bacteria, and dosage errors. It 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 completing his or her training.
This is sad but true. Studies have shown that the quality of care stays relatively steady for 10 years or so after training, but often slowly declines thereafter. Often as one ages, study of the current medical literature gradually declines to only reviewing the abstracts, then reviewing only the table of contents, and then 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 caring for patients 20 years ago because I took on an administrative position that left insufficient time to be 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 a physician is confident and feels he/she is 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 their earlier mistakes or from 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 she doesn't know enough about the problem, and then using good judgment by referring the patient to another doctor or at least discussing the issue with an expert.
A doctor working with partners or colleagues has a potential advantage when striving to provide excellent care.
I cannot count the times I was given very good advice from a colleague when I had a problem or difficult decision to make in a patient's care. Reviewing a bone marrow sample at the two-headed microscope with a superb lab tech saved my butt a number of times. However, there is a big “but.” The colleague must be willing to disagree with the physician's opinion, which may cause hard feelings. The doctor asking for help must take the advice seriously and, if necessary, get another opinion from a different colleague. Some of thee issues are resolved at a regular tumor board meeting, which often raises novel approaches or a change in the sequence of care.
Being a physician is a privilege and an honor.
We have a special place of honor in society that is awarded to us and we must not let our egos or the pursuit of financial gain tarnish our commitment to serve our patients. The patient comes first and, when we forget that for any reason, we rightly lose the trust of patients and no longer deserve our special status in society.Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.
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