Donald Berwick, MD, former head of CMS, has written an article for the Journal of The American Medical Association, April 5, 2016, Entitled “Era 3 For Medicine and Healthcare.” In it, he describes Era 1 of healthcare as the time when doctors and other health professionals were simply trusted to practice, and spend healthcare dollars, without much oversight out of respect for their education and status. This era ended because clinicians, left to their own devices, proved unable to restrain healthcare spending or follow scientifically-proven best practices. Era 2, of which Dr. Berwick was an important proponent, was the era of overweening healthcare management, with clinicians forced to use electronic health records that worked very poorly in pursuit of dozens of goals, many of which were of no proven value. This era is itself in the process of ending badly, with CMS publicly backing off its support of Meaningful Use, the widely reviled initiative to dictate to physicians how to use the EHR’s they weren’t sure they wanted in the first place. Era 1 was unsustainable, but era 2 has had the effect of demoralizing physicians to the extent that physician burnout is being described as an epidemic.
In his proposal for era 3, it is clear that Dr. Berwick has not repented of his role in inflicting era 2 on American healthcare. Some of his proposals have merit: the number of outcomes that are measured should be drastically reduced so that attention can be paid to a few, important outcomes. Professional prerogatives can be a barrier to doing things better- physicians should not be able to pull rank when making decisions about outcomes that require the actions of teams. Some of Dr. Berwick’s recommendations are simply wistful: we should all behave civilly to each other. We should reject greed, and focus upon the common good. But the heart of Dr. Berwick’s essay is his belief that the problem with era 2 was that sound ideas were badly applied. He does not seem to see that quality management, as he conceives of it, cannot be applied to much of healthcare.
There are certain healthcare processes with clear, measurable good and bad outcomes that lend themselves to quality management as if they were industrial processes. It is clearly bad to have a wound infection after major surgery, and the processes of major surgeries should be managed to decrease the number of wound infections. The way that myocardial infarctions are properly treated in 2016 is better than how they were treated in 1986, and steps should be taken to ensure that MI’s are treated as they should be in the modern era. The situations in healthcare that are well-suited for scientific management are highly important, but they are few in number. For the great majority of healthcare encounters, quality is hard to define, let alone manage.
I would welcome comments on this observation: I have had conversations with people who either just got health insurance for the first time, or have had changes in their health insurance, and find that after they have paid their monthly premiums they don’t have much left to pay the out-of-pocket costs left to them by their insurance plan. They stay away from the doctor unless they have a catastrophe first that maxes out the amount they have to pay for health care that year, and only then do they feel they can afford visits for maintenance care and minor illnesses. I want to provide care at a reasonable price that heads off some of the catastrophes. It’s not as good as waving a wand that keeps my patients from needing my care forever, but it’s the best I can do.
In fee-for-service medicine, a doctor accepts money in exchange for a diagnosis. This is especially true if health insurance is involved, because without a diagnosis (accompanied by a ridiculously arcane code) the bill won’t get paid at all. I worry that this exchange is sometimes harmful to patients.
There are some problems with diagnoses. The first is that they usually lead to treatment, which may or may not be helpful. It takes a really good relationship with a patient who has a problem to tell him to do absolutely nothing about it, even when that is the best advice he could take. It’s far easier to write a prescription in the hope that it doesn’t cost too much and helps a bit without causing much harm. This seems to be what happens in the minute clinics, urgent care centers, and other sources of hit-and-run medical care.
The more harmful thing about diagnoses is that patients often absorb them into their identities. They start with, “my knee hurts,” are told by a doctor that, “you have arthritis,” and from there go on to conclude, “I am a person with arthritis, and this means that I am always going to have pain that changes my life.” The diagnosis emphasizes the patient’s disability and dependency, and makes the patient lesser for it.
This is especially true of mental health diagnoses. You can’t bill for an office visit because the patient is “sad” or “apprehensive,” so doctors diagnose “depression” and “anxiety.” This creates the expectation that the patient is going to receive an antidepressant or anti-anxiety medicine, perhaps the one that was advertised on television last night. After that, it is too easy for further office visits to center on the medicine: Does it work? Are there side-effects? Should we increase the dose, or try a different one entirely? It is too easy for important conversations to get lost in managing the diagnosis.
I don’t want to earn a living making diagnoses. I will use them when they are helpful, just as I use everything else at my disposal. Sometimes patients come in just because they are confused, or frightened, or unhappy. That’s not a disease, it doesn’t need a diagnosis, they’re just folks who need some help.