I appreciate the recent comments on my post – When patients dislike treatments. As I traveled this weekend, I pondered my concerns about the “quality” movement, claims of EBM (note that true EBM does not have this problem), and P4P. The comments helped crystallize my thinking.
As a physician, I always consider the entirety of the patient as we develop a diagnostic and treatment plan. The internal medicine tradition taught me that. As I talk with family physicians, their tradition also focuses on the patient. Too often subspecialists and subspecialty societies focus on the disease.
In my cognitive construct, I cannot separate the disease from the patient. While some patients have a single disease process, many have multiple diseases. Even when patients have the same disease, they have different belief systems, ages, and decision making desires.
If I do not sculpt a diagnostic or treatment plan for the patient, then I am not doctoring.
Others have said this better, but I will still try. Each patient represents a special challenge for great physicians. As we strive towards greatness we must understand the patient’s goals and use these goals to modify guidelines. Guidelines are written for diseases not patients.
Many critics will cry that we can measure quality and we must. One of my favorite quotes from the philosopher Onora O’Neill,
“Yet faith in performance indicators is hard to dislodge. Every time one performance indicator is shown to be inaccurate, shown to encourage perverse behaviour, or shown to mislead the public, eager people imagine that they will find other performance indicators free of such adverse effects. Experience suggests that they are as mistaken as those who produced the last lot of indicators.â€
Many want to place a number on quality. We love ratings. We desire grades. But often medicine is much more complex. Great physicians always marry the art of medicine with the science of medicine. I believe that all physicians understand this, but unfortunately actuarial types continue to insist on scoring our performance.
Sometimes I feel like an ice skater who receives a mediocre score from the Russian judge.
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2 Responses to Great physicians focus on patients, not on diseases
Jared
October 9th, 2007 at 7:29 am
DB,
You, for the sake of completeness should also mention that in medical school, for at least the two years of the basic sciences, students receive at least 10 times the treatment of diseases and treatments compared to patients as people.
Our education system in that regard is defective by design.
-SSG J
amit gupta
October 9th, 2007 at 1:54 pm
Is it wrong if the subspecialists focus on the disease? I guess thats the reason why we need specialists. I agree that they should focus on the disease in the context of the whole patient. Often time, generalists and internists refer the patient to specialists just to share the burden of care.