Healthy Skepticism Library item: 13108

Warning: This library includes all items relevant to health product marketing that we are aware of regardless of quality. Often we do not agree with all or part of the contents.

Publication type: news

Sanghavi D.
Why do doctors fixate on diagnosis, not treatment?
Slate 2008 Mar 12
http://www.slate.com/id/2186446

Full text:

When doctors are freed from commercial pressure, how well do they
perform? We’ve grown accustomed to scapegoating pharmaceutical
companies for health-care ills˜consider movies like The Constant
Gardener and the recent New York Times Magazine exposé by a
psychiatrist paid by drug makers. The implication is that if left alone
by money-grubbing drug companies and health insurers, physicians make
the right decisions on behalf of their patients.

Not so fast. It turns out that improving the quality of health care has
only a little to do with drug companies. Their influence is a symptom
of a deeper underlying pathology. The real trouble is that
doctors˜somewhat paradoxically˜are simply not focused on actually
treating disease.

A key indicator of this problem emerged last October, when a team of
researchers led by Rita Mangione-Smith reviewed children’s medical
records from 12 major American cities and found that fewer than half of
children got the correct medical care during doctor visits. The
researchers asked basic questions such as these: Did doctors properly
inform mothers to continue feeding infants who had diarrhea? Was HIV
testing offered to all adolescents diagnosed with a sexually
transmitted disease? Was a follow-up visit scheduled after a child’s
medication changed for chronic asthma? These were all simple things
doctors should have been doing yet weren’t. (A similar study of adult
quality of care was published in 2003 with similar results.)

This seems absurd. Physicians are some of the most hypereducated
professionals around, with eight years of higher education, followed by
three to 10 years of residency and subspecialty training over thousands
of hours. They also must pass some of the most exacting and complex
licensing exams ever written, including at least four separate tests
requiring weeks of dedicated study to achieve board certification. And
yet, according to studies like Mangione-Smith’s, most doctors in
practice don’t pass muster in administering optimal care for elementary
conditions like infant diarrhea. What is going on?

There are at least two explanations. First, clinical training in
primary care˜including pediatrics, internal medicine, and family
practice˜excessively focuses on the diagnostic hunt rather than the
more routine rounds of treatment that follow. It’s tempting to think
that most doctors are detectives nailing baffling diagnoses, like Hugh
Laurie’s character on House. In part, this view of medicine accounts
for the success of Jerome Groopman’s book How Doctors Think, which
explores how wrong diagnoses occur. In almost every educational
venue˜from morning teaching sessions for residents to the weekly case
conference featured in the New England Journal of Medicine˜medical
trainees spend hours learning about how to diagnose rare ailments. And
then, abruptly, discussion ends, as though treatment were an
afterthought.

The not-so-subtle subtext: Medicine is about the exciting search for a
diagnosis, and any old doctor can write a prescription once the real
work is done. This same bias pervades insurance rules. To be paid at
the appropriate level, physicians must exhaustively document all sorts
of irrelevant diagnostic data˜such as a rectal exam in toddlers seen
for a comprehensive asthma evaluation˜rather than the rationale for the
treatment they prescribe.

On a separate but related front, medical education today fixates on
acquiring knowledge that is largely unrelated to patient care. Consider
the college prerequisites to attend medical school (for example,
physics and organic chemistry) and the morass of molecular biology,
anatomy lessons, and pharmacology that follows and must be committed to
memory. Of course, a general foundation is important. However, the
sheer abundance crowds out an important˜in fact, the only˜skill that
matters in treating a patient: how to critically appraise published
clinical trials. Few doctors ever read them. In effect, medicine has
become a priesthood of practitioners who never review or learn to
interpret the Bible to minister to their flock; they instead rely on
secondhand wisdom. Or, worse, on Google.

That is why, for example, the average internist can describe the
branching patterns of the major coronary arteries but not the primary
clinical trials assessing how much, if at all, various
cholesterol-lowering agents cut heart-attack risks. Or, for that
matter, whether the trials were soundly conducted. Yet in real
practice, diagnostic puzzles are rare, and knowing the molecular basis
of an illness does little good. Instead, children see pediatricians for
ear infections, diarrhea, and attention-deficit disorders. Adults see
internists for high blood pressure, diabetes, and chronic pulmonary
disease. Filling the training vacuum, an unregulated, for-profit
industry of information peddlers is emerging to interpret clinical
trials and guide treatment.

These groups essentially write CliffsNotes for doctors, and their
influence on medical care cannot be overstated, though it’s largely
invisible to consumers. The most widely used service is UpToDate.com, a
private-equity-backed, subscription-only Web site that, according to
some research, is accessed by half the clinicians at hospitals
affiliated with Harvard Medical School at least five times a week.
Eighty-seven percent of U.S. teaching hospitals subscribe to it. On the
site are thousands of recipelike entries on everything from toddler ear
infections to drug therapy for heart failure. UpToDate.com has become
the cookbook for medical treatment. No professional primary-care
medical association, like the American Medical Association or American
Academy of Pediatrics, has created anything like it.

To its credit, this site is subscriber-funded and refuses advertising,
unlike rival sites like Medscape and eMedicine. But there’s no
guarantee it’ll stay that way, especially if it is sold or goes public.
And while the overall quality of information is quite good, the
treatment guidelines tend to favor medications over modifying behavior
and lifestyle, are not vetted by any government or other professional
association, rely a lot on the personal views of the one or two authors
of each recipe, and rarely include any cost-benefit analysis.
Fundamentally, by neglecting treatment, doctors have outsourced it to
private contractors who don’t answer to any authority. (This is why
drug companies can launch misleading marketing campaigns without a
unified voice arguing on the side of the data.)

Even if perfect treatment guidelines were to appear magically, it takes
a lot of work to teach doctors to follow them. Consider ear infections
in children, which are vastly overtreated with powerful antibiotics. In
2000, a group of Boston researchers created an ambitious three-year
program (using sociological methods used by missionaries to score
religious converts) to educate local pediatricians about proper
ear-infection treatment. They explained how to talk to patients,
control symptoms without antibiotics, and create educational handouts
for patients. They taught doctors what they should have learned in
medical school and, as reported in Pediatrics this year, substantially
cut antibiotic use. The only sticking point is that it all took a big
investment of time and money.

Treatment neglect has big consequences beyond ear infections. Medical
errors may claim almost 100,000 lives each year, often from basic
skills like poor handwriting on prescriptions. In her book,
Overtreated, Shannon Brownlee explains how ignoring treatment has led
to odd discrepancies in medical care; for example, some towns in
Vermont had tenfold higher rates of pediatric tonsillectomy than
others, despite having the same kinds of patients.

Refocusing doctors on actual treatment, instead of pointy-headed
diagnostic puzzles, will take serious effort. In the meantime, patients
should ask a simple question: “Can you describe the evidence for my
treatment?” For better or worse, the answer will tell you a lot about
the care you’re getting.