In praise of impersonal medicine

Many people complain that medicine is too impersonal.  I think it is not impersonal enough.  I have nothing against my physician (a local magazine says he is one of the best in the area) but I would prefer to be diagnosed by a computer.  A typical physician spends most of the day playing twenty questions. Where does it hurt?  Do you have a cough?  How high is the patient's blood pressure?  But an expert system can play twenty questions better than most people.  An expert system can use the best knowledge in the field, it can stay current with the journals, and it never forgets.

Consider how many people die because physicians forget the basics. Gina Kolata reports on a Medicare program to rate hospitals on the quality of care provided in the treatment of  heart attacks, heart failure and pneumonia - these three areas chosen because there are standard, clinically proven, treatments that everyone agrees are highly beneficial.

At Duke University's hospital, for example, when patients arrived short of breath, feverish and suffering from pneumonia, their doctors monitored their blood oxygen levels and put them on ventilators, if necessary, to help them breathe.

But they forgot something: patients who were elderly or had a chronic illness like emphysema or heart disease should have been given a pneumonia vaccine to protect them against future bouts with bacterial pneumonia, a major killer. None were.

All bacterial pneumonia patients should also get antibiotics within four hours of admission. But at Duke, fewer than half did.

The doctors learned about their lapses when the hospital sent its data to Medicare. And they were aghast. They had neglected - in most cases simply forgotten - the very simple treatments that can make the biggest difference in how patients feel or how long they live.

...[Similarly, the] hospitals were asked how often their heart attack patients got aspirin when they arrived (that alone can cut the death rate by 23 percent). When they were discharged, did they also get a statin to lower cholesterol levels? Nearly all should, with the exception of patients who have had a bad reaction to a statin and those rare patients with very low cholesterol levels. Did they get a beta blocker?

Once hospitals learned their score, it was up to them what to do. Over the next year, ones that improved in these measures saw their patient mortality from all causes fall by 40 percent. Those whose compliance scores did not change had no change in their mortality rate, and those whose performance fell had increases in their mortality rates.

"Those are the most remarkable data I have ever seen," said Dr. Eric Peterson, the Duke researcher who directed the study and has reported on it at medical meetings.

Unfortunately, we (doctors and patients) have a model in our head of the nearly omniscient doctor carefully attending to the needs of every patient on an individualized basis - medicine as craft.  Instead what we need is medicine by the numbers.  But doctors don't like being told what to do.

"We tried to come up with a standardized order set," with all the measures that Medicare was asking about, Dr. Gross said. "But the doctors didn't want to use the sheet," insisting they would just remember those items. Then they forgot.

The solution, Dr. Gross said, was to assign specially trained nurses to see what care was provided and remind doctors when important steps were omitted. The result was immediate improvement, Dr. Gross said, even in items not on Medicare's list.

The nurses, in effect, are being trained to follow standardized procedures, just as does an expert system.

Thanks to the John Palmer, The Econoclast, for the link.