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Saturday, February 4, 2012

The art and science of healthcare - and why we need both!

A cornerstone of the "quality" movement in healthcare is the idea that we can't improve what we don't measure.  This has led to any number of achievements that would have been impossible otherwise: reducing hospital infections, improving surgical outcomes and a host of others.  The concept is pretty straightforward.  Absent a good way to measure, reasonable clinicians can (and will) argue incessantly about whether any particular bad outcome was random, or something else.  (A surprising number of physicians - even some with a strong track record of secularism - will attribute the worst outcomes to "God's will."  Go figure.)  But if one hospital's, or one team's, or one surgeon's results are statistically different than another's - whether better or worse - well, then something interesting may be going on.

Another such hallmark is standardization.  Treating the same problem the same way seems pretty logical.  Even when there is more than one right way to do something, standardizing practice keeps down unnecessary complexity in the system, reducing both cost and the likelihood of error.  (For more on the latter, see my last post.) Like measurement, however, the idea of standardizing practices in healthcare brings surprisingly mixed reviews.   We've all heard the mantra:  "practicing medicine is an art."  This happens to be a true statement. However, there is a counter-statement that is just as relevant:  "all that is unscientific isn't necessarily art!"  What IS true is that providing the best healthcare requires that doctors adapt the treatment plan to meet the individual needs (and preferences and values) of each individual patient.   This is what I would call "beneficial variation."

Unfortunately, much of the actual variation in our healthcare system is not of this kind.  It turns out that when different doctors choose different antibiotics to treat the same kind of infection or suggest one operation over another, too often the reason has more to do with the doctor than the patient.  (Question to doc: "Why did you choose this approach?"  Answer:  "Well, that was the way I was trained."  Hearing this expression continues to cause my hair to stand on end.)

Is there, then, any room for "art" in Medicine?  Yes, and the need has never been greater.  More on that tomorrow.

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