Health care’s big picture: Fix the systems to support individuals

A message to all physicians from Steven J. Stack, MD, chair of the AMA Board of Trustees.

By — Posted Oct. 15, 2012.

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Health information technology, sustainable health care financing and quality health care delivery all rely on complex systems involving a variety of processes and people. All of them require a systems-based, not individual-focused approach to achieve success. Yet what makes obvious sense at a system level may be untenable at the individual level, and often physicians at the bedside feel alone in their recognition of this reality.

To demonstrate the point, let’s consider a few clinical examples:

  • Consistent use of the Ottawa Ankle Rules could substantially reduce plain film x-rays used for ankle injuries.
  • Computed tomography use has rapidly escalated and in some instances appears to be unnecessary and/or harmful.
  • Antibiotics don’t help viral infections, and their overuse leads to antimicrobial resistance and complications.

Notwithstanding the above, physicians use ankle x-rays, CT scans and antibiotics at times in a manner contrary to established treatment guidelines.

Sometimes this may be a knowledge deficiency or even a professional shortfall. For these instances, educational efforts such as those undertaken by the American Medical Association and the AMA-convened Physician Consortium for Performance Improvement play a useful role. More commonly, though, the true culprit is our fragmented and inequitable health system.

Sixteen percent of all Americans and 34% of the patients in my suburban emergency department are uninsured. For these patients, there is no ready access to appropriate outpatient follow-up care. Watchful waiting may mean more time off the job or a costly repeat visit to an ED. “See your primary care doctor” or ”Follow up with the orthopedist” can be a cruel joke, not useful advice. For the uninsured and patients on Medicaid, problems with transportation, employer inflexibility, no or low insurance coverage, and educational limitations add additional challenges.

Against this backdrop, many physicians have ordered an ankle x-ray or prescribed an antibiotic to a patient whose personal circumstances make outpatient follow-up particularly burdensome or unlikely. For a patient with unrelenting abdominal pain, even if nonemergent, a CT scan may be the only available option to exclude a whole host of worrisome diagnoses within the short time of an ED visit. Technology and/or pills, even with their own costs and undesirable consequences, become surrogates for unattainable access to affordable and reliable outpatient medical care.

Please note that I am not relying on the fear of trial lawyers or the pressures faced by busy clinicians to justify suboptimal care. Defensive medicine and work force shortages (real or artificial) are challenges in their own right, but those aren’t the topic of this column. Nor am I proposing that we physicians don’t have an obligation to optimize the care we provide to be cost-effective and consistent with scientific evidence.

Instead, I assert that medical treatment for 50 million uninsured and 60 million Medicaid patients, fully a third of our population, adheres to rules of pragmatism not captured by evidence-based medicine. Rather than being a failure of physician professionalism, quite a few seemingly “inappropriate” tests and treatments are the result of a physician’s imperfect but sincere attempt to help a patient in a nation replete with First-World technology but financed and administered in a Third World manner. Until our nation moves past the delusion that individual professionals are at fault for societal choices and systems-based problems, we will not succeed as we could and should.

The solution to this problem of allegedly unnecessary tests and antibiotic use goes well beyond physician education and professionalism. If, as a nation, we want to seriously and successfully address these challenges, we must reform our current fragmented, costly and inequitable health system to support access to quality care that facilitates adherence to scientific evidence. Until then, it is misplaced and unfair for policymakers and standard-setters to impugn the physician’s professionalism for treating the patient immediately before him in a manner considerate to the patient’s personal circumstances.

As of this writing, less than two hours from now, I will start a noon-to-midnight shift in the emergency department. For 12 hours, I will struggle to navigate a dysfunctional health system for the benefit of my patients. During the shift, I can anticipate treating patients with uncomplicated broken bones but no access to follow-up care; patients with chronically untreated hypertension and diabetes who eventually will suffer largely preventable renal failure, strokes and heart attacks; and patients with chronic pain and/or opiate dependency for whom there is no help whatsoever that I can offer. Improving the quality of care for these patients requires a systems-based approach, not the remediation or leveraging of my individual professionalism.

In my work with physicians and other societal leaders, I am repeatedly reminded of the many ways that, as we say at the AMA, “Together, We Are Stronger” (link). How we communicate and collaborate with each other to solve daunting societal challenges is very important.

To my colleagues in the policy arena, I ask a deeper appreciation for the real-world complexities faced at the bedside and attention to systems-based reform necessary to support the improved outcomes we all desire.

To my fellow physicians, I ask each of us to reaffirm our personal commitment to both the patient at the bedside and the health of our nation as a whole. We have important and constructive leadership to offer in both settings.

A physician’s professionalism is something to be supported and appreciated, but real-world support must go beyond spoken words and documents. It must include the kind of system changes that support physicians as clinical leaders and compassionate healers caring for their patients in an environment that works best for both.

A closing note: I’ve received some wonderful correspondence as a result of my previous columns. I read each of them and make a personal effort to respond to every AMA member who writes me (nonmembers, please join up to take part in the dialogue). If this column resonates with you, for good or bad, please drop me a note.

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