Wednesday, August 23, 2017

Why Medicine Can't Be Managed

If twenty-odd years of administrative meddling should have taught us anything, it's that all the plans in the world for medicine and health care are rarely worth the paper they're printed on.

When your career in medicine is (pardon the pun) on life support, you have a good amount of time to reflect on what aspects of the job you like, what aspects you hate, what aspects keep you going, and what aspects make you run screaming or crying yourself to sleep. The answers are going to differ from person to person, particularly on the positives, but it's a safe bet that increased administrative demands will be on the list of negatives for most.

Every few years, politicians and health care administrators everywhere seem to fall in love with the latest idea - as often their own as the product of business schools - to transform health care systems once and for all into an equitable, timely, universal, sustainable, high-quality, affordable, high-performance, efficient, patient-centered, population-focused, preventive, state-of-the-art, continually improving utopia. As plainly impossible that such an exercise is, a whole lot of people and resources are poured into these initiatives again and again, and job descriptions for health care professionals have become increasingly burdened by management jargon that is so alien to patient care it might as well be written in hieroglyphics.

There's no escape from the sheer complexity of health care and medicine, which is why so many of these simplistic, acronym-laden schemes fail dismally. However, there is a way to at least get a handle on the underlying causes of complexity in health care.

The earliest practitioners of scientific medicine thought of the five corners of a pentagram as representing the four elements (earth, air, fire, water), and a fifth "element" of psyche or spirit. Students of Pythagoras went further, asserting that the letters representing each element spelled out the name Hygieia (pictured above), daughter of Asclepius, the doctor-god of Greek myth. We've come a long way in our understanding of disease since the days of Pythagoras, but the pentagram remains a useful tool for understanding medicine and health care.

Rather than try and define modern medicine strictly in terms of doctor and patient, we're better off considering a matrix of highly interdependent relationships. Each "corner" itself has its own complexities, in particular Resources, meant to encompasses socioeconomic and political factors. More important than the complexity of each factor, however, is that a change in any one factor or relationship will affect every other relationship, rarely in predictable ways.

Take a simple example, the development of a more accurate screening test for colon cancer. On the surface it's a scientific matter alone, demanding not much more than a commitment on the part of government or insurers to pay for the upgraded test. On the surface.

The doctor has to be educated on the science, in order to be able to properly counsel the patient. Any new screening test will necessarily lead to more follow-up tests. That changes resource demands throughout the system, principally the costs of follow-up tests and practitioner time. If screening successfully lowers the incidence of colon cancer, the population as a whole will eventually see increases in other diseases, diseases that might be more resource-intensive to treat. This isn't to say that's a bad thing - death from cancer is never good - but the forecasts and calculations are almost impossible to get right, let alone to weigh against other public policy concerns.

The interdependence even holds true for matters that, on the surface, don't seem to affect resources much, such as Medical Assistance in Dying (MAiD). The practice can radically alter the way doctors and patients communicate with one another. Medical "science", including research and ethical debates, does not as yet have clear answers to where MAiD is appropriate and where it isn't. The law or College guidelines can force the matter and compel doctors to act, but for many the practice of MAiD changes the definition of doctor. Moreover, as MAiD becomes commonplace, it can lead to less research or interest in progressive diseases - multiple sclerosis, ALS, some cancers - as these conditions lead to patients being "written off" as worthy of search for a cure.  

This brings me to the source of endless grief for many in health care, management schemes and system metrics without real appreciation for their consequences on care. Want to try a sausage- or auto-manufacturer's philosophy to patient flow in a hospital? What happens when the disease doesn't want to cooperate? When haste leads to more errors? When the fingers are all pointed, is there ever a moment's thought given to the possibility that the plan was the problem?

This is not an argument against any kind of health care reform, but instead a prompt for humility. Many, many variables are at play in medicine in health care, and the overwhelming majority are interdependent, unpredictable, and human. A failure to appreciate the consequences - human, ethical, legal, biologic, and economic - and Pythagoras' pentagram will produce something far more commonly associated with five-pointed stars.

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