Dr. Costello’s “Best of Health” Quarterly · Vol. II, No. 1 · Spring, 1991
The Quality of Medicine
Quality Medicine is expertise and service. Expertise is defined as the right diagnosis and the right treatment provided in a manner that is proper and empathetic. Service is that expertise applied in a timely manner, including both acute care and long term continuity-of-care. The purpose of this article will be to examine this definition of the quality of Medicine, and establish it as the foundation of any decisions that will be made on health care in America.
The quality of Medicine is also a function of community standards which vary with the sophistication of the medical providers, the sophistication of the patients, and the communities’ financial strength in supporting new technologies.
…the right diagnosis and the right treatment…
Expertise is a function of the doctor’s knowledge of disease, sufficient investigation of the ill patient and appropriate treatment. Until recently the only limits on this process were the doctor’s education, the patients moral or financial wishes for tests and treatment, and the community’s level of medical technology.
In the last five years the third party payers have wanted to limit this process of reaching the right diagnosis and treatment by cost. They are doing this in two ways. The first is by reimbursement befuddlery. This is the delay in paying or the refusal to pay health care claims to either patients or health care providers. The second is through practice guidelines.
There are two kinds of practice guidelines. The first kind of guidelines is recommendations made by a panel of physicians after studies have been done to determine the best diagnostic test or treatment for a particular medical problem. An example is cholesterol screening. This is a good guideline.
The second type of practice guidelines is dangerous to your health. The third party payers are defining medical and surgical practice by rigid algorithms and flow charts designed with little understanding of the uniqueness of disease presentation and response to treatment. They limit the process of diagnosis and treatment to only those practice guidelines that have been approved.
Getting to the right diagnosis and treatment is made more difficult. The process which formerly only required the doctor’s knowledge, the patients approval, and the community’s technology now requires the burdensome approval of the bureaucratic third party payers.
This has been done in the name of “quality”. However, the real purpose of these guidelines is to reduce the number of diagnostic and therapeutic procedures ordered and thereby reduce their costs. Worse, these guidelines will fix obsolete diagnostic and therapeutic procedures for budgetary convenience.
These guidelines also denigrate the entire process of developing new diagnostic tools and therapies. They are an insult to the many dedicated physicians and scientists over the last two centuries.
Journals such as the British Medical Journal, Lancet and The New England Medical Journal have the finest written tradition of the scientific method in the English speaking countries, with over 150 years of ongoing “practice guidelines”. Do you really expect the government and the insurance companies to keep their guidelines as up to date as the leading edge standards of these medical journals?
Witness the current cost and struggle it is to bring a new drug to market. The length of time it would take to change an approved “practice guideline” is mind boggling!
Once these rigid guidelines are in place, the next step will be to allow other health care providers, i.e. medical technicians, nurse practitioners, or physician assistants other than physicians to perform these duties, based on the premise that medical diagnosis and treatment is ‘cookbook’. Anybody can diagnose and treat with a minimum of training and at considerable cost savings. There will be more on this third party payer behavior in another “Best of Health” Quarterly.
One development that has been good for the “quality” of medicine has been the requirement for continuing medical education. This is a need that has grown out of the rapid technological advancements in medicine and insures the physician knowledge base stays current. Another positive development has been the patients’ increase in awareness of diseases and treatment and their more informed participation in the decisions on therapy.
…in a manner that is proper and empathetic…
To continue the discussion, expertise requires “a manner that is proper and empathetic.” Proper in this context means honest and ethical. This arises from the original Hippocrates Oath which I have provided on page 4. It is worth perusing.
Empathy means the capacity for one to participate in or experience another’s feelings, ideas and emotions. An empathetic relationship does not develop overnight. It is based on ongoing interaction of the doctor and patient. Quality in medical care preserves this doctor patient relationship.
…in a timely manner, including both acute care and long term continuity-of-care…
Service is expertise applied “...in a timely manner, including both acute and long term continuity-of-care...” This is the aspect of “quality” that the Third party payers pretend does not exist. Medicine is a service! They want you to think it is a product!
To clarify the timeliness of acute care an analogy will be utilized. At one time or another we have all sat in a restaurant wondering when the meal was going to be served. We all marvel at the service of restaurants like McDonald’s. Imagine your surgeon providing the service of the bad restaurant when it was time to take your appendix out. “Call my lawyer!” you would scream. (I wish I could have done that at some restaurants!)
Medicine is people serving people. Good service requires incentives for the person providing the service. When return on effort is restricted and the lazy physician earns as much as the physician who put in that little extra, the physician trying harder quits and “quality” suffers. Then patients suffer.
…Medicine is a service…
If you have any doubts about this aspect of human nature, the next time you are at a restaurant indicate to your waiter that you don’t believe in big tips and watch how your service deteriorates. Or ask yourself the question, “Would I rather wait for my regular doctor or for a doctor at the Veterans Hospital?”
The timeliness of “long term continuity-of-care” is an even more important aspect of the “quality” of medical care in that it is an integral aspect of the physician patient relationship. Continuity-of-care is more than a copy of the patient’s medical record. It is getting to know the patient and the patient getting to know the physician. Eventually trust develops to the point that difficult issues can be discussed with confidence that help will be forthcoming.
Also a knowledge of the patient is built up in the physicians mind that transcends the medical record. The patient has a problem. The treatment is obvious and the patients tolerance for it is already “built in” to the physicians therapy. This relationship of interactive understanding takes years to develop. The older physicians know all about this. It is why they never kept detailed records. They knew their patients.
…a function of community standards…
Quality is also dependent on community standards and its financial strength. Communities make two decisions in health care. Does the diagnostic or therapeutic procedure help? Is it affordable? The third party payers seek to restrict the patients care further by asking is it affordable for this particular patient based on their level of insurance coverage? This is wrong to do. Whether a test is affordable should be a question asked only at the level of the community, not the individual.
If the community standard is a CAT scan for a particular problem then the patient at the public hospital should get the same test as the patient in a private hospital. The level of service will be different but the diagnosis and treatment are the same. For example, the patient at the public hospital may have to wait three hours before and after his test in a drafty hall with only his hospital gown on, but he gets the test.
The sophistication of the providers and patients also determines care. The physicians of Tibet won’t be providing the same care as the physicians in Boston and the patients expectations will be similarly different.
Thank you for reading this article all the way through. It is our hope that you, the patient, apply this definition of quality of medicine when thinking about medical care for yourself or your loved ones. Don’t confuse quality, expertise and service with cost in medical care decisions.
The Hippocratic Oath mentioned above is printed in this issue: read the Oath.