Friday, September 23, 2011

Clinician as the Politbureau of medicine?

Do you think that medicine in the US is centralized? I do, but not in the way that we generally understand centralization. And furthermore, it is this centralization that I believe is making the idea of shared decision making so intimidating to some. Here is what I mean.

If you read management texts, centralization refers to an organization that is run predominantly top-down. In other words, a couple of oligarchs at the top of the ladder make all the decisions without consulting anyone below. In this way all the power is concentrated in the hands of the few. In an antithesis to this, in a decentralized organization, grassroots input and initiatives are incorporated into the fabric of the organization. And while in the times of a great crisis, when rapid decisions are necessary, the benefits of centralization may outweigh its risks, during normal day-to-day operations, such unilateral power can result in obviously negative consequences, from discontent among the employees to making the wrong choices. Furthermore, as organizations grow in size, it gets that much more difficult to run them effectively within the centralized paradigm.

Now, let us look at medicine. The traditional model of the doctor-patient relationship relies on the clinician to know what is right for the patient: take this pill and don't worry about the side effects, dear. Now, clearly, when someone shows up to the emergency room in septic shock, there is very little room for a democratic process; we want the doctor to do rapidly what needs to be done to save the patient. But this is a catastrophic exception to the rule of what modern medicine cares for. From pre-diabetes to pre-hypertension to "borderline cholesterol" to osteopenia to mild depression, these are the "diseases" that are prevalent in the office of the 21st century. None of these is particularly urgent or life-threatening. And if we are honest with ourselves, even a devastating diagnosis of cancer does not demand an instantaneous intervention: in the vast majority of cases there is ample time for discussion and contemplation. So, the centralized approach is the wrong way to go. Thus enter the robust discussion about shared decision making. 

Another reason that centralization of medical decisions is crumbling is the expanding patient panels that clinicians need to engage with in order to stay solvent, all within the context of increasing compliance and regulatory burdens along with decreasing reimbursements. Without an equal growth in one's cognitive ability to multi-task, this escalating imbalance is creating a rising risk for unilateral decisions to be plain wrong.

So, in my mind, this is yet another argument for all parties to embrace shared medical decision making to the extent we as patients are willing and able to do so. Because what is the alternative?          

1 comment:

  1. "From pre-diabetes to pre-hypertension to "borderline cholesterol" to osteopenia to mild depression, these are the "diseases" that are prevalent in the office of the 21st century. None of these is particularly urgent or life-threatening"
    Good ideas & questions in your post.
    In FM, where I've experienced > 150k patient office visits, patients perceive most of the visits as "urgent", so they say whatever is necessary to get the appointment on an urgent basis. Their want is life-style or culturally driven, not usually medically driven. They also don't worry about the "pre-disease" states that Pharma gets doctors to push.
    A sports medicine model of thinking may be beneficial, as the patient wants to get "back in the game" or use an authority to stay out of "the game" and communicate the decision to the "coach" (employer, etc.).
    Patient centering is a communication/decision model that many are trying, but they come across as payment or physician centered decision processes.
    Human centering in which both dyadic participants (patient and doctor) connect as humans and share decisions equally hasn't developed much of a following yet. Decision making influence by the human dyad varies as they shift into different roles during the office encounter, e.g. patient, doctor, consumer, consumer coach, sufferer, healer, counselor, learner, teacher, etc.

    Insurance companies, physician groups, the Medical Industrial Complex, and organized medicine are not yet excited about variations in the decision processes. "Quality" outcomes are not yet patient sensitive, as they eventually should be. The EHR and PHR, though, are adding to the push for varying the decision processes. But, as you point out, something has to change.