There are now so many rules and regulations in medicine that it is difficult for doctors to express any individuality. Like the burgers at McDonalds that are constructed in such a way that they taste the same regardless of your locale, doctors are expected to behave similarly when confronted with similar circumstances. Or at least that is how the proponents of algorithmic medicine see it. In addition, electronic health record systems create uniformity by enforcing work flows and utilizing pre-defined order sets and note templates. Everyone is supposed to write the same notes, order the same tests, do the same procedures, and make the same decisions. There is little room any more for Art in the the Art of Medicine. The Standard of Care has become a razor’s edge. Minor deviations from the straight and narrow path result in a plunge into the Abyss. And the Abyss is full of nastiness ranging from medical malpractice suits to accusations of fraud by the Centers for Medicare and Medicaid Services (CMS).
It wasn’t always like this. At the start of the 20th century we had Osler’s sound advice on the four components of the physical exam: inspection, palpation, auscultation, and, especially, contemplation. Now the most important part of the History and Physical seems to be the 14 point review of systems. Physicians used to develop patient care plans by combining the knowledge gained from reading the medical literature with the knowledge gained by their personal experience. Interpretation of the medical literature was tempered by the realization that study results are only generalizable in a limited way to individual patients. The best doctors were smart and experienced. Today only evidence-based medicine is deemed acceptable. Theoretically evidence-based medicine can be practiced by a computer or a robot. It is deterministic medicine, devoid of the human element. Its practitioners are interchangeable, indistinguishable units, replaceable and expendable — cogs in the broken clockwork that is the Healthcare System.
But patients are complex and evidence-based medical guidelines overly simplistic and mechanical. Patients are not mathematical entities that can be manipulated by algorithms. Patients have their own lives, their own priorities, and their own needs that don’t necessarily mesh well with a set of how-to-take-care-of-disease-X instructions. And the algorithms themselves are suspect. A large number, if not most, of the evidence-based recommendations have an evidence level of “C”, meaning they are based on “authority” (the authors’ intuition?) and not on randomized controlled trials. Despite these flaws, guidelines are not just guidelines anymore. The Google dictionary defines “guideline” as “a general rule, principle, or piece of advice.” Unfortunately guidelines generated for doctors have turned into rigid laws. Failing to follow these so-called guidelines can result in a charge of Medicare fraud.
The American Board of Internal Medicine (ABIM) seems particularly interested in reining in doctors. Their Choosing Wisely® program attempts to define medical tests and procedures that waste money or are unhelpful. Being a creation of the ABIM, the ABIM is very interested in implementing this program. They want CMS to enforce the Choosing Wisely recommendations with financial penalties. The ABIM, which already has a strangle-hold on physicians with its maintenance of certification (MOC) program, also proposes that perfect scores be achieved on questions related to costs and redundant care as a requirement for board certification. Besides the obvious conflict of interest here, is knowing the cheapest treatment really the most important thing a doctor should know?
With so many meddling busybodies trying to micromanage the practice of medicine, is there any room left for individuality? Shouldn’t doctors be able to choose the tools and techniques that best suit them individually to achieve their ends without outside interference? Shouldn’t the results of medicine be more important than the process of medicine? Too many third-parties like the ABIM, the insurance companies, and CMS have made it their business to tell doctors how to do their jobs. In the Ideal Medical Universe (the IMU — an imaginary alternative-history universe in which doctors have power over their destiny) we doctors would tell them all to back off. Then we could collectively take a deep breath and spend some time in contemplation. Contemplation as to how best to regain control of our profession.