News/Commentary

This is from Pauline W. Chen, M.D.’s column, Doctor and Patient, in the New York Times.

As a transplant surgeon, she makes a powerful case for how doctors and patients benefit from the kind of processes that are key to successful pre-transplant, in hospital and post-hospital care. It is a picture of what many health policy experts hope for.

Evidence on which to base care decisions.

Outcomes tracking to see which doctors’ patients do better than others.

Separation of responsibilities so that everyone is clear who is doing what and why. Organ transplantation can bring all kinds of bioethical issues to the table. These doctors try to be very careful they can explain what they did and why.

My only question about this column is one the writer can’t answer because she is not a doctor who sees patients in their offices over a period of years.

Transplantation is a highly-focused, carefully choreographed medical specialty.  Transplant teams actually do rehearsals for especially complicated transplantations with multiple donors, so calling it a choreographed specialty is not fanciful.

Daily medicine is what you and I bring into our doctor’s offices. We have problems not already well-defined. Our doctors know our symptoms could be caused by any number of things.

Can Dr. Chen’s transplantation experience translate into the daily doctor’s office? Hospital rounds?

I don’t pretend to know the answer. I do know that is the question on the minds of doctors who are doing the care and not the measurement of care, far,far away from their exam rooms.

We desperately need ways in which to make the best care decisions we can as the doctor or the patient.

It is the process of getting to decision-making—-and who is part of that process—-which is making many doctors worry about whether they will be taking orders, not giving them, on behalf of their patients because of some high priests of medical evidence who issue commandments.

Their concerns are not without foundation but there is a solution in here somewhere.

One doctor I know well calls himself a “minimalist.” He believes too many doctors do too many things to patients they don’t need. However, when his patients are really sick, he moves into high gear it is hard to believe this is the same person.

He has an excellent reputation and excellent patient outcomes. Although that’s not why he works this way, he could be the poster doctor for the evidence-based medicine movement.

He does it because he thinks its the right way to practice.

That is why there is reason to believe common ground can be found between care-giving doctors and those who do research or help make policy.

They all want the same thing: good results for patients.

Dr. Chen, now, will take you into the world of transplant surgery and the patients who so desperately need these doctors’ help.

It’s part of your education as a patient or family member. She makes it easy to learn.

New York Times

…”But critics warn that such research could ultimately lead to a one-treatment-fits-all approach and that the government could become an unwelcome third party, dictating “appropriate” decisions in the doctor-patient relationship.

“I’m not so sure, though, that doctor-patient relationships are currently free of third-party oversight to begin with. Moreover, I am not convinced that oversight necessarily weakens a doctor’s connection with his or her patients. In fact, when done well, oversight can actually strengthen that relationship.”

In writing of a patient, Alice, who needed the author to persuade the health plan that “authorization” for treatment was urgently needed, Dr. Chen says,  “I still get upset when I think about how I needed to plead with an anonymous voice for what was right for her. While I now accept the constant presence of an invisible and powerful third party in my interactions with patients, I can still feel my shoulders tighten whenever I hear the word “authorization.”

“But it is not the third party per se that causes the hairs on the back of my neck to rise. It is the sense that some of their decisions are based not on well-researched recommendations but on interests, agreements and circumstances that have little or nothing to do with good care. And because I know it is possible to have oversight that strengthens the doctor-patient relationship while relying on evidence-based treatment recommendations.

“I know because I have been part of one of the most successfully regulated medical fields in this country: transplantation.”

Source:  New York Times, February 26, 2009