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Sunday, January 29, 2012

The changing goals of healthcare

The IOM has published a wealth of interesting papers. My attention this week was drawn this week to a paper entitled "Knowing What Works in Health Care: A Roadmap for the Nation" which can be found at
http://www.nap.edu/catalog/12038.html. It speaks to the need for a transparent and believable process which is used to assess what delivers value to patients and how to package that information where it is accessible and understandable to health care providers and to patients and their families. It is a complex problem which will require collation, synthesis, and interpretation of vast amounts of information.

It brought to mind how the landscape of the health care delivery world has changed. That might seem like I am stating the obvious but I believe that the changes which are most fundamental one the ones that are least appreciated. When Jesus was dining with the sinners and tax collectors, he was asked by the Pharisees why he would engage in such behavior. His response was"
“It is not the healthy who need a doctor, but the sick. I have not come to call the righteous, but sinners.” (Mark 2:17)
This is a far cry from the present world where doctors offices are filled with people who are the worried well. This underscores how our perspective on the purpose of health care has changed. While Jesus' remarks may have been recorded almost 2000 years ago, the role of physicians really did not change much until mid way through the last century. Physicians took care of people who were sick and generally acutely sick or injured. There was plenty to do and the outcomes were often not desirable ones. Well people did not seek out care from physicians because there was no reason to believe that physicians could deliver anything of value to a well person and perhaps even those with chronic and non-life threatening conditions. The question now is whether times have actually changed.

For those who needed the attention of a physician, for the most part the interventions were for acute conditions and the time frame required to assess success or failure was measured in hours to days. The goals of treatment were very simple. Did the patient live or die. No one was concerned about 30 day re-admission rates. Until relatively recently (meaning the last 50 years), few people were admitted to hospitals for anything (Jimmy Carter was the first President of the US actually born in a hospital). The revolution unleashed by drug development, especially the development of antibiotics (see "Demons Under the Microscope" for a great read on this http://www.amazon.com/Demon-Under-Microscope-Battlefield-Hospitals/dp/1400082137) completely changed not only how physicians practiced, but fundamentally changed what the goals of our jobs would end up being.

There are still many physicians who deal with life or death situations. However, increasingly our services are delivered to patients who are no longer sick in the same sense as those viewed as ill in previous generations.  Perhaps even more fundamental is the change in the time line for the assessment of success or failure of interventions. We no longer exclusively attempt to focus on acutely saving lives. Measurement of outcomes in acute care settings is still demanding and can have pitfalls, but it is inherently easier than measuring more difficult to define outcomes which may occur years in the future. In my opinion, the IOM paper was written because of the need to know what works in the realm outside of acute life or death scenarios. We need to be able to figure out which interventions are best for patients when we look out months, years, or decades. This is exceptionally hard and in certain circumstances perhaps not even possible no matter what technology we deploy.

Our confidence in the health care industry is to a substantial degree still living off the momentum created by the almost magical accomplishments in acute care setting that have occurred in the past century. It reminds me a an Arthur C. Clark observation.
Any sufficiently advanced technology is indistinguishable from magic. Arthur C. Clarke, "Profiles of The Future", 1961  
There is no question that we are still are amazingly good at dealing with acute care situations where we can deploy technology which has the semblance of magic. It is questionable whether accomplishments in this realm should translate into confidence in medicine's ability to intervene and make meanigful impact in a more distant time frame.




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