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Wednesday, September 16, 2009

Ignorance is bliss

The longer I practice medicine the more I am struck with how strange the delivery of patient care has become. I believe the driver of this strangeness is rooted in a fundamental ambiguity as to what missions physicians are trained to achieve.

What are we as physicians supposed to do? What are the nature of the problems that we are trained to address? What interventions we perform or direct are of greatest benefits to the patients we see?

In order to address these questions, it is best to examine what drives patients to seek the care of a physician. Despite the fact that Americans have over one billion physician visits each year, we have limited detail on the specifics of what patients aimed to accomplish. Despite lacking data on specifics, it is reasonable assume that visits can fall into certain broad categories. Problems may acute or chronic, involve single or multiple organ systems, be associated with high or low stakes, marked or minimal symptoms, and may be readily amenable or not be amenable to specific interventions. The matrix of possible combinations is huge.

The ability to effectively deal with a patient who presents with any one of the many possible combinations is a product of training and experience. It is not possible that any single physician can be competent in managing all the different possible combinations. That reality is a driver of the movement toward specialty care.

The movement toward specialty care has created opportunities and choices for physicians. Because physicians cannot acquire all the knowledge and skills required to manage all the possible combinations, they must decide what not to learn and in what realms where they will not maintain competence. This is where problems develop.

In the present practice and training universe, what types of competencies are most attractive for physicians to acquire? The incentive matrix which drives these decisions is almost as complex as the matrix which defines patient disease characteristics. Attractive problems/scenarios include defined, correctable problems whose solutions are highly remunerated. The flip side of this equation are the tasks which focus on the management of "wicked", chronic, complex medical problems. Even before factoring financial rewards (which are limited for addressing such issues), it is not unexpected that physicians would tend to avoid acquiring the specialized skill sets required to manage such problems.

What falls into this bucket of complex, chronic care? These problems are open-ended, manageable but not curable, uncertain in terms of course and response to treatment, and time consuming to manage. As the population ages, these are common scenarios. The question is where is the downside for physicians in cultivating incompetence in terms of managing these types of problems?

It reminds me of an article published in the WSJ a few years back. I have pasted the introduction below. The full article can be found at the link below.

The Art of Showing Pure Incompetence at an Unwanted Task
by Jared Sandberg
Friday, April 20, 2007provided byWSJ

To learn something at the office can be difficult. But to refrain from learning something requires years of practice and refinement.

It's an office skill that Steven Crawley finds indispensable. "The inability to grasp selective things can be very helpful in keeping your desk clear of unwanted clutter," says the executive in HR, or what he calls "the dumping ground" of all unwanted office tasks. "I have developed a very agile selective memory across a wide range of nonvalue-added activities."

Thus it appears that many of the most valued tasks in terms of delivering value to patients have been placed in the dumping ground of unwanted tasks.

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