Everyone is a Stakeholder in Medicine
By Hans Duvefelt, M.D.
Everybody is a stakeholder these days in what we broadly call medicine, or health care. But there is little agreement on what medicine is and what the priorities of the health care “industry” should be.
I propose this breakdown of medicine into three separate phenomena.
Let me explain:
Micromedicine: one on one, real doctoring
Doctors from antiquity have served their patients one on one, as individuals. Osler, the father of modern medicine said: “It is much more important to know what sort of a patient has a disease than what sort of a disease a patient has.”
My generation of physicians has seen the individualized care of patients fall from grace in favor of seeking the lowest common denominator for a particular medical problem. Hypertension treatment, for example, was tailored to the “phenotype” of each patient: A high strung or Type A patient would get put on a beta blocker when I started out in Sweden, even though my American pharmacology text, Goodman & Gilman, pretty much dismissed beta blockers for hypertension. We knew better. A patient with overweight and edema would get a diuretic. When ACE inhibitors came along and did well in some randomized control studies, everybody suddenly ended up on them, regardless of what else was going on with them. That is still the party line, at least in the United States.
Micromedicine is concerned with accurate diagnosis, individualized treatment, and patients’ values and priorities. It doesn’t matter to the individual patient if one type of blood pressure medication generally performs better than another if that patient’s blood pressure is elevated because of undiagnosed hyperthyroidism, alcoholism, coarctation of the aorta or a pheochromocytoma.
Micromedicine considers the average but never assumes that averages dictate action in individual patient encounters.
Macromedicine: population management
At the risk of offending some of my colleagues, I hereby declare that Population Management is reductive, simplistic and beneath physicians to spend their career on. It is a skeleton framework best handled by paraprofessionals. It is the broad strokes view from 30,000 feet, useful for policymakers and actuaries, but useless for individual doctors and patients in the exam room.
Macromedicine is all about averages. It is JNC blood pressure targets, Hemoglobin A1c targets, use of aspirin and statins, immunizations and bone density screenings.
In case anybody needs me to justify myself, a very low blood sugar in an eighty-year-old patient can result in a fall with a hip fracture. Aspirin use was recently a good thing, and now it isn’t a good idea for most people. That’s how fickle the mistress of Quality Population Management can be. And don’t get me started on Lipid targets, the bane of our existence until the revised 2013 Lipid guidelines, and still a thorn in our sides because old habits die hard, especially among the less educated in our field.
Unfortunately, much of our time and effort in the office, those precious fifteen minutes with our patients, is spent on public health issues that even a nursing degree is superfluous for: If everyone should be offered a flu shot in the fall, you don’t need medical professionals to offer it. We can answer questions and reinforce the message, but it is a waste of our time to make us the primary promoters of such things.
Macromedicine is concerned with the masses, not infrequently at the expense of individuals that don’t seem average.
Metamedicine: the parallel universe of non-clinicians
Pharmacy benefit managers, prior authorizations, ICD-10 codes, EMR vendors, meaningful use, maintenance of certification — sometimes it seems that these non-clinical entities and considerations rule our lives, drain our energy, instigate burnout and overpower the fundamental motivations of physicians to help their patients.
I call all these things metamedicine. The word is analogous to the metadata that is recorded on websites and on our computers, like tracking codes, cookies, and even (invisibly) parallel to the music we listen to in the form of grace notes.
Metadata is necessary, but it shouldn’t overshadow real data; no amount of metadata can replace the value or experience of actually looking at a Da Vinci or listening to Beethoven.
Metamedicine means money unrelated to the patient visit. It means profit for middlemen. It means clutter in the diagnostic and therapeutic encounter. It is not the heart of the matter. It means measuring that which is easy to measure. It means satisfaction surveys and cycle times, it means cherry picking the easier cases to achieve better statistics; it means viewing patients as mere numbers.
Metamedicine is less concerned with patients and more with the data itself.
“A Country Doctor” is a family physician who blogs at A Country Doctor Writes:.