Two things stimulated the thoughts that follow.
The first was comments made by Dr. Jerome Groopman in the first chapter of his new book " How Doctors Think" when he opined that clinical algorithms (I tend to place algorithms and guidelines in the same conceptual box) fall apart when physicians need to think outside the box and (I would add) when the framing up of an ambiguous clinical situation needs to be done. His concern was that current house officers are so guideline and algorithm oriented that perhaps that the outside the box,creative, independent thinking region of their brains may be at risk for atrophy.
The second was observations from a "CME" dinner talk about diabetes (one that was not given by Joslin).It seemed that all of the questions hinged on how to get a patient to "goal". It did not seem to be at all about tailoring the treatment to the patient or really treating the patient at all but it was about the getting the numbers right. I wondered what even happened to old house office motto of " treat the patient not the numbers".
It seems to be all about number now. the numbers of the statistics of the clinical trial, the numbers that committees set for goals that should be achieved,the number of hours in which antibiotics must be given to reach a quality goal for treatment of community acquired pneumonia,the number of minutes a physician is allotted per patient, the likelihood ratio regarding a diagnostic test. Groopman said it well:
" Today's reliance on evidence-based medicine risk having the doctor choose passively,solely by the numbers. Statistics cannot substitute for the human being before you; statistics embody averages, not individuals."
Only a thinking physician in collaboration with the patient can determine if the "best therapy from a clinical trial fits a patient's particular needs and values"
Observing house officer on round lead Groopman to the following conclusion:
" ...the next generation of doctors was being conditioned to function like a well programmed computer that operates within a strict binary framework."
Is that valid?
The emphasis on guidelines and algorithms fits in nicely with those whose vision of medical care includes a major role for "mid-level" practitioners.(This is a interesting term.Note we do not say lower level practitioners.Who would want their medical problem assessed or treated by a lower level practitioner? If PAs and NPs are mid level, for what type of practitioner would we use the term "low level"practitioner?).
The guideline-algorithm mentality also may suggest the idea of a physician as an exchangeable commodity.Dr. Stuart Henochowicz , whose whose interesting blog is MEDVIEWS, defends the position that doctors are not commodities in a recent Medscape interview.
