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Medicine Is Not Rocket Science

July 18, 2009

Messieurs Nelson and Stelzer explain what Obama’s plan “to move the U.S. health care system to broad adoption of standards-based electronic health information systems, including electronic health records” entails:

When up and running the IT system, we’re told, will reduce hospital stays, avoid unnecessary testing, require more appropriate drug utilization, and garner other efficiencies. But no “system” can do that. All it can do is provide central controllers with the information to enable them, instead of your doctor, to decide just how long you should be allowed to recover after surgery, whether you might be permitted to have the tests needed to make that decision other than by using broad statistical averages that ignore individual patient differences, and which medications are appropriate for you.

Sound extreme? Consider this further promise of the Obama organization: “Barack Obama and Joe Biden will require that [disease management] plans that participate in the new public plan .  .  . utilize proven disease management programs.” Patients suffering from diabetes, heart disease, high blood pressure, and other chronic conditions will do it the Obama-Biden way or else be excluded from insurance coverage. And decisions about whether this is good medicine or not will be facilitated by the IT system, which, in the unlikely event that it works, would enable your doctor–and the system’s managers–to find out all about you by pushing a button. The judgment as to what to do by way of treatment will, alas, be made by people you have never met but who nonetheless can decide whether what your doctor recommends should be covered by insurance or is wasteful or contradicts the findings in the latest statistical study, perhaps reflecting the results of a small statistical sample of patients in Norway.

This is exactly the problem with attempts to standardise health care: human bodies each have their idiosyncrasies, there is no such thing as a one-size-fits-all therapy. Everybody who has ever taken an aspirin against a headache knows what I’m talking about. Sometimes the medicine works, sometimes it doesn’t. Some tab works great against your migraine, but not so much against your sister’s. Your neighbour swears by ibuprofen, you get digestive problems from it. But your neighbour’s reaction might be consistent with that of 78% of the 126 patients who filled out a questionnaire after a controlled experiment by an Australian clinic 12 years ago. Yours might be consistent with the 2% of those patients who checked the “I get gastrointestinal problems from it” box. Alternative drugs that may not cause side effects in you may not be offered by the health system because they are more expensive and only 2% of patients are expected to prefer them anyway.

Beyond unpredictable organic differences there are also differences in personal preferences. The patient should always have the option to chose one type of therapy over another even if he has no better reason than an emotional penchant for doing so. The same holds true for methods of examinations. Sometimes the most efficient method in financial terms isn’t what the patient wants to have done. The patient should be allowed to call the shots instead of being run through an assembly line of examinations, half of which may not make sense in his individual case in the first place. It’s bad enough to be ill, unnecessary examinations or decisions made over the patient’s head only add to the burden.

Then there’s the factor that medicine isn’t a finished chapter of science. Many, many, many diseases are still rather mysterious to doctors and new findings will demand adjustments of therapies and even of diagnoses. Treating pathological symptoms as if they were all fully decoded will necessarily lead to a dead end in the development of medical improvements. Consider underdiagnosed diseases, for instance. They will stay underdiagnosed under a ‘standardised’ system because such a system will, by definition, take a certain state of knowledge as its basis and lay out guidelines on how to proceed in which type of case from there. Those rules will not be any more flexibly adjusted to scientific discoveries as they will be to individual needs, that is to say hardly at all.

Besides, experimentation and the ability to compare methods are an important part of improvements in medical treatments. Think about the immense diversity of doctors in your country and how they would not all treat a given case the same way. Ultimately, medicine is about what works (President Obama should be familiar with that concept since he keeps on applying it – in theory – on government). An attempt to standardise treatments will result in eliminating all but the method that statistically works best at the point in time at which the system is set up. Yet ‘best practice’ is not a constant. It gets improved over time through experimenting with alternatives. The one-size-must-fit-all system will eliminate or at least hamper experimentation.

Read Messieurs Nelson and Stelzer’s entire piece to learn what a nightmare the British health system is which is the live form of what Obama has in mind for the American system.

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