[NPInfo] Superb reading

[David Mittman]

I would venture to say that this physician has explained why NPs and  
PAs are the success we both are.
We are not looking for zebras, generally- just some horses galloping  
around.
Dave

Training Daze
Why do doctors fixate on diagnosis, not treatment?
By Darshak Sanghavi, M.D. (pediatric cardiologist and assistant  
professor of pediatrics at the University of Massachusetts Medical  
School)

http://www.slate.com/id/2186446/7

When doctors are freed from commercial pressure, how well do they  
perform? We've grown accustomed to scapegoating pharmaceutical  
companies for health-care ills—consider movies like The Constant  
Gardener and the recent New York Times Magazine exposé by a  
psychiatrist paid by drug makers. The implication is that if left  
alone by money-grubbing drug companies and health insurers,  
physicians make the right decisions on behalf of their patients.

Not so fast. It turns out that improving the quality of health care  
has only a little to do with drug companies. Their influence is a  
symptom of a deeper underlying pathology. The real trouble is that  
doctors—somewhat paradoxically—are simply not focused on actually  
treating disease.

A key indicator of this problem emerged last October, when a team of  
researchers led by Rita Mangione-Smith reviewed children's medical  
records from 12 major American cities and found that fewer than half  
of children got the correct medical care during doctor visits. The  
researchers asked basic questions such as these: Did doctors properly  
inform mothers to continue feeding infants who had diarrhea? Was HIV  
testing offered to all adolescents diagnosed with a sexually  
transmitted disease? Was a follow-up visit scheduled after a child's  
medication changed for chronic asthma? These were all simple things  
doctors should have been doing yet weren't. (A similar study of adult  
quality of care was published in 2003 with similar results.)

This seems absurd. Physicians are some of the most hypereducated  
professionals around, with eight years of higher education, followed  
by three to 10 years of residency and subspecialty training over  
thousands of hours. They also must pass some of the most exacting and  
complex licensing exams ever written, including at least four  
separate tests requiring weeks of dedicated study to achieve board  
certification. And yet, according to studies like Mangione-Smith's,  
most doctors in practice don't pass muster in administering optimal  
care for elementary conditions like infant diarrhea. What is going on?

There are at least two explanations. First, clinical training in  
primary care—including pediatrics, internal medicine, and family  
practice—excessively focuses on the diagnostic hunt rather than the  
more routine rounds of treatment that follow. It's tempting to think  
that most doctors are detectives nailing baffling diagnoses, like  
Hugh Laurie's character on House. In part, this view of medicine  
accounts for the success of Jerome Groopman's book How Doctors Think,  
which explores how wrong diagnoses occur. In almost every educational  
venue—from morning teaching sessions for residents to the weekly case  
conference featured in the New England Journal of Medicine—medical  
trainees spend hours learning about how to diagnose rare ailments.  
And then, abruptly, discussion ends, as though treatment were an  
afterthought.

The not-so-subtle subtext: Medicine is about the exciting search for  
a diagnosis, and any old doctor can write a prescription once the  
real work is done. This same bias pervades insurance rules. To be  
paid at the appropriate level, physicians must exhaustively document  
all sorts of irrelevant diagnostic data—such as a rectal exam in  
toddlers seen for a comprehensive asthma evaluation—rather than the  
rationale for the treatment they prescribe.

On a separate but related front, medical education today fixates on  
acquiring knowledge that is largely unrelated to patient care.  
Consider the college prerequisites to attend medical school (for  
example, physics and organic chemistry) and the morass of molecular  
biology, anatomy lessons, and pharmacology that follows and must be  
committed to memory. Of course, a general foundation is important.  
However, the sheer abundance crowds out an important—in fact, the only 
—skill that matters in treating a patient: how to critically appraise  
published clinical trials. Few doctors ever read them. In effect,  
medicine has become a priesthood of practitioners who never review or  
learn to interpret the Bible to minister to their flock; they instead  
rely on secondhand wisdom. Or, worse, on Google.

That is why, for example, the average internist can describe the  
branching patterns of the major coronary arteries but not the primary  
clinical trials assessing how much, if at all, various cholesterol- 
lowering agents cut heart-attack risks. Or, for that matter, whether  
the trials were soundly conducted. Yet in real practice, diagnostic  
puzzles are rare, and knowing the molecular basis of an illness does  
little good. Instead, children see pediatricians for ear infections,  
diarrhea, and attention-deficit disorders. Adults see internists for  
high blood pressure, diabetes, and chronic pulmonary disease. Filling  
the training vacuum, an unregulated, for-profit industry of  
information peddlers is emerging to interpret clinical trials and  
guide treatment.

These groups essentially write CliffsNotes for doctors, and their  
influence on medical care cannot be overstated, though it's largely  
invisible to consumers. The most widely used service is UpToDate.com,  
a private-equity-backed, subscription-only Web site that, according  
to some research, is accessed by half the clinicians at hospitals  
affiliated with Harvard Medical School at least five times a week.  
Eighty-seven percent of U.S. teaching hospitals subscribe to it. On  
the site are thousands of recipelike entries on everything from  
toddler ear infections to drug therapy for heart failure.  
UpToDate.com has become the cookbook for medical treatment. No  
professional primary-care medical association, like the American  
Medical Association or American Academy of Pediatrics, has created  
anything like it.

To its credit, this site is subscriber-funded and refuses  
advertising, unlike rival sites like Medscape and eMedicine. But  
there's no guarantee it'll stay that way, especially if it is sold or  
goes public. And while the overall quality of information is quite  
good, the treatment guidelines tend to favor medications over  
modifying behavior and lifestyle, are not vetted by any government or  
other professional association, rely a lot on the personal views of  
the one or two authors of each recipe, and rarely include any cost- 
benefit analysis. Fundamentally, by neglecting treatment, doctors  
have outsourced it to private contractors who don't answer to any  
authority. (This is why drug companies can launch misleading  
marketing campaigns without a unified voice arguing on the side of  
the data.)

Even if perfect treatment guidelines were to appear magically, it  
takes a lot of work to teach doctors to follow them. Consider ear  
infections in children, which are vastly overtreated with powerful  
antibiotics. In 2000, a group of Boston researchers created an  
ambitious three-year program (using sociological methods used by  
missionaries to score religious converts) to educate local  
pediatricians about proper ear-infection treatment. They explained  
how to talk to patients, control symptoms without antibiotics, and  
create educational handouts for patients. They taught doctors what  
they should have learned in medical school and, as reported in  
Pediatrics this year, substantially cut antibiotic use. The only  
sticking point is that it all took a big investment of time and money.

Treatment neglect has big consequences beyond ear infections. Medical  
errors may claim almost 100,000 lives each year, often from basic  
skills like poor handwriting on prescriptions. In her book,  
Overtreated, Shannon Brownlee explains how ignoring treatment has led  
to odd discrepancies in medical care; for example, some towns in  
Vermont had tenfold higher rates of pediatric tonsillectomy than  
others, despite having the same kinds of patients.

Refocusing doctors on actual treatment, instead of pointy-headed  
diagnostic puzzles, will take serious effort. In the meantime,  
patients should ask a simple question: "Can you describe the evidence  
for my treatment?" For better or worse, the answer will tell you a  
lot about the care you're getting.