Why is Medicine so Primitive?

The practice of modern medicine is surprisingly primitive.  My doctor only recently started to provide printed prescriptions instead of the usual scrawl.  Incorrectly filled prescriptions can be serious and computer printed prescriptions are an obvious response yet even today only one in four physicians use some form of electronic health records and only one in ten really use electronic records to follow a patient’s entire history.  My credit card company knows far more about my shopping history than my physician knows about my medical history.

Medicine is primitive in another way.  The number of treatment regimes supported only by tradition and authority is very high.  Here’s a recent example:

For the past 30 years or so, doctors have routinely given pregnant
women intravenous infusions of magnesium sulfate to halt contractions
that can lead to premature labor.

…[a] team reviewed 23 clinical trials worldwide involving 2,000 women who
had received the drug to quell contractions. They found that it did not
reduce preterm labor and that more babies died when their mothers took
the drug than in a control group where the mothers had not been given
it.

…Grimes and Nanda estimate that about 120,000 American women receive mag
sulfate each year for premature contractions, and they say some
evidence suggests it may be associated with 1,900 to 4,800 fetal deaths
annually in the United States.

This would be a shocker except for the fact that stories like this are common – by some accounts a majority of medical procedures are not supported by serious scientific evidence.  Indeed, what are we to make of a profession where evidence-based medicine is only a recent and still far from accepted movement?

Why is medicine so primitive?  One reason is that medicine is the largest area of the economy still dominated by artisanal production.  I will be blunt: We need assembly line medicine, medicine that is routinized, marked and measured. As I have argued before I would much prefer to be diagnosed by a computerized expert system than by a physician. The HMOs, Kaiser in particular, have done good work on measuring the effectiveness of different procedures but much more needs to be done to bring medicine into the twentieth century let alone the twenty first.   

Comments

How dare you question practitioners of a field without yourself being in that field? /sarcasm (reference to Caplan's paper on mental illness and the reactions thereto)

The problem is that the physicians (or any other single group) just do not own or control enough of the process to make end-to-end computerization worthwhile.

If you really want to use an industrial process, maybe someone can point to a company that has successfully implemented end-to-end enterprise resource planning successfully. There are many more stories of failures in ERP than success. Why would medicine be any different?

Alex,

You wrote: "I would much prefer to be diagnosed by a computerized expert system than by a physician."

It may well be the case that YOU would be better diagonosed by a machine, but I would argue that this is because you are such an admirably rational chap. The problem is that there are lots of people who are so introverted and/or warped that their best hope is to develop a trusting relationship with their physician that facilitates their being transparent about their problems, history, and life style choices. Don't forget Alex that we are social animals; a good physician is like Sherlock Holmes unraveling a mystery in these cases; a machine could have solve few, if any, of the cases the Holmes (and Watson) unraveled.

So announce your view that "I would much prefer to be diagnosed by a computerized expert system than by a physician" again, and again, and I will agree with you every time, for YOU that is.

"Medical malpractice attorneys like to claim that they are the only check on poor doctors and bad medical practices, yet the industry also has a hand in preventing effective use of other quality enhancing methods."

Sounds very similar to the effect of Sarbanes-Oxley on the financial industry. You'd be amazed at how many technologies and quality improving things are eschewed just because they enhance the ability of future litigants and/or SEC investigators to misconstrue something or expose the firm to undesirable and pointless litigation. SOX protects investors by decreasing shareholder wealth.

Medicine in many cases is best seen as a social ritual that brings comfort, rather than a set of biological interventions that bring about therapeutic results.

Indeed, the degree to which the social ritual brings comfort is responsible for a large component, perhaps the major component, of its therapeutic effect -- the placebo effect. This makes me question whether treating medicine as an "industrial process" is likely to succeed, or is even desireable. There is some debate as to whether the placebo effect improves objective outcomes (ie - can cure cancer) but most medical treatment is used for chronic conditions as a sympomatic relief -- and there is no doubt of its effectiveness there.

Of course there are interventions that are necessary and effective, but tough to know exactly which ones.

BTW, I'm somewhat upset to hear the specifics about magnesium sulfate therapy. They put my wife on it for our first child. Her pressure crashed after delivery and she almost died, wonder if it was from the mag sulfate. . .

You want to read "The Score" by Atul Gawande in last week's New Yorker (http://www.newyorker.com/fact/content/articles/061009fa_fact). It's a fascinating study of the change in medicine (Caesarians) due to the introduction of metrics. (The Apgar score quantifies the status of the newborn, giving doctors something to shoot to improve. Use of the forceps can't be taught, it's a craft, while the Caesarian can be taught.)

Matt: your comment seems awful harsh considering this is an economics blog. Economists are certainly closer to auto mechanics (diagnosing what went wrong or right after the fact) than scientists (using experiments designed to avoid bias). They also often seem willing to denigrate the non-licensed class of "armchair economists." And just like your doctor, they probably are right that their training and experience gives them a leg up in diagnosing problems. Sometimes this is correct, but it should not be used as a cudgel to discount or dismiss opponents to the conventional wisdom.

Also for Alex: since medicine is lagging as primitive, where would you rate the field of public health? They certainly have been taking a lot of flack from the right this week (with the Lancet article), but public health interventions have far more proven results than most medical treatments...

I second what Dr. Tom has said above.

Medical practice is very much a "cottage industry" or artisan business if you like. This makes implementation of EHR or other uniform systems very difficult. Add to that the daily time and money pressures and modernization is very difficult.

As far as diagnosis, I prefer a real human physician, who can spot physicial, social and emotional aspects of my condition that computerized lab tests never could. Internist and family docs are absolutely amazing much of the time for their ability to pull together a great deal of data in a big hurry and be right.

And of course human behavior drives much of of health system (quit smoking, eat less, exercise more, etc.).

Oh, in relation to the explanation of the disparity between Grimes and Nanda's estimates and the study; I don't want you to tell me that its only a 95% confidence interval, so there is a 2.5% chance that it is below that. I know the results are conveivably consistent. It would also be conceivably consisent if G&N were claiming that magnesium sulfate *saved* lives. But if the real number of fetal deaths from mgso2 were 5k, the implication would be that there was a serious error in the methodology of the 1998 study, so that study could not be used to *support* the 5k estimate. I think that explains why I am puzzled

The New Yorker article by Gawande is highly recommended. It illuminates 'process' and why medicine changes to X and not Y. Or doesn't change.

Topher provided a link - see above.

I suspect the best way to improve medicine is great training and better conditions at the second level - nurses, paramedics, techs, and even the billing and insurance staff.

And availability is important. If a surgeon moves to Beverly Hills and will only do breast implants for thirty years it doesn't really matter if he scribbles the presciptions, he is not 'available' as a physician in any meaningful way.

I agree with "Matt" - that physicians are less scientists than they choose to believe.
Since physicians co-opted the term "doctor" from academics such as (dare I say) economists,
I say we respectfully ignore the point made by "Dan K" and take back the title.

-Drew

One reason for the primitive state of medicine is that patients are in a poor position to evaluate the true quality of the care they received. This sounds stupid, of course; after all, you can tell whether you are sick or well, and you can tell whether a particular ailment has been cured or not. But generally there is no way for an individual patient to know whether a particular procedure was necessary or was performed merely from custom or to pad the bill. Suppose a doctor gives antibiotics for a viral infection, and the infection clears up; we are likely to give the doctor credit. Or a fetal monitor shows an elevated heartrate and a C-section is performed; we tend to believe that the procedure was necessary, and most people will believe the doctor performed a life-saving operation.
Consider that a vast number of alternative practitioners, from aromatherapists to foot reflexologists, are able to stay in business by convincing their patients of the merits of treatments which must by and large be useless. Some of the processes of modern medicine are in the same class, and they have the additional cachet of being part of the approved edifice of Medical Science as Approved By The AMA. Confirmation bias will work to maintain the illusion of effectiveness.
Unfortunately data gathering by itself won't solve all problems, since in many cases only short-term outcomes are considered and subtle long-term downsides would be overlooked. For example, Vitamin K supplementation for newborns has been shown to prevent a number of deaths from VKDB, but aside from some leukemia studies no one has attempted to see whether there are long-term ill effects of this procedure.
Many of these problems could be addressed by datamining a sufficiently large database of complete medical histories. Some large drug companies, such as Pfizer, have terabytes of patient data that could be used. Given the potential for liability in cases where existing procedures were shown to be detrimental, however, I expect that the data will remain private.

VA hospitals have done good work on computerization.

Prof. AT,

Part of the reason for the scrawl may be that MDs do not want many patients to decipher the prescription instructions†¦.not because they are hiding anything but rather to add to the mystique.

There is so much that is unknown about human health and function. The evidence-based approach would not address the psychological function/role that today’s medicine plays. We pay for the theatrics because we want the attention and sense of security that it provides. The medical community/clique charges for it because demand is present.

Medicine and God are our only protections against the unknown. We are less entranced by the latter but pay more for the former.

If the Kaisers of the world do become the norm, where will we seek the love and nurturing?

In the late 60s and early 70s there was much enthusiasm for automated diagnostic facilities, based on an unwise extrapolation of the power of early lab testing. So your sentiments have a rich tradition.

There are two parts to your "primitive" complaint. They are quite different.

In terms of clinical trials, medicine has been far ahead of ... say ... economics. The experimental designs of clinical medicine were well established when sociologists and economists persistend in weak case-control studies. The problem, alas, is that we can't clone a hundred humans, experiment on them, and sacrifice half. Human experimentation is very, very expensive and very problamatic.

Your other complaint was healthcare automation. That is my job, I've spent about 20 years on various aspects of this. You cannot begin to imagine how hard this is, particularly in the US. If you were to try to relate ICD-9 codes to SNOMED concepts you'd get the faintest whiff of the challenges. Many great names in American automation, from Lockheed to IBM to Boeing have entered this domain with great confidence, only to slink away shattered wrecks. We are making progress, but it's trench warfare. Physician resistance is the least of our problems, in my experience physicians are often keener than they rationally should be.

The biggest problem, unfortunately, is that the economics of healthcare are screwy. There are almost no economic advantages to physician automation, and many economic disadvantages. Physicians who automate are often making semi-charitable contributions, at the least they forsake more profitable investments. In domains in which the economic vectors are aligned automation is fast and relentless. A visit to a radiology department will be enlightening.

Agreed, drastic change is needed and it's not likely to happen due to the entrenched practices of the field. HMOs haven't been able to induce more rationality. In fact, the only way I see change happening is from single-payer health care. That may be sacrilege here, but just as the government was the only one able to support good network standards (comapre Internet to the old dead proprietary systems like Compuserve) it may be the only institution capable of forcing a change in health care practice.

That or Wal-Mart.

save the rustbelt - you've bought the AMA's line dating from the Flexner Report era about proper training hook, line, and sinker. See for example, Organized Medicine in the Progressive Era by James Gordon Burrow.

When my mother was an RN for a GP, she did most of the strep diagnosis (swab, putting the samples in the incubator, analyzing the results) and gave it to the doc. He then confirmed it, and she called in the Rx. Physician time: 10 seconds (if that) to confirm what someone with much less schooling (though considerable experience) could tell. Cost of materials: $0.25 (late 70s, early 80s). Cost of visit: $40. You don't need a full-blown physician for everything they would like you to think you do.

Of course, now that the profession controls entry and licensing, the AMA is less important. They did their work, and the barriers to entry are firmly in place. It's slow and expensive by design, and mostly unnecessary. Now a knee operation I'll grant you is different, but 80% of what people pay doctors for is the result of good cartel control.

>There are more failures than success in ERP?
In ERP installations, there is usually a mismatch between 3 things: the documented work process, the way the (mis)managers think/say the work gets done and the way the work *actually* gets done. If you implement only one of the 3, then you waste vast amounts of time and money. This is why companies can spend a hundred million dollars on a failed implementation of an ERP system, or why the FBI wasted even more money on a failed case management system.

Franchise systems work well because they minimize the gap between the 3 things. And the more successful a franchise is, the smaller the gap between how it is done around the corner versus how it is done on the other side of the planet - the key to success for McDonalds.

Getting back on subject, I am also reminded of the first 100 years of the AMA, where they claimed that food had no effect on diet, and it was "quackery" to suggest otherwise. Then, starting in the early 70s, as the evidence of cholesterol finally built up to inescapable levels, they admitted that diet *does* have an effect.

Or how ulcers were, for decades, treated by expensive medicines that could have been cured by a small handful of antibiotics. I suspect that the pharmaceutical companies knew this, but preferred for patients to spend $150/month on "lifestyle" drugs rather than $20 on antibiotics.

And now, it looks like Cervical cancer (and penile cancer - rare among the circumcised) can be prevented by a vaccine against HPV. There is some evidence that an adenovirus may be linked to obesity.
http://www.scienceblog.com/cms/contagious_obesity_identifying_the_human_adenoviruses_that_may_make_us_fat_9901

I'm now wondering, just *how* *many* diseases and syndromes are caused by some infection or another. All of them? Most? Some? A few?

I used to work for a company in the business of handling electronic prescriptions. And at that time, there were about 150 pairs of drugs with similar names that did wildly different things.

The FDA was originally established because the general population wasn't capable of determining the health and efficacy of drugs, and because Sinclair's The Jungle was so gross. That process has been manipulated and perverted, first by the tobacco industry, and now by the PR industry. Books like "Trust Us, We're Experts" go into details of how science has been derailed and perverted in the name of corporate profiteering.

Like StevenSC (one of the above posters) puts it, autopsies are almost nonexistant. If it were up to me, every death would result in an autopsy, and one of the things I'd have them checking would be "lifestyle" issues such as obesity, arterial plaques and looking for those plaques related to alzheimers. If people in the future want to live to be 200+, we need to know what we're doing wrong now - and do *less* of that; and what are we doing right - then do *more* of that. We can't do that without accurate feedback.

I'm in Kaiser (have been since 1992, in three different places) and have been very satisfied both with the quality of care and with the human interface (except for the telephone service). But I think it is misleading to group Kaiser, a non-profit care provider, in with other HMOs who are insurance companies contracting for care with a large number of practitioners. The incentives are entirely different -- for instance, the matter of computerized records, available to everyone on staff. The use of nurse practitioners where appropriate. Direct entry of prescriptions to be filled at the inhouse pharmacy. In other words, characterized by a number of features previous commenters think should happen but never will. They do.

Teaching science is a lot more difficult than teaching doctors to memorize. There's no evidence that the people selected into (or selecting for) medical school have any idea how to pick scientists; they haven't yet tried. So modernizing medicine isn't going to happen until people feel they need a scientific alternative.

But the most likely reason medicine is so primitive is because generally speaking, most people get healthy on their own--and if they didn't, humans wouldn't exist. The few people who get sick want treatment, not science. I.e. they want attention, in some form. All of the ways to reduce errors reduce what little human attention is present. People are as happy with a variety of witch docs as they are with med docs--from chiropractors to crystal danglers and herb eaters, etc.

anonymous,

Everyone who practices a trade works on certain make/model/system. Physicists don't work much with plants, geologists don't work on cars, and writers don't build cars.

Do you want a list of available tests that docs can order? Most of us understand the scientific method. Granted, few of us who spend 8+ hours per weekday seeing patients spend much time in a lab. There are only so many hours in the day. There is a subset of us who spend the vast majority of their time in the lab or evaluating studies.

Medical schools spend a decent amount of time trying to figure out what type of person is the best candidate to get into medical school. They want to pick folks who will finish, do well on board exams, get into good residency programs, and (minority of the students) do some research.

Do you have any data to back up any of your contentions?

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