Annie [above left on the day she arrived] was a retirement present from my practice partners . Her first friend, Studly, [above middle] lives down the road, but eats and sleeps here [going home for the odd holiday]. Woofie, above right, showed up after a year or so as a stray, taking up full time residence after being shot in the chest [mistaken for a Coyote we think]. Annie has an electric fence encircling about an acre of our property because she is just not highway·savvy, while the other two are free range denizens of the hood. Annie waits patiently at the edge of her domain while the boys go on their morning and evening walk-abouts.
Thirteen years have passed, and things are a little different now. Annie has bilateral hip arthritis, and [untreated] lays around moping. But she can return to her old frisky self with a single dose of aspirin a day. It’s remarkably effective, but getting her to take it is another matter entirely. She often turns her nose up at the liver flavored Nutri·Vet doggie aspirin, even when sealed inside of a Greenie [a pill pocket designed for such purposes]. So over time, we’ve learned that:
if: we don’t feed the dogs automatically in the morning
and if: we wait until Annie starts lobbying to be fed [by head butting my leg]
and if: she hasn’t seen me preparing the aspirin bomb [broken up pill sealed in the Greenie]
and if: we give her the bomb slightly reluctantly as a treat in response to her demands
then: she sucks it down with relish
and then: we feed the dogs
Any break in the chain, and we’re in a forced drugging situation [not conducive to good inter·species relations]. forced drugging is okay for a one shot heartworm pill or maybe a short course of medication like antibiotics for a discrete illness, but not for everyday meds. So every morning, the background issue around here is "Has Annie been bombed?"
Little question that this is a story about how old people spend their time and about my lifelong attachment to dogs, but I have another agenda in the telling. In medical school and during the first part of an Internal Medicine residency, I think I had an algorithmic view of medications. This medicine is for these things. And that medicine is for those things. This is the dose for this med, etc. But then then came the clinical part of my Fellowship with our Rheumatology Group. Since many of those diseases are of unknown etiology, and the treatments are often empirical, things were very different:
based on, concerned with, or verifiable by observation or experience rather than theory or pure logic…
At first I thought I’d fallen in with a bunch of lunatics. On rounds, we’d spend forever retaking the history and repeating the exam. Then we’d retire to the ward conference room and have a long discussion about treatment, and about what parameters we’d follow to judge the effect of the treatment, whatever it was [and sometimes it was nothing, as in benign neglect]. I was used to the speed-dial ER mindset, and this seemed like a lesson in what it was like to have OCD in a war zone. Every treatment was a therapeutic trial [emphasis on every]. With every medication trial, we were seeking a therapeutic window in terms of dose. But after a time, I came around to see the wisdom in that way of thinking. We were using medications on the toxic end of the spectrum with crippling chronic diseases and the only solid proof was in the unique response in any given patient. It was a good lesson for all of medical practice. I never got over that way of thinking [and never plan to]. When I got to psychiatry, it was a natural fit [unknown etiology, significant toxicities, chronic course, proof in individual results, benign neglect option, etc].
Back to Annie. This aspirin choice came after trials with several other anti·inflammatories [GI problems] and some concoction being pushed by our vet called Zoom [poor results]. With the aspirin, ½ an adult aspirin worked [~160 mg]; a baby aspirin didn’t [~80 mg]; so on to the 120 mg doggie aspirin which also worked – at least for now.
While this little tale of Annie’s treatment has an obvious moral-to-the-story
, its moral only really works in a Marcus Welby, M.D.
world [Marcus Welby was a long-running television program about a doctor who devoted 24/7 attention to the patient of the week, with no other apparent cases or duties] – a world in which every case is an Annie
. In case it’s not clear, my topics here are modern medical practice
and treatment guidelines
– obviously too big for a single post [maybe too big for a single blog]. But here’s a viewpoint piece from the JAMA that frames some of the issues:
by Donald M. Berwick MD
JAMA. 2016 315:1329-1330.
Constant conflict roils the health care landscape, including issues related to the Affordable Care Act, electronic health records, payment changes, and consolidation of hospitals and health plans. The morale of physicians and other clinicians is in jeopardy. One foundational cause of the discord is an epic collision of 2 eras with incompatible beliefs.
Era 1 was the ascendancy of the profession, with roots millennia deep—back to Hippocrates. Its norms include these: the profession of medicine is noble; it has special knowledge, inaccessible to laity; it is beneficent; and it will self-regulate. In return, society conceded to the medical profession a privilege most other work groups do not get: the authority to judge the quality of its own work. However, the idealism of era 1 was shaken when researchers examining the system of care found problems, such as enormous unexplained variation in practice, rates of injury from errors in care high enough to make health care a public health menace, indignities, injustice related to race and social class, and profiteering. They also reported that some of the soaring costs of care were wasteful — not producing better outcomes. These findings made a pure reliance on trusted professionalism seem naive. If medical professionals were scientific, why was there so much variation? If they were beneficent, how could they permit so much harm? If they self-regulate, how could they waste so much?
The inconsistency helped birth era 2, which dominates the present. Exponents of era 1 believe in professional trust and prerogative; those of era 2 believe in accountability, scrutiny, measurement, incentives, and markets. The machinery of era 2 is the manipulation of contingencies: rewards, punishments, and pay for performance. The collision of norms from these 2 eras—between the romance of professional autonomy on the one hand, and the various tools of external accountability on the other—leads to discomfort and self-protective reactions. Physicians, other clinicians, and many health care managers feel angry, misunderstood, and over controlled. Payers, governments, and consumer groups feel suspicious, resisted, and often helpless. Champions of era 1 circle the wagons to defend professional prerogatives. Champions of era 2 invest in more and more ravenous inspection and control…
I was trained in an Era 1 world, one where medical morality and standards were meant to be an inside job. And whether by design or good fortune, I spent my practicing years in a domain that was close enough to welby-esque for this discussion – as a sole practitioner, on no provider panels, with time enough to practice Annie medicine. So I have a big bias on both of these topics [modern medical practice and treatment guidelines]. But as my daughter, a practicing child psychologist, puts it, "Dad, you could never get away with the way you did it now!" While I expect she’s probably right, that doesn’t change what I think one bit. I still think the Annie model of
personalized individualized medicine is the right way to do things.
But I absolutely can’t argue with Dr. Berwick’s point about the pollyanna idealism and the dark side of Era 1. I wouldn’t even argue that it was those other doctors who didn’t do it right. Medical Care isn’t the Wild West. It’s an essential profession that needs oversight and discipline – not cowboys and entrepreneurs. And I realize that because of my own experience, what I see in modern medical practice and in treatment guidelines is the pollyanna idealism and the dark side of Era 2. But unfortunately, there’s plenty to see.
So I guess this post is my COI declaration for my future comments about modern medical practice and treatment guidelines…