Doctors found better at standardized than individualized patient care

 

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Carol Forsloff - New research finds doctors do better at hypothetical medical treatments following a standardized approach to care than individualized care based upon actually seeing patients.

This is important information given the fact doctors ask patients to keep appointments and follow certain schedules for treatment.

But what doesn't happen is a doctor individualizing care from what they see or are told during the patient visit.

This comes from research by the University of Illinois at Chicago and the VA Center for Management of Complex Chronic care and is the largest research on this topic, presently published in the Annals of Internal Medicine.

"Physicians did quite well at following guidelines or standard approaches to care, but not so well at figuring out when those approaches were inappropriate because of a particular patient's situation or life context," said Dr. Saul Weiner, associate professor of medicine and pediatrics at UIC and staff physician at the Jesse Brown VA Medical Center, who was lead author of the study.

As a consequence, Weiner said physicians need to determine the reasons why a patient is failing rather than just following the standard treatment approach or increasing the dose of drugs prescribed.  

 Specific issues, such as the lack of health insurance, the need for less costly treatment, or difficulty understanding or following instructions, are contextual pieces of information that must be recognized also in patient care, according to this research in order to avoid errors in making decisions.

The study used actors trained to simulate real patients in 400 visits to a wide range of physician practices in Chicago and Milwaukee, including several VA sites.  In each situation the identities also had medical records and insurance information provided.  The doctors involved did not know which "patients" were actors.

These "actor patients" were then compared with the results of real patients, in this case four case scenarios were developed with each case having four variants.

The actors followed scripts that had "red flags" of significant issues which, if confirmed, would need to be addressed to avoid error. The actors always started with the same two red flags, but were randomly assigned to respond differently based on the variant.

For example, in a case involving a 42-year-old man concerned about worsening asthma, the actor mentioned both a biomedical red flag (coughing at night) and a contextual red flag (losing his job) that suggested acid reflux and loss of health insurance, respectively, as a key part of the problem.

The study looked at whether the physician picked up on the red flags and implemented an appropriate care plan for each of the case variants.

At visits where no modification of customary practice was required, 73 percent of physicians provided error-free care.

But at visits where individualizing care required an alternative to the customary treatment, only 22 percent of physicians provided error-free care during a contextually complicated encounter, 28 percent during a biomedically complicated encounter, and 9 percent during a combined contextually and biomedically complicated encounter.

"To date, measures of doctors' performance have focused on situations where knowledge of the individual patient is ignored," said Weiner. "Under those conditions, physicians did fairly well. But as soon as care required more than following an algorithm -- finding out what's really going on with a patient and acting on that information -- only a minority of physicians got cases right."

The researchers also looked at the demographics of physicians, that included training and experience as well as races of people assigned to the doctors in the study.

"We expected that if physicians had more time with patients, they would be more likely to individualize care," Weiner said. "But what we found was that among those visits where physicians did a great job identifying contextual issues and addressing them, they did not on average spend any more time with patients than the physicians who didn't recognize contextual issues. That was surprising."

The study found that physicians were more likely to respond to the biomedical rather than contextual red flags even when both were equally important to planning appropriate care. "We believe that reflects the way in which physicians are educated," said Weiner. "The lesson here is that there has to be a dramatic change in the way we train physicians."

Problems in Medicine: physician incompetence , under reporting, errors

 

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Carol Forsloff - Attorneys often claim when they are involved in a lawsuit with a doctor, that physicians hang together when it comes to testifying against each other or even supporting patient claims of bad medicine against a doctor, and new research supports to some extent that is true. 




In a survey of doctors, most doctors were found to support the idea of reporting incompetent or impaired folks in the medical profession but when faced with doing so many do not follow through.  

“Many states have mandatory reporting statutes, requiring physicians and other health care professionals to report to appropriate authorities those physicians whose ability to practice medicine is impaired by alcohol or drug use or by physical or mental illness,” researchers say.  

Data  shows the rate of reporting is significantly lower than it should be, given what is said to be the estimated numbers of physicians who become impaired or who are otherwise incompetent to practice. 

Catherine M. DesRoches, Dr.P.H., of Massachusetts General Hospital, Boston, and colleagues did a study to examine doctor's beliefs, actual experiences and level of preparedness involving impaired or incompetent physicians in a survey of 1,891  physicians practicing in the United States in 2009.  The results tell the story of how physicians actually respond when faced with having to file a report. 

The survey found 64 percent of those surveyed agreed that impaired or incompetent physicians should be reported and 17 percent said they had actual knowledge of someone in their group with these issues but only 67 percent of these doctors actually filed a report about their colleagues or others they knew had impairments in the practice of medicine. 

Minority physicians were significantly less likely than other physicians to report, as were international medical graduates compared with graduates of U.S. medical schools.   Big city doctors were more likely to report than those in small practices. 

Most physicians said the reason they didn't report is they felt someone else was handling the problem, along with believing nothing would happen if they did file a report or that there would be retribution. 

“These national data regarding physicians’ beliefs, preparedness, and actual experiences related to impaired and incompetent colleagues raise important questions about the ability of medicine to self-regulate. More than one-third of physicians do not completely support the fundamental belief that physicians should report colleagues who are impaired or incompetent in their medical practice. This finding is troubling, because peer monitoring and reporting are the prime mechanisms for identifying physicians whose knowledge, skills, or attitudes are compromised,” the researchers say. 

These statistics, when combined with the growing rate of medical errors found in research done over the past ten years shows a serious issue in medicine, according to those involved in collecting the data.  The Institute of Medicine looked at the problem in 1999 and found this:

"Between 45,000 and 98,000 Americans die each year as the result of medical errors. If the lower figure is used as an estimate, deaths in hospitals resulting from medical errors are the eighth leading cause of mortality in the United States, surpassing deaths attributable to motor vehicle accidents (43,458), breast cancer (42,297), and AIDS (16,516). Moreover, these figures refer only to hospitalized patients; they do not include people treated in outpatient clinics, ambulatory surgery centers , doctors' or dentists' offices, college or military health services, or nursing homes . Medical errors certainly occur outside hospitals; in 1999, the Massachusetts State Board of Registration in Pharmacy estimated that 2.4 million prescriptions are filled incorrectly each year in that state—which is only one of 50 states.

In the case of physician involvement in reporting incompetence, some of the suggestions for improving physician reporting made by the researchers , as published in the latest edition of JAMA, include strengthening external regulation, making sure reporting systems protect confidentiality and to make sure that those who do report get confidential feedback of the outcomes of any actions taken. 

“All health care professionals, from administrative leaders to those providing clinical care, must understand the urgency of preventing impaired or incompetent colleagues from injuring patients and the need to help these physicians confront and resolve their problems. The system of reporting must facilitate, rather than impede, this process. Reliance on the current process results in patients being exposed to unacceptable levels of risk and impaired and incompetent physicians possibly not receiving the help they need,” the authors conclude.