One size does NOT fit all!

Doc writing on clipboardThe July 20 issue of Annals of Internal Medicine included a report on a study showing that most medical doctors perform “cookie cutter” medicine and don’t provide patients individualized care based on their specific needs.

The study, by the University of Illinois at Chicago and the VA Center for Management of Complex Chronic Care, was the largest ever to be conducted using actors presenting as patients in doctors’ offices.

“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, lead author.

Weiner said physicians need to understand why a patient is failing, for instance, to control their asthma, rather than just increase the dose of the drugs they prescribe. Specific issues — such as the lack of health insurance, the need for less costly treatment, or difficulty understanding or following instructions — must be recognized when making clinical decisions. Inattention to such issues leads to what are called “contextual errors” in patient care.

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. At each clinic, identities were created along with medical records and insurance information for the actor-patients. The doctors had all agreed to participate in the study but were not told which patients were actors.

Unlike real patients, the actors, or “unannounced standardized patients,” consistently adhered to a script, enabling researchers to make comparisons of physicians’ performance across the visits, said co-author Alan Schwartz, a methodologist and UIC associate professor of clinical decision-making.

Four case scenarios, each representing a common outpatient condition, were developed. Each case had four variants — uncomplicated, biomedically complex, contextually complex, or both biomedically and contextually complex.

The actors followed scripts that contained hints or “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.

Not many did. For those patients where individualized care required modifying the “customary treatment,” only 22% of the doctors provided error-free care during a contextually complicated encounter, 28% during a biomedically complicated encounter.

When both contextually and biomedically complications were present, only 9% of the doctors made error-free medical decisions.

Even when no “complications” were present and doctors didn’t have to modify “customary practice,” only 73% provided error-free care.

“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.”

Interestingly, it didn’t even matter if the doctor spent time with the patient — they still got it wrong. “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.”

The lesson we, as non-medical wellness providers, have to learn is that — unlike the allopathic paradigm — one size does NOT fit all. While it’s important to be aware of clinical guidelines and customary practice, we can’t so slavishly follow the guidelines that we overlook patients’ individual needs. Every person who enters our office is unique and we have to approach each encounter as a distinctive opportunity to provide care tailored made for that individual.

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Not a surprise, Medical doctors are not trained in wellness. They as a rule look to alleviate the symptoms and unless there is a medical cause have little impact other than referral at times.

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