FORCES THAT INFLUENCE THE SYSTEM
To understand the medical culture, it's not enough to understand about doctors. Increasingly, medical care delivery is influenced by "systems." The word system, though heard a lot in medicine these days, doesn't have a precise definition in this context. For simplicity, let's say it refers to the managerial structures in place to deliver medical care. The united states doesn't have one system, it has thousands of them.
And while the managerial structures may differ, everyone has some kind of managed care, from charity care in county hospitals to the most generous fee-for-service insurance plans. Health care managers who work for these systems frequently promote preventive testing, particularly testing for cancer. Some are undoubtedly motivated by the best intentions, truly believing that testing for cancer is in the population's best interest. But there are other, less altruistic, interests served by promoting cancer testing, which need to be taken into account as well.
Given the old adage that an ounce of prevention is worth a pound of cure, it is perhaps not surprising that preventive medicine seems universally endorsed. For the last 30 years or so, moreover, the medical system has been criticized for being more concerned with treating disease than preventing it. Not only does the criticism make a good sound bite, but it is, of course, true.
Unfortunately, many people have gone on to conclude that doctors should focus on preventing disease instead of treating it. While this is a very appealing notion at first glance, the truth is more complex. True prevention (e.g., keeping adolescents from smoking or getting them in the habit of using seatbelts) is best accomplished in social settings other than a doctor's office. Physicians' preventive efforts are narrower, and largely involve looking for early forms of disease. Functionally, this means ordering tests an exercise, as we have seen, with problems of its own.
Nevertheless, managers love to promote their system's preventive services. Preventing disease has broad public appeal because it both applies to more and more people and has the luster of being a public health service. It's a tangible way of showing that their system "cares." Because cancer is such a scary disease, cancer prevention programs have special appeal. Breast and cervical cancer screening have the extra appeal of addressing women's health issues. In short, many managers see cancer testing as good PR.
Cancer testing as measurable quality improvement The current effort to make medicine more systematic has served to promote cancer testing too. In the last decade, medical managers have looked to the manufacturing industry in lowering error and to make the "product" of medicine more consistent from doctor to doctor.
Quality improvement teams, which have sprung up in many health care organizations, strive to introduce "systems thinking" among medical service providers. While these efforts can be useful, they are limited to those functions that can be made systematic such routine processes as preparing a patient for elective surgery or monitoring the use of blood thinners in patients prone to clotting, for instance and whose output is measurable and in which "improvement" can be gauged shorter waiting times, or having more patients whose blood is thinned within the desired range. Cancer testing fits this scheme nicely.
It's a routine service. It is easy to know whether it happens or not. And the goal is clear: to test more people. Therefore, the rate of cancer testing is among the most common quality measures appearing on health care report cards.
Two things about this trend concern me. The first has to do with the (understandable) use of measures that are convenient. If systems focus on what they can easily measure, it is inevitable that they'll miss an important part of health care. Managers like having a list of services that physicians should provide during an outpatient encounter. It helps define the product, makes it more measurable, and makes the physician more accountable. But even if the services are useful, these efforts can distract from more important issues those most relevant to the sick, which get crowded out by those most relevant to the healthy.
My second concern has to do with how physicians react to being measured. We all want to perform well; in fact, we were selected for medical school based on our good grades in college. If "getting a good grade" in medical practice means ensuring 100% of women we see get a mammogram or a Pap smear, that is what most of us will try to do even if the women don't want to be tested.
The desire to perform well may lead us, if not to outright coercion, at least to persuasive tactics: overstating the benefit, ignoring the downsides, and suggesting that people are making a mistake if they don't follow our recommendations.
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