My parents have always made their own bread, a skill I have never been able to master. The other day my dad was showing off this beautiful loaf of bread he had made, and I asked him how he did it. He said “I don’t know. I followed the recipe and then added more flour until it looked right.” Huh. So the recipe was wrong? “Well, not really. It just needed more flour.”
As I was reading our dear leader Brad Wright’s policy wonk piece from March 12 I clicked on John Goodman’s piece on personalized medicine and it occurred to me that my father’s approach to bread baking is a good analogy for how doctors confront protocols and guidelines. Goodman has a great blog, by the way, over at the National Center for Policy Analysis.
Let’s start with the recipe itself. You think you want to make, say, a pie. You don’t know what kind of pie, just “pie”. But you’re an experienced baker, you’ve been baking for 20 years. You look in the index and find the directions for “pie”. You follow the directions exactly. You end up with something that looks like pie. But it’s not quite right, it doesn’t fit exactly. There’s no filling. You haven’t decided how to personalize the pie, make it yours. According to our analogy, the baker is the doctor. He’s very experienced, and has been practicing medicine for a long time. He sees a patient whom he decides has, say, diabetes. He looks in the index of his protocol manual, as he has been told to do by the administrators of his EMR, and follows the directions for “diabetes” exactly. But the patient doesn’t get better. The doctor hasn’t found out what kind of person his patient with diabetes is, so he can tailor the recommendations to the patient, that is, he can personalize it.
To extend the analogy, say this baker makes his pie according to the directions but because of his experience, knows a few ingredients are missing, so he adds them. Like my dad, an experienced bread-maker, adding flour. The results are much better, and he is able to charge more for his superior bread. But the doctor does this for his diabetes patient, and the patient’s insurance company calls him saying it won’t pay for the added items. They aren’t in the recipe.
Now someone comes to the baker and says: “Baker I ate your pie and I got sick. What did you put in it?” The baker replies that he followed the recipe, but when pressed admits he added a few things, but nothing that could make the pie-eater sick. The pie-eater doesn’t believe him but the worst that he does is no longer buy pie from the baker. The patient comes to the doctor and says: “Doctor I did what you said but I got sick. What did you do?” The doctor says he followed protocol, but when pressed admits he added a few things, but only things that would improve the patient’s care. Doctor is sued for 10 million dollars. Conversely, a person buys a pie and says to the baker: “This pie tastes terrible. What happened?” And the baker answers that someone got sick from a pie he made with additions, even though it wasn’t his fault, so now he just follows the recipe. The patient says to the doctor: “This treatment isn’t working for me, what happened?” And the doctor says: “I got sued for personalizing care, so now I just follow protocol.”
Tired of this analogy? Me too. Here is the problem with cook-book medicine. You’ll come out with something that looks like quality care, but doesn’t really satisfy anyone. It’s nice to have guidelines, so you know in general how things are done by other doctors and experts in the field, but if you don’t have the freedom to use judgement gained by experience to adjust care to the patient at hand, the end product doesn’t work. I guess my point in all this is that quality care cannot be legislated and measured with strict guidelines. Quality health care is like good pie; you know it when you see it, and you leave it to the professionals.