A message to all physicians from Steven J. Stack, MD, chair of the AMA Board of Trustees.

Health information technology, sustainable health care financing and quality health care delivery all rely on complex systems involving a variety of processes and people. All of them require a systems-based, not individual-focused approach to achieve success. Yet what makes obvious sense at a system level may be untenable at the individual level, and often physicians at the bedside feel alone in their recognition of this reality.

To demonstrate the point, lets consider a few clinical examples:

Notwithstanding the above, physicians use ankle x-rays, CT scans and antibiotics at times in a manner contrary to established treatment guidelines.

Sometimes this may be a knowledge deficiency or even a professional shortfall. For these instances, educational efforts such as those undertaken by the American Medical Association and the AMA-convened Physician Consortium for Performance Improvement play a useful role. More commonly, though, the true culprit is our fragmented and inequitable health system.

Sixteen percent of all Americans and 34% of the patients in my suburban emergency department are uninsured. For these patients, there is no ready access to appropriate outpatient follow-up care. Watchful waiting may mean more time off the job or a costly repeat visit to an ED. See your primary care doctor or Follow up with the orthopedist can be a cruel joke, not useful advice. For the uninsured and patients on Medicaid, problems with transportation, employer inflexibility, no or low insurance coverage, and educational limitations add additional challenges.

Against this backdrop, many physicians have ordered an ankle x-ray or prescribed an antibiotic to a patient whose personal circumstances make outpatient follow-up particularly burdensome or unlikely. For a patient with unrelenting abdominal pain, even if nonemergent, a CT scan may be the only available option to exclude a whole host of worrisome diagnoses within the short time of an ED visit. Technology and/or pills, even with their own costs and undesirable consequences, become surrogates for unattainable access to affordable and reliable outpatient medical care.

Please note that I am not relying on the fear of trial lawyers or the pressures faced by busy clinicians to justify suboptimal care. Defensive medicine and work force shortages (real or artificial) are challenges in their own right, but those arent the topic of this column. Nor am I proposing that we physicians dont have an obligation to optimize the care we provide to be cost-effective and consistent with scientific evidence.

Instead, I assert that medical treatment for 50 million uninsured and 60 million Medicaid patients, fully a third of our population, adheres to rules of pragmatism not captured by evidence-based medicine. Rather than being a failure of physician professionalism, quite a few seemingly inappropriate tests and treatments are the result of a physicians imperfect but sincere attempt to help a patient in a nation replete with First-World technology but financed and administered in a Third World manner. Until our nation moves past the delusion that individual professionals are at fault for societal choices and systems-based problems, we will not succeed as we could and should.

The solution to this problem of allegedly unnecessary tests and antibiotic use goes well beyond physician education and professionalism. If, as a nation, we want to seriously and successfully address these challenges, we must reform our current fragmented, costly and inequitable health system to support access to quality care that facilitates adherence to scientific evidence. Until then, it is misplaced and unfair for policymakers and standard-setters to impugn the physicians professionalism for treating the patient immediately before him in a manner considerate to the patients personal circumstances.

Excerpt from:

Health care’s big picture: Fix the systems to support individuals