Friday, April 29, 2011

More on the future of healthcare: a tale of quantity and quality

American healthcare is changing at the moment, and is doing so rapidly. As I’ve highlighted in the past, the way that we pay for healthcare is changing at the moment, and will continue to change until a more sustainable model is found. The rise of integrative medicine is an irreversible trend, and I predict that in the future, primary care physicians will move away from pharmaceuticals, embracing instead diet and lifestyle, simple home remedies, and many will incorporate supplements too. Additionally, and without trying to play the role of soothsayer, I predict that in the future, we will see a greater effort to integrate the occasionally opposed principles of quality and quantity.

The development of scientific method, from the 17th century through the 20th, has brought many things to the field of medicine. Modern diagnostics, labwork, imaging, and pharmaceuticals are only the tip of the iceberg. Diseases have been essentially eradicated, debilitating illnesses cured, and lives saved. This blog entry is by no means meant to diminish the work of the generations of doctors and researchers who have taken us so far. Even so, we are now starting to see some of the limitations of our current use of scientific method.

These limitations are dictated by an essential feature of the scientific method – the need for quantification. Science runs on experiments and reproducibility, the ability to observe measurable changes, and be able to communicate them to colleagues. To do that, everything needs to be quantified, from milligrams of a drug, to cholesterol levels, to changes in waist circumference. Ironically, even quality of life has been quantified so that the effect of pharmaceuticals can be measured.

Unfortunately, quantity of health doesn’t always equate to quality of health, and in some cases, quality of health is sacrificed in favor of quantifiable measures. Pharmaceuticals and surgeries can regulate your cholesterol, blood sugar, weight, and blood pressure, but that combination doesn’t make a healthy person – it makes a person who is statistically less likely to suffer a cardiovascular event. By no means am I saying that this is somehow bad – as a doctor, I work every day with patients to reduce the likelihood that they’ll suffer a heart attack or stroke. What I am saying, however, is that health is a complex mix of quality and quantity that needs a better system of assessment.

Quality is traditionally trickier to work with. For one, it requires more time to assess. Also, training physicians who are able to assess and determine quality is far more complicated than training physicians who can assess quantity – the one involves an ability to understand and interpret the human condition, the other the ability to read a lab report. True primary care physicians should have the ability to assess health in its fullest scope, and should be trained to do so.

Next week, I’ll discuss the growing Death with Dignity movement in greater detail, but suffice it to say that this is a case study for the debate on quality vs quantity. The life of a terminally ill patient can be prolonged far beyond what nature alone would allow, but often at the price of quality of life. The Death with Dignity movement attempts to reconcile those two opposing principles for the terminally ill. While this branch of the debate on quality vs quantity is sometimes dramatic, many more Americans quietly wrestle with quality and quantity in their everyday lives. Such people include those Americans who struggle with chronic diseases, some of whom feel the cures are often worse than the disease.

As healthcare changes in the future, let’s commit ourselves to a future where both quality and quantity are both taken into account. This is the core principle of patient-based medicine. One of my guiding principles in patient care comes from my teacher and mentor, Dr. Maryanne Ivons, who paraphrased Dr. Samuel Hahnemann in saying, “It’s not about you. It’s all about the patient. It’s about what they want, and getting them healthy.”