William Cayley: Are we getting too systematic for our own good?

bill_cayley“We need to standardize our systems of practice to improve our quality metrics and do a better job of caring for our patients.”

Such was the thrust of a recent management meeting, yet it left me wondering whether or not we are headed in the right direction. Increased public reporting of quality “metrics,” focus on “pay-for-performance,” and implementation of (allegedly) evidence based protocols for treatment and prevention have led to more and more focus on measuring what we do, and organizations are pushing for standardization to reduce “variance,” and promote uniform delivery of what is hoped to be high quality care.

However, a dissenting voice at the meeting questioned whether standardization may stifle local innovation, citing unique solutions local clinics had adopted to meet their own specific, local needs in ways particular to their circumstances. Beyond the issue of clinical innovation, a recent article exploring American family medicine raises questions for me as to whether systematization and standardization have anything to do with good primary care medicine.

Young and colleagues interviewed 38 family physicians and found they delivered care in less expensive facilities and generated lower overall charges for physician fees. However, these outcomes were not achieved by strictly adhering to guidelines, but rather by how they individualized the management of new symptoms and chronic conditions.

From a different angle, Downing has raised questions fundamental to the place of systems in medicine in general. The fundamental point he makes is that “large complex artificial systems such as biomedicine lack feedback,” and so can become self perpetuating and answerable primarily to their own internal dynamics—which often may be focused more on economics than on health, natural ways of healing, or interpersonal relationships.

Being organized, deliberate, and careful about what we do in medicine is obviously vital, and being systematic can certainly help us be more organized, careful, and deliberate. But to the extent that systems end up serving their own internal demands rather than the needs of those they were designed to serve we have a problem, and when the drive for uniformity and standardization stands poised to threaten the individualized care that is foundational to what doctors do best, we have to question whether we are really doctoring any more.

Modern medicine is complex. Modern systems can help us confront and manage some of that complexity. But patients are people and health is more than numbers to be measured and standardized. We need to think carefully about what we do, and find ways to creatively and carefully maintain the tension between standardized systems and the individualized care of each unique patient who comes to us for help.

I declare that that I have read and understood the BMJ Group policy on declaration of interests and I have no relevant interests to declare.

William E Cayley Jr practises at the Augusta Family Medicine Clinic, teaches at the Eau Claire Family Medicine Residency, and is a professor at the University of Wisconsin, Department of Family Medicine.