Recent years have seen a lot of optimistic talk and writing about the “Patient Centered Medical Home”, the promise of population registries and electronic health records for preventing and managing chronic disease, and the ideals of training the personal physician for the 21st century. The goal of integrating personal care with the best that technology has to offer seems to present us with “the best of both worlds.”
Yet, that promise gives me pause. Trekkies will recognize that phrase, “the best of both worlds” as the title of an award-winning episode of Star Trek in which the valiant crew of the Enterprise faced down the fearsome “Borg”, a race of beings both biological and cybernetic who sought to assimilate all other life forms into their massive collective. Individuality and uniqueness were subsumed into the uniformity of their seemingly all-powerful system.
What do the Borg have to do with modern medicine? A bit too much I fear. While I’ve long been generally supportive of many recent advances in medicine, and family medicine in particular, a recent read of Ray Downing’s book Biohealth sparked for me a healthy skepticism of systems in medicine, and some recent patient care experiences have only fanned the flames of my doubt and wariness.
In his book, Downing explores the way that systems, even those designed with the best of intent, can gradually grow too become self-perpetuating, pervasive, and even perverted away from the goals they set out to achieve. Recent experience as our local medical community has implemented computerized physician order entry (CPOE) and population management has proven that true. For example,
• Why was my patient with atrial fibrillation, being admitted for a 3rd attempt at medical and electrical cardioversion, who had a therapeutic INR, placed in sequential compression devices (SCDs)? Because they were a default selection in the admission order set.
• Going further, why are SCDs even an option in the order set, and why do I have to keep telling residents to not order them on most medical patients, when recent evidence and guidelines from the ACP recommend against mechanical venous thromboembolism (VTE) prophylaxis for most medical patients? Because “‘the system” requires we demonstrate interventions are being used to reduce VTE risk.
• Why are my hypertensive patients being asked to come in for fasting blood sugar measurements, even with random sugars less than 100 recorded in the past year? Because the protocol says we have to do annual fasting sugars on all hypertensives to screen for diabetes.
• Lastly, going back to the first patient, why was he even having a 3rd cardioversion attempt, when we was not sure that restoration of sinus rhythm on his past two cardioversions made him feel any better? Because, to paraphrase the old “Bionic Man” series, “we have the technology and we can fix him.”
One could easily say that in each of these cases, all that’s needed is the application of some patient-centered and individualized common sense. I used to say that! However, the problem is that the systems we are putting into place, under the guise of “patient centered care” and presuming to know what our patients want, ultimately develop enough self-perpetuating inertia that it takes more and more energy to pick the right fight of individualization in each case. We do indeed seem to be heading towards a Borg-like medical system that ostensibly claims to offer the best of both worlds, but in the end subsumes the needs and goals of the individual under the agenda of the system.
However, in this case the last laugh may be on the Borg-like system itself. The US medical system has been shown many times to be not only the most expensive, but also to produce the poorest outcomes for the voluminous amount of money spent. This is bad enough, but as I ponder the patient stories related earlier, I think we are also heading towards another distinction. The Borg may in the end be shown to wear a clown-face, as I think our increasingly self-perpetuating medical system may not only be the poorest at providing good outcomes, or the most expensive, but I fear we may also become the silliest.
Resistance may seem futile, but it also helps to remember that sometimes laughter is the best medicine.
DECLARATION OF INTERESTS:
“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 other than my passion for things Star Trek.”
William E Cayley Jr MD MDiv
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.