Demanding Medical Excellence

(Critical Survey of Contemporary Fiction)

For most of the history of medical practice, quality care has been defined by the providers of that care, doctors and hospitals. Doctors have been viewed as professionals and their practice held as a form of art, beyond supervision or review by outsiders. Michael Millenson shows how sophisticated data analyses have challenged that perspective in DEMANDING MEDICAL EXCELLENCE: DOCTORS AND ACCOUNTABILITY IN THE INFORMATION AGE.

Many studies cited throughout the book show that standards of care that can improve patient outcomes—lower mortality rates, shorter hospital stays, less discomfort reported by patients—are not always employed, even though most are accessible through medical journals. The problems in delivering this “best practice” care are numerous. Doctors resist changing their practices until shown concrete examples of improvement, they do not hear of improved practices, or the medical systems in which they are enmeshed do not allow easy implementation of different practices.

The first hurdle, that of proving efficacy of different practices, can be leaped through sophisticated data collection and analysis. Millenson illustrates this point through several examples showing widely different treatments in different geographic areas, or even at different hospitals within an area. Rates of various surgeries differed by several hundred percent for such procedures as tonsillectomies and hysterectomies, and even within a given hospital doctors treated heart attack victims differently. Once doctors reached a consensus on best practice, patient outcomes improved dramatically in each case, including dramatic decreases in the use of tonsillectomies and hysterectomies.

Doctors long resisted publishing statistics on care, but in an era of competition, they found that they either had to show quality or would face customers who bought the least expensive services. The implementation of health maintenance organizations brought a focus on costs, but HMOs too found that they needed to demonstrate quality, and in some cases careful studies found that better care could be provided at lower cost. Lowering costs raises the specter of rationing, but Millenson argues convincingly that some sort of rationing must occur, and that more care is not always better, as in the case of unnecessary surgeries.

The strongest lesson of the book is the need for patient advocacy. Because best practice is not adopted everywhere, treatment must involve a dialogue between patient and doctor, with each providing information from different sources. A single doctor no longer can or should be seen as all-knowing, and patients should educate themselves.