The Least Common Denominator Paradox-Our New Era of Check Box Medicine

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medical guidelines

My wife recently had a weird respiratory problem that caused us to interface with our 2015 medical care system and what we found was really disturbing. Our multi-decade long push toward standardizing medical care with guidelines and check boxes has had a curious side effect – a lack of independent thought. Let me explain.

Back in the 1980s when I went to medical school, they taught us how to think. Few guidelines existed yet, so the theory was that a doctor who was broadly educated could determine, patient by patient, the likely diagnosis and the workup needed, all of which would lead to a treatment. Fast forward to the 90s and early 2000’s, when the idea, mostly pushed by insurance companies, began to emerge that doctors should follow flowcharts and check boxes, which would reduce medical cost by leading the doctor toward a likely conclusion. In the last 5 years, this same concept has been pushed heavily by the federal government, with the ACA memorializing the concept of medical guidelines through the IPAB, a group of doctors who determine what the flow charts and check boxes should be.

All of this sounds like a good plan, right? Why not help doctors make decisions? What could go wrong? Fast forward to this past month when my wife and I tried to interact with our new flowchart/check box medical care system. I call the problems we experienced the “least common denominator paradox”.

My wife had a respiratory issue that was rare, in fact it took me a few days of searching on the Internet just to find it’s name. This was getting worse, so we had two visits to the ER and two specialist visits. She had a personal physician (me) who either attended all of these visits or sent her with a short, but detailed medical history – so she had an advantage. What did we find? Every medical interaction was just one big tussle with the all powerful “guidelines”. The flowchart said that if someone has a hard time breathing, you throw steroids at the problem (never mind that steroids don’t help the problem my wife had). At each visit, I could see the doctors either mentally ticking off the check boxes in the flowcharts in their heads or more telling, in the electronic medical records on their tablets. The problem was that my wife’s rare condition wasn’t in these flow charts, so what was meant to improve medical care, actually made it totally ineffective and more likely to do harm due to the side effects of the care than to help. This is the crux of the “least common denominator paradox”.

Guidelines and flowcharts work reasonably well to treat the 80% of people who present to a doctor with a common problem, in other words, the least common denominator. Where they fail is on the rare problems. Why? A guideline devised to treat the top 10 most common problems that 80% of the patients present with is already huge and unwieldy. Now consider that the other 20% of rare conditions are likely encompass 100 disorders which are all difficult to distinguish from the common conditions. If you try and stuff those into the guideline, the concept breaks down and fails. This is where the doctor’s 10-15 years of schooling is supposed to “kick in” and allow the physician to think independently. The problem is that years and years of dependence on the crutch of flowcharts, guidelines, and check boxes has turned some of my colleague’s brains to medical mush. It’s far too easy now with electronic medical records, insurance companies, and now the federal government breathing down your neck, to just do what the group think in the flow chart says you should do, even if you’re presented with a problem that doesn’t fit neatly into the boxes on the iPad. In fact, my concern is that this new virus infecting the heart of medicine has begun to spread to medical education, where doctors are taught more how to follow the guideline than how to think independently.

There’s another serious side effect of our rush to make doctors practice according to check boxes and flowcharts – it becomes incredibly easy for industry to manipulate the monkeys in white coats checking all the boxes. What if Pharma got a few hand picked physicians on the big guidelines committees? We’ve all seen report after report that Pharma has easily infiltrated FDA drug approval committees. How long would it be before the doctors just became the “rubber meets the road” arm of the Pharma sales machine?

The upshot? The “least common denominator paradox” is a serious infection afflicting our Nation’s healthcare system. In order to make medical care easier and more reproducible, we have sacrificed independent thought. Given that 20% of the patients account for 80% of the cost and that a good chunk of those patients have rarer conditions that the medical care system can’t readily identify nor help, the new check box medical care system should increase costs rather than reducing them. It’s also allowed Pharma to finally get what it wanted all along, the government forcing doctors to prescribe their best selling drugs without questioning their efficacy. When doctors become nothing more than a sales and distribution arm of Pharma, we have a very serious problem indeed!

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Chris Centeno, MD is a specialist in regenerative medicine and the new field of Interventional Orthopedics. Centeno pioneered orthopedic stem cell procedures in 2005 and is responsible for a large amount of the published research on stem cell use for orthopedic applications. View Profile

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