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David A. Shaywitz: Problems With Obama's Drive to Standardize Care

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By David A. Shaywitz
Thursday, September 17, 2009; 2:35 PM

Our health-care system is now facing a problem that has plagued business leaders for years: how do you balance consistency and innovation?

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The drive for consistency in health care is based upon the observation that physicians across the country treat similar medical conditions in dramatically different fashions. Sometimes, these different approaches are costly, such as using a more expensive treatment when a less expensive approach might be as effective. In other cases, these practice variations are dangerous -- failing to provide patients with treatment the evidence suggests is best.

Standardizing the delivery of care -- identifying "best practices," and then insisting physicians follow these guidelines -- could, in theory, save money while improving quality, and it is the basis of Obama's health-care proposal. For many managers, one of the great attractions of consistency initiatives is that they offer instant metrics, quantitative methods of evaluating how well you are doing simply by measuring how close you are adhering to the established standard.

Yet, these exact metrics are also what most concern many physicians, as the drive for standardization seems to have far outstripped our ability to identify appropriate standards. Many practice guidelines are based on limited data, and in many cases, it's not clear that strict adherence to these guidelines actually improves patient outcomes.

If medicine lurches in the direction of guidelines and algorithms, two important opportunities may be lost:

-- First, we may lose the chance to individualize care; a treatment ineffective for most patients may be enormously useful for some.

-- Second, we may lose the opportunity to tinker and innovate -- so many powerful discoveries originated with a clinician's chance observation or slight deviation from standard treatment.

Success will require that we clearly differentiate between guidelines based on the most robust evidence -- strong recommendations that truly deserve to guide clinical practice -- from all other guidance, which can inform care, but should not dictate it.

We must also ensure that to the extent standardized treatment protocols are employed, they are routinely used to evaluate and improve care, not just deliver it. Treatment algorithms could enable the rigorous comparison of different therapeutic approaches when there are several reasonable alternatives, potentially providing more actionable conclusions than an army of tinkering practitioners. All of this, though, would require planning, expertise, commitment, and funding.

David A. Shaywitz is a management consultant in New Jersey and co-founder of Harvard's PASTEUR program in translational research.


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