The Trouble with Hippocrates in the Digital Age of Health Care
Will doctors be willing to give up some control to serve the greater good?
Every year, tens of thousands of medical school graduates around the world, verbally recite the Hippocratic Oath in some form. In exchange for countless hours of study and sleep deprivation, these newly minted physicians are granted the remarkable privilege of autonomy to practice with immense latitude. However, I would contend that such autonomy must be narrowed considerably, and a new paradigm must replace, or reshape, this age-old tradition, to match both current and future trends in society and health policy.
In 1964, Dean Louis Lasagna of Tufts University modified the most widely-used version of the Hippocratic Oath to include, in its opening phrases, this statement:
“I swear to fulfill, to the best of my ability and judgment, this covenant: I will respect the hard-won scientific gains of those physicians in whose steps I walk, and gladly share such knowledge as is mine with those who are to follow.”
There are many equally noble statements that follow this first pledge, and they include pledges of respecting patient privacy, caution against over treatment, and pledges to show compassion and empathy for patients. But the promise to respect and adhere to medical science as well as to pass on this knowledge is rightfully placed first on this venerated list. Unfortunately, in today’s digital age, it is increasingly difficult to truly satisfy this pledge.
Medical Science is exploding, and most of it is noise
According to the 2015 PubMed catalog of medical literature, ~three thousand four hundred (~3,400) new scientific articles are published in print and online medical journals every day. With well over one million ‘peer reviewed’ articles published annually, it is understandable that physicians feel overwhelmed and inundated with medical ‘evidence’ about any and all conditions they may encounter on a daily basis. There is progressive ‘information fatigue’ from which many physicians recoil, leaning instead upon their own experience and intuition, and leaving the latest clinical trial data by the wayside. Over time, this will inevitably lead to medical errors and poor outcomes.
Even if doctors were somehow magically able to ingest and implement knowledge from all of those articles (see Elon Musk’s new company, Neurolink, that implants data into human brain), not all journals were created equally, and the quality of literature varies dramatically. Which articles do you pay attention to? Does the larger MD community agree with that list? It can be extremely confusing without some guide or resource. Information without context is simply noise.
Doctors are not able to adhere to the best evidence, and it’s hurting patients
To control this flood of new medical information, numerous medical societies issues guidelines that are updated regularly to incorporate the latest trial data and medical literature. These expertly curated clinical practice recommendations are an anchor for physicians from which to base their practice habits. Yet, despite this important and evidence-based resource, physicians often fail to adhere to those guidelines.
A 2004 RAND study analyzed the physician practice habits with regard to simply following the guidelines for a given patient’s characteristics: gender, age, lab data, medical history. This RAND study demonstrated that nearly 50% of the time, the standard of care or guideline-recommended care was NOT prescribed to patients. For some conditions, this performance dipped much lower into the 20% range.
“Researchers concluded that appropriate application of the evidence in practice occurs only 54% of the time.”
Although these were shocking numbers to absorb, were they meaningful clinically? Did it really impact patient outcomes? Subsequent studies demonstrated that failure to adhere to guideline-recommended care was a critically meaningful statistic. 2005 study by Martin et al. at UCLA found that the degree to which doctors followed the guidelines inversely correlated with patient morbidity and mortality rates (see Figure 2 below).
Quality Finally Matters in Medical Decision-Making
In 2015, Congress passed the MACRA law, which enforces sets of medical quality metrics (MIPS criteria) that are rooted in generally accepted medical guidelines, rewarding providers who adhere to select quality practices — and penalizing those that do not — in the form of adjusted Medicare reimbursement. These MIPS criteria have finally added some teeth to value-based care in our health system, which most believe is long overdue and worth continuing. However, will providers actually improve their habits based on this alone? Unlikely. There is a severe lack of visibility into the decisions a physician makes, let alone a mechanism to improve that decision when needed. How can hospitals and health systems ensure an improvement in physician decision-making that is desperately needed to improve patient outcomes and that is now impacting their overall Medicare revenue?
Less Physician Autonomy = Better Outcomes
The title borders on sacrilege. How dare I question the time-honored — and fiercely protected — privilege of physician autonomy? But the argument is much simpler now due to the financial impact of MACRA on Medicare revenue. If your employed physicians are not abiding by quality metrics that your institution has agreed to report upon, those physicians are losing money for your health system (you can read about the 500 billion dollar opportunity to save here). The fee-for-value health care model will not sustain clinical decision making that doesn’t abide by quality standards most of the time. Certainly there should and will be clinical judgement applied to every case, but the bar must be set higher, and the visibility and accountability for physicians must be applied to this new, quality-focused and revenue-impacting bar.
I believe it behooves medical systems to take away autonomy from their physicians for the most basic of decision-making: vaccinations, cancer screenings, and even cardiovascular and metabolic disease prevention. There is simply no excuse for failing to order a colonoscopy, mammogram, or pap smear for your patient because every patient matters. Similarly, there is no excuse for having 90 million prediabetics in the US, with over 80 million of them completely unaware of their condition, leaving them at higher risk for a cardiovascular event. The rates of our most prevalent cardiometabolic risk factors: diabetes/prediabetes, hypertension/prehypertension, obesity, and smoking are all on the rise in the US, and our medical system’s current evaluation, treatment, and monitoring of these conditions is substandard.
The MIPS quality metrics are designed to identify and close those gaps, but even these are not enough to encompass the entire realm of disease prevention and treatment. And we simply cannot rely on each individual doctor or nurse practitioner across this country to EACH operate at the top of their license, on every patient encounter, in every clinic, every day. Our providers are unrealistically expected to catch every risk factor their patients may possess, even when those patients are overwhelmingly not in the office for risk factor assessment, but rather a common cold, knee injury, or headache. Coupled with the brevity of patient visits these days — 10 minutes with your doctor if you’re lucky — this becomes a near impossible task to do right consistently.
Who Has the Time to Be Right?
We must also remember that for as much as we pride ourselves on knowing the literature, the guidelines change constantly. How can providers be expected to follow what the guidelines and best practices say to do for each patient, when those guidelines themselves are updated every 1–2 years? With the aforementioned deluge of medical information that bombards us each day, and updated guidelines issued by societies every year, we desperately need digital tools that will package and personalize the guidelines for our patients, so that we don’t have to possess a comprehensive and immediate recall of the evidence-based medical approach for each patient, but rather, we are supported by such tools to do that for us, allowing us to focus on the human aspect of explaining and advocating for those treatments that are indicated. We need tools that will show the physician the indicated therapies and approaches matched to each patient, while also linking these decisions to quality metric adherence, and eventually, to automate these pathways and take this decision off the proverbial ‘plate’ of our providers. In the end, physicians would retain some means to veto said recommendations, but it would be accompanied by a required justification to go against proven treatment pathways.
There is currently only one solution that directly improves physician quality and evidence-based performance at the point of care. HealthPals’ CLINT is designed to insert its clinical intelligence in the providers ‘line of sight’ as they make decisions before a patient encounter, in the room with a patient, or immediately after the encounter. That intelligence provides critical and timely treatment pathway recommendations that are rooted in guideline-driven, evidence based care, and which can be customized to an institution’s care pathways as well. By taking the guesswork out of the equation, CLINT improves workflow efficiency, treatment efficacy, and quality adherence at the point of care. And at a population level, CLINT identifies every guideline- and quality-metric gap in care from every patient in your system, so you don’t even need an in-person patient encounter to receive relevant insights on your patients.
The Latin phrase ‘Primum Non Nocere’, ‘First, do no harm’, is a Latin edict that also embodies the principles of the medical profession. By not providing guideline-driven care to our patients, we are, in effect, doing harm through inaction. We must be always ‘respect the hard-won scientific gains’ that have defined evidence-based medicine.
Health policy is finally realizing this problem for what it is, and physicians must rise to meet this challenge by embracing technology solutions that solve it.