It is time to abandon the notion of heroic individualism in medicine and embrace the science of data collection and analysis in the form of standardized care

Medicine has taken a bad rap on the quality front in recent years, beginning with the Institute of Medicine’s 1999 report, “To Err Is Human: Building a Safer Health System.” But to hear Brent C. James, MD, describe it at the 2006 annual meeting of the Radiological Society of North America, medicine has made enormous strides toward quality in this century. Prior to the start of the 19th century, those who sought the attention of a physician had a one in 10 chance of survival. Nonetheless, a lack of standardization in medical care coupled with Medicare’s looming fiscal crisis mean that there is more work to be done, and it needs to be done quickly.

James, executive director, Institute for Health Care Delivery Research, and vice president, medical research and continuing medical education, Intermountain Health Care, Salt Lake City, posited that not only is the physician community best qualified to address this issue, it is the responsibility of the physician community—not insurers—to solve the problem.

James’ list of what it means to be a medical professional includes three main tenets: a fiduciary trust, the idea that the patient’s health is placed before any other goal; the management of specialized medical knowledge; and a social contract between the healing professions and society that any patient can have some level of assurance of some minimum performance involving ethics, fiduciary trust, and knowledge application.

When all of this evolved around the turn of the 19th century, he explained, the key concept of “the craft of medicine” evolved. “And the promise we made as a profession is that this approach guaranteed the best possible result to every patient,” James said.

But James has an axe to grind, and it is the imperative of standardization in medicine. “Think of it this way, with that famous medical maxim, ‘When you hear a hoof beat, think horses,’ ” he prefaced. “But for some reason, within medical practice under the craft of medicine, we treat every patient as a zebra, one at a time. This has a fairly interesting secondary impact. It takes the idea of professional autonomy and transmutes it into something called personal autonomy: The idea of medical practice as heroic individualism, with an attitude. The idea that what I know works for me, what you know works for you, ‘Hey, you don’t bother me, I won’t bother you, after all, aren’t we all independent experts?’ “

Later in the meeting, James presented an extended delivery of the remarks made at the opening session, laying out his argument for the standardization of care. This is tough talk for the medical profession, his delivery was monotone, his humor was dry, and only a fraction of the original audience remained at the end of his talk. So it is with a sense of duty that I share his very important message with you.

James shared an anecdote gleaned from a visit to the thoracic surgery department of a major Eastern teaching hospital in which the chairman described to the fellows a smorgasbord of approaches to a surgical problem and told them to pick the one they like. “Don’t we know what works?” asked James. “Don’t we have a clue about what actually works? Is it really all based on opinion?”

Compounding the problem is the difficulty in keeping up today with the medical knowledge portion of the professional covenant described by James. “At the time I went to medical school, the doubling time for medical knowledge was 35 years,” said James. “Today, the doubling time for medical knowledge is 8 to 10 years. The illiterate today are not those who can’t read and write. It is those who can’t learn, unlearn, and relearn.”

The Economic Imperative

James spent considerable time on the teachings of the man he referred to as our nation’s CFO, David M. Walker, Comptroller General of the United States. According to James, Walker has spent his term traveling the country, telling anyone willing to listen that the crisis is coming not in 2019, as the recent report from the Medicare trustees suggests, but in 5 or 6 years, when we will need to start dipping into the Medicare Trust Fund. Because the Medicare Trust Fund contains Treasury bonds, the only way we can redeem the bonds is to increase taxation, reduce spending, or shift federal spending.

James also shared that the Dartmouth Atlas has identified two state-of-the-art health systems that could reduce the Medicare bill by 30% if emulated by every hospital in the country. “You realize that radiology is inherently dangerous?” James asked the audience. “Oh, you’re thinking it’s that ionizing radiation. That’s the least of your worries. Here’s a classic example.”

James described a mobile x-ray program for lung cancer screening operated by the federal government when he was a child growing up in Iowa. The truck showed up year after year for 7 years until the government figured out it was finding 100 false positives for every case of true cancer. “It turns out that the efficacy of a test depends not just on sensitivity and specificity, it also depends on the prevalence rates in the underlying community,” James said. “And the trouble is that the workup is dangerous. It turned out we were killing more people with false positives than we could ever save. That’s danger.”

It is also history, but we know where James was going.

We have a fiduciary responsibility in radiology, not just to our patients, but our nation, to deliver value-added care.

Cheryl Proval is business editor of  Axis Imaging News. For more information, contact .