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    Wednesday, July 07, 2004

    Tending Our Gardens: I love going to our community garden. Usually, I go after work with a couple of the kids in tow. After being cooped up in the office all day, it feels so good to stand in an open field exposed to sun and wind. And because I go after work, I often find myself musing on the analogies between the community garden and modern American medicine.

    On its face, the community garden seems a system that would be ripe for flirtation with communism, as its origins during a more socialist stage of our history would suggest. The state (or in most cases, a city) owns a plot of land that its citizens can use to grow food. But, of course, the community garden is anything but communist. It is quintessentially American. Each gardener or family pays the city a nominal fee for a plot of land. And each gardener or family can do what they want , how they want. They can devote their plot of land to one crop or a variety. They can plant as far apart or as close together as they want. They can have an organically maintained garden, or a chemically maintained garden, or one that is hardly maintained at all. Walk around the average community garden and you'll see as many types of gardens as there are gardeners. And everyone's happy, because they can garden in a way that suits them best .

    Imagine, however, if the community garden were a communal garden instead, and all of its harvest shared among the gardeners. There would be a lot of resentment among the more productive gardeners towards the less productive. Rules about what to grow and how to grow it; how often to weed and how to weed, would soon be instituted. No one would be allowed to risk new varieties of vegetables or new gardening techniques for fear it would diminish the harvest. It would sap all the fun out of gardening.

    Alas, practicing medicine these days is too often like tending a communal garden. We may not have a socialist healthcare system, but we have one that is pretty darned close. Because third party payers pay most of the healthcare bills in this country (in contrast to the patient), they decide what constitutes good medical care. And because they aren't the patients, they base their quality standards on what's considered best for populations rather than individuals. They analyze patients' bills to see if their doctors are ordering recommended labs and screening tests, or to see if patients are visiting the doctor with necessary frequency. And in some cases, they've set up "disease management" programs that track a patient's lab results and symptoms to make sure they meet the standards.

    At first glance, this may seem like a good thing. Standardized care means everyone gets quality care. But, the problem is that in medicine, one size does not fit all. Take, for example, diabetes. There are well-established standards for good diabetic care. A diabetic patient will, in most cases, do better if his blood sugar is consistently less than 120, if his blood pressure is less than 130/80, and if his cholesterol levels are kept at very low levels. However, for some diabetics, meeting those goals comes at too high a price. There are diabetics who can not maintain ideal blood sugar levels without sending their sugars spiralling to intolerably low levels, those who cannot maintain ideal blood pressure levels without getting hypotensive when they stand up, and those who cannot achieve ideal cholesterol levels because of side effects of cholesterol medications. In each of these cases, it would be better medical practice to ignore the standard and treat the patient.

    But, in our third party quality control system, there's no room for individuality. An insurance company auditor doesn't care about the details (or isn't trained to notice them.) His only concern is whether or not the numbers are where they're supposed to be. If they're not, the doctor gets chastised. The chastisement may be in the form of an "educational letter" reminding him of the standard of care. Or it may be more punitive. Either way, the net result is a tendency among doctors to treat the numbers, not the patient.

    And that is, indeed, bad medicine.

    posted by Sydney on 7/07/2004 08:26:00 AM 0 comments


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