Why One-Size-Fits-All-Medicine Doesn’t Work

“If we know what those best practices are, then I’m confident that doctors are going to want to engage in best practices. But I’m also confident patients are going to insist on it.… In some cases, people just don’t know what the best practices are.”

— President Barack Obama interview with Diane Sawyer, ABC News, June 2009.

But every patient does not, in fact, react in the same way to expert opinion. Nor does every doctor. More below the fold.

Over the past four years, we have interviewed scores of patients around the country about how they make medical decisions. We found “maximalists” who want to do everything possible and “minimalists” who are convinced that less is more; “believers” who are certain that a good solution exists for their illness and “doubters” who worry that almost any treatment will be worse than the disease. They developed these mind-sets largely based on past experience with illness, and they use them as a starting point for weighing risks and benefits in their health care.

Experts also have these distinct mind-sets, both as individuals and as groups. The federal Preventive Services Task Force, for one, embodies a minimalist, doubter mind-set. That is why experts can look at the same data and still disagree about what is best.

The authors, Drs. Pamela Hartzband and Jerome Groopman from the faculty of the Harvard Medical School and the Beth Israel Deaconess Medical Center in Boston, don’t think this is a problem. I don’t either. What’s your view?

Comments (3)

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  1. Devon Herrick says:

    This is a tough issue. A general lack of competition means that best practices do not disseminate across the health care system because there is no incentive to do so. A physician who overuses an MRI machine has every incentive to continue to overuse the machine if he/she is getting paid for each procedure. Competition would squeeze out some of the waste but does not because nobody is competing on price or quality. On the other hand, no one set of rules or so-called, best practices will work in all circumstances. Hartzband and Groopman are wise to be skeptical of the pie-in-the-sky view that — in medicine — one-size fits all.

  2. Brian says:

    I agree that the one-size fits all view is something we should be skeptical of. People, however, need to be aware of the fact that there are different mindsets among the experts and those different mindsets can affect if people end up getting treatment or at least what kind of treatment they end up getting.

  3. MarkH says:

    Sorry, this comes off a bit anti-science to me. Are you saying we shouldn’t use scientific data to drive medical decisions?

    I’m sure you’re not. Instead, your saying data should guide medical decisions, but physicians should be the ultimate arbiters of care. Guidelines are fine and good (surviving sepsis anyone?), but best practice rules might run roughshod over the individual patient.

    There are a lot of instances, however, where best practices, even generalized might help patients. Examples might include determining the appropriateness of screenings, inappropriate use of antibiotics in likely viral illness, and inappropriate ordering of tests such as MRI for uncomplicated back pain. We know these things happen, they shouldn’t. If science demonstrates these generate costs and there is no evidence base for their use, how can it hurt to say they should not be paid for?