I want my health care to be personalized AND I want it standardized.
When I go to my doctor, I want her to treat me like an individual who has different wants and needs than her next patient. Even though she may spend only a few minutes with me, she makes me feel like a unique person. She remembers who I am and the challenges I am facing. She doesn’t just dispense medical care; she cares for me as a person.
But I also want my health care to be standardized. If I suffer from a specific illness, I want to be able to get the best scientifically validated treatment for that illness taking into consideration my specific preferences and needs. I don’t want to be given my doctor’s favourite treatment if that is not the best and validated treatment approach.
The delivery of health care is often not standardized. Different patients will be offered different approaches for the same health problem. For a given problem, some patients will be hospitalized while others will not; some will get surgery and others will have a medical treatment instead. This makes a lot of sense if the variation is based on variation in the illness or the patient, or even variation in the patient preference.
These variations in care are often based on what the health care provider prefers. Preference may be because of the way he or she was trained or past experience. This is not a good idea unless the health providers preference is for the best scientifically validated treatment. Whenever there is large variation in treatment for the same problem, it indicates:
1. We don’t have good scientific evidence to prove what the best treatment is, and thus there is no “preferred” treatment.
2. Some care providers are giving inferior treatment by using their preferences instead of the “gold standard” or evidence based treatment.
3. There is evidence that two or more treatments are the same and then it doesn’t really matter which is used.
I used to think that this was true only in my own field of child mental health. In many cases, you could predict what treatment a child was going to receive by looking at the preferences and biases of the health care provider rather than the child’s health problem. So for example, if your nine-year-old child had severe anxiety and panic attacks that were preventing them from attending school, professionals trained in family therapy would offer family therapy, psychoanalysts would do psychoanalysis, cognitive behavior therapists would do cognitive behavior therapy and physicians would prescribe one or more drugs. This wide variation in treatment is unacceptable.
Wide variation in treatment in the health system is a signal that decisions are being made without the use of evidence.
Two issues that we have to grapple with in these variations are because of skills, knowledge or experience of the health care provider and cost of the treatment.
If an intervention requires a certain type of skill that the health care professional does not have, then the solution needs to revolve around the patient preference. Clearly defined options should be given to the patient. “The research suggests that ABC treatment is about 10% more effective and I can refer you to Dr. Y. I can treat you with XYZ approach which is pretty good but not as good as ABC.
If treatment is varied because of the values, needs or preferences of the patient, that is appropriate as long as the patient understands the options. For example, a treatment that can be administered with a daily pill might be chosen over a more effective treatment that is delivered by means of a two hour intravenous treatment in a hospital (especially if the patient has to travel two hours to get the treatment). Similarly, a treatment that has fewer side effects might be chosen over a more effective treatment with more side effects. The key is that variation should be for the patient’s best interest as judged by the patient. Consequently, a full discussion about the advantages and disadvantages of each treatment option is needed.
Treatments that cost the health system will usually be chosen over more expensive treatments so that more patients can be served. Day surgery is now used for problems that used to require hospitalization. Generic drugs are often prescribed instead of brand name drugs. If a patient’s insurance will pay for a more expensive alternative, this is often possible.
What can you do to ensure that you are being offered the best treatments possible?
1. Ask questions about the treatment that is being offered to you. Questions you could ask include: “Is there good evidence that this treatment is effective?”; “What are the other alternatives to treating my health problem?”; or “Can you suggest something for me to read about this treatment or alternative treatments?”
2. Use trusted sources to look up information about your treatment. One of the best sources is Medline Plus, the National Institutes of Health, health information portal. It provides information and links to other sources. Well known health charities such as the Canadian Cancer Society and the Heart and Stroke Foundation. Avoid any website that is selling anything.
3. If you are unsure and the situation is serious, you may want to ask your doctor to refer you for a second opinion.
~Dr. Patrick McGrath