The practice of medicine is under attack, and not just in the United States. Physicians everywhere are being separated from their patients and from the practice of medicine by forces beyond their control.
“Engineers and managers are trying to reinvent medicine, and they are succeeding,” said Owen Korn, MD, associate professor of surgery at the University of Chile Clinical Hospital in Santiago. “I call them the four horsemen of medical practice, and they are trying to destroy the world of medicine.”
Dr. Korn described the four horsemen, evidence-based medicine, electronic medical records, medical management, and accreditation, during the 2016 Hale Lecture, “The Four Horsemen of the Medical System Apocalypse,” on Saturday morning. All four horsemen emerged as self-proclaimed saviors of medicine, he said, and all four have metamorphosed into forces of destruction.
“These four horsemen are turning patients into consumers and physicians into players in a system designed to reduce costs rather than the burden of disease and to maximize profits instead of health. The practice of medicine has moved from compassion to management.”
Evidence-based medicine arose from the recognition by Archibald Leman Cochrane, MD, that many clinical decisions are little more than guesswork and personal preference. That initial insight led to The Cochrane Collaboration and the growing importance of meta-analysis. It also led to the pre-eminence of evidence-based medicine, developed by epidemiologist and biostatistician Gordon Henry Guyatt, MD.
“We now have a hierarchy of evidence in medicine that gives the greatest weight to meta-analyses of randomized controlled trials and the lowest weight to expert opinion,” Dr. Korn said. “A recent meta-analysis of bariatric surgery, for an example, is based on just 164 studies out of more than 25,000 initially identified articles. When you are the patient, would you rather be treated by meta-analysis or by a real doctor with real experience with real patients?”
Electronic medical records arose from the good intentions of making more data more accessible to clinicians and researchers. That initial goal has become a hell of impenetrable screens that devour physician time and attention that should be devoted to the patient and are poorly integrated into patient care.
“Who are the real winners of the move to EMR?” Dr. Korn asked. “Not patients, and certainly not doctors. The only winners are the companies that create and sell EMRs.”
Management is a business concept that has to do with controlling costs and maximizing profits by organizing, coordinating, and directing the activities of an organization. Nothing in the concept has anything to do with maximizing the health of patients or supporting the clinical practice of medicine by physicians.
“Management in health calls our patients customers,” Dr. Korn said. “That doesn’t work for the simple reason that the customer is always right, but the patient is not always right. That’s why doctors are needed.”
Accreditation is another good idea gone wrong. Accreditation has devolved into nothing more than documents, manuals, rules, guidelines, and procedures, Dr. Korn said. And for the physician who is too busy caring for patients to read the reams of paper involved, there are manuals help to understand the manuals.
“Patients have become populations, and they are being auctioned off to the highest bidder for the highest profit,” Dr. Korn said. “We don’t need more medical management and more electronic systems to improve the health of our patients. We need just the opposite. There is a notion to consider, the notion of going back to the basis of medicine. We need less management and more compassion.”