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RIGHT PATH
G iven the strong current of rugged individualism
that always has run through American culture,
it’s not surprising that we, as healthcare
consumers, want, and expect, treatment plans that are
tailored to our unique biology and circumstances. But is
purely personalized care always the best medicine?
Despite strong evidence on the benefits of cholesterol-
lowering statin medications for patients with certain
cardiovascular-disease risk factors, there is considerable
variation in which patients are prescribed the drugs —
with physician preferences and geography often carrying
more weight than data from large randomized controlled
trials, which are considered the gold standard for clinical
research. Similarly, the research is unequivocal on the
benefits of administering certain antibiotics at key points
before specific operations, yet it isn’t always done. And if
the evidence points to the value of colonoscopy screening
in normal-risk patients beginning at age 50, we don’t
expect our doctor to decide on a case-by-case basis
whether or not to recommend it.
In other words, even as many people like to romanticize
medicine as something of an art, in which decisions about
treatment are made creatively and individually, that is
not really what we want in cases where the science clearly
points to a single approach as most effective. Then, we’d
prefer to go by the book.
“Intuitively, we want care that is patient-specific. But
in reality, patients are much-more similar than they are
different,” says Tom Rosenthal, MD, chief administrative
officer for UCLA Health. “When care is purely
individualized, we find a lot of variation that isn’t
explainable by the evidence and isn’t in the patient’s
best interest.” In addition, there is “variation that is not
based on necessity and therefore arguably wasteful. By
standardizing the appropriate aspects of care and setting
up processes to ensure that they are delivered reliably,
we reduce that random variation. In so doing, we improve
quality while reducing cost.”
Standardization makes for a more-consistent product,
adds Samuel A. Skootsky, MD (RES ’82, FEL ’83), chief
medical officer of the UCLA Faculty Practice and Medical
Group, which oversees the outpatient practices of UCLA
Health. That, “almost by definition, means higher quality.
Particularly when patients are engaged to help define the
standardized-care pathways, it’s more likely to result in the
outcomes that they want,” he says.
Although evidence points to the need for more
standardization as a way to improve the safety and
efficiency of care, no one is advocating a checklist
approach to all aspects of medicine: Some individual
physician discretion will always have its place. Moreover,
Dr. Skootsky is quick to point out that within most
standardized pathways, there will be exceptions.
“A particular patient may come along for whom the
standardized approach is not in his or her best interest,”
he says. “In such cases, you can’t be dogmatic. Instead,
it’s an opportunity to learn, then see if this is a situation
that should be built into the approach for the future.”
U MAGAZINE
27