Genomics, Not Cookbook Medicine?

genomicsGenomics promises the next wave of medical innovation. It will remake clinical care. At least that’s what the genomics researchers say.

Today, medications get tested on thousands of people. Hopefully, safety and efficacy in thousands of study patients means medication will work on each individual patient.

Can we do better?

Genomics

Imagine if we could match someone’s exact genetic coding with a perfectly suited treatment? Genomics promises to do that, soon.

Personalized medicine, pharmacogenomics, presupposes individuality. People respond uniquely to medication. Currently, we aim for similar targets in every patient on a particular pill but are not surprised that individuals respond uniquely.

It explains why, all things being equal, a patient needs more medication than her sister for the same condition.

Not Cookbook Medicine

Genomics undermines a powerful movement. Evidence based medicine (EBM) has preached standardization, clinical practice guidelines and ‘quality’ for decades. Evidence based medicine swelled on the imprimatur of statistical analysis.

Devotees believe the path to excellence and efficiency lies on the narrow road of crisply defined process.

Top-Down Control

Academics, central planners and politicians love EBM. They wield EBM to proscribe medical deviance. Clinical judgement takes the hindmost.   Planners stand on giant studies and proclaim ideal treatment and best practices. Politicians lean on wayward physicians who allow too much patient choice in treatment, too much individuality.

Genomics delivers a new songbook. It sounds like old-fashioned pathophysiology that EBM discarded in the 1980s. Pathophysiology irritates statisticians and politicians. It encourages clinicians to think instead of memorizing clinical guidelines. Thinking is messy, hard to control.

Future

Genomics might become just another cookbook. It might dictate treatment based on computer analysis of patients’ genomes eliminating clinical judgment. Regardless, it will still ruin the one-size-fits-all approach clinicians get graded on now.

Hard core, individualized science might make a comeback. It will change everything. And it won’t be cheap.

photo credit: telegraph.co.uk.com

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Healthcare’s Only Hope (is NOT Government)

healthcare's only hopeHealthcare loves new ideas that promise even a glimmer of improvement. Every new approach brings hope that maybe this will fix healthcare.

We believe that some one, or some thing, will put everything right.

Like Princess Leia, we believe our only hope exists but disagree on where to find it. (Video clip: “Help me Obi Wan Kanobi you’re my only hope.”)

We can organize fads or solutions by the level at which they promote their change.

Individuals

Some believe specific providers will deliver an ideal healthcare system. We just need nurse practitioner led clinics; more nurses, nursing assistants, more doctors…

All providers overlap in the services they provide. But healthcare’s far too diverse for us to believe one type of provider can be healthcare’s only hope.

Teams

‘Team care’ used to guarantee thoughtful nods from audiences. Specialized teams promised to solve everything from education to quality and efficiency. They help. But they don’t make individuals and organizations obsolete.

Organizations

Many pundits believe something like Kaiser Permanente offers healthcare’s only hope. Organizations and process solutions hold promise for operational efficiency. KP seems to deliver great patient service and holds collectivist values many find attractive in Canada. But they only serve select populations and have had to close down in some locations.

Social Institutions

  • Military?
  • Private business?
  • The free market?
  • Organized religion?
  • Unions?

 Government

Should we place our only hope in government?

If so, which level of government?

  • Municipalities don’t get enough help from the province.
  • Provinces continually ask for help from the feds, so clearly they can’t provide healthcare by themselves either.

Maybe a national plan would solve everything, like the British NHS we copied in the 1960s?

John Roberts served as a Liberal cabinet minister in the Trudeau and Turner governments.  In 2003, he wrote an essay in Searching for the New Liberalism: Essays in Renewal. He wrote that since the 1930s,

“…government departments multiplied and expanded, and a plethora, almost uncountable, of crown corporations was established.” 

Government was poor, however, at managing for a variety of reasons — the political processes of government militate against flexibility, decentralization and the delegation of responsibility; personnel management, an essential instrument of management, remains largely outside the hands of political direction; government does not have profit as a bottom line objective and therefore finds it difficult to apply as a means of bureaucratic control; the objectives of government are as mixed and as varied and as contradictory as the members of society.  These amorphous purposes, the lack of precision in purposes, make public management cumbersome rather than streamlined.”

Roberts, a believer in big government, says government cannot manage because:

  • Government resists flexibility, decentralization or delegation
  • Government struggles with personnel management
  • It has no bottom line for bureaucratic control (unlike profit in business)
  • There are too many objectives
  • Purposes are amorphous and imprecise

Healthcare’s Only Hope?

Here are some steps we might consider instead of searching for Obi Wan:

1. Stop looking for healthcare’s only hope. It does not exist. Complexity requires complex solutions.

2. Empower providers. Explore how ALL PROVIDERS can work to the full scope of their expertise. Not just nurses and pharmacists (as the latest only hope for healthcare). Doctors could supervise other providers in large clinics much like dentists.

3. Liberate, don’t regulate. Instead of saying “You can’t do that” we should say, “Show me how well you can do it.” Let individuals, teams, organizations and social institutions prove their worth in the results they deliver.

4. Challenge veto power and special interests. We are immobilized in a system where every stakeholder can insist why everyone else cannot do something or change the way they currently work. Everyone has veto power. Everyone can say “No” – Regulatory colleges, unions, associations, hospitals, and special interests.  No one allows anyone freedom to prove their worth.

5. Innovate, experiment and learn. Stop thinking healthcare is so concrete, so specialized. Most things do not have ONE obvious answer. Focusing on innovation, experimentation and outcomes could move us beyond our devotion to rigid ideas of evidence (logical positivism) without falling into postmodern relativity.

6. Challenge hegemony wherever it exists. Arbitrary governing authorities that regulate, legislate and manipulate healthcare according to their own vision of utopia guarantee stagnation.

7. Get government out of management. Only pride, power-lust or ignorance insists government manages best. Bureaucrats are not business leaders. Healthcare deserves the best leadership and management expertise available. Youthful poli-sci grads are great for many things, just don’t ask them to manage healthcare.

8. Empower Patients. They’re smart. For the most part, patients do not need, or want, to be passive, obedient recipients of healthcare largess. Patient empowerment and accountability offers a huge untapped opportunity to reform healthcare.

9. Diversify labour. Who, besides the unions, benefits from having 98% of the hospitals unionized in Ontario?

After we tackle these issues, we could examine hospital ownership, public health mandate, CCAC, LHINs, and much more, all within a national insurance plan like Medicare.

What to you think? Are we searching for healthcare’s only hope? Are we putting too much faith in government to save us? Are we hoping to find some other super-solution for all that ails healthcare?

 

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Healthcare Socialism AND Capitalism

red-pill-or-blue-pillGreat headlines sell newspapers.

Black and white issues demand attention.  Clear extremes introduce conflict into otherwise dry discussion.  They call listeners to take a stand, make a decision, to stand up for ‘what’s right!’

Healthcare pundits and experts have failed to ‘fix’ the system for decades.  It’s impossibly complex.

They grow frustrated.

We grow impatient.

Frustration craves simplification.

Simplicity fuels decisive action.

But healthcare complexity requires balance and nuance. Headlines designed to sell on conflict and our impatience with complexity helps polarize healthcare debate.

Healthcare Extremes

Ideological socialists fight passionately against anything to do with choice, competition, or markets.  Dogmatic capitalists rail against state ownership of production, third party control and freeloaders.

Socialists insist healthcare, like the military, should be centrally funded and controlled. Capitalists argue the opposite.

Both extremes fail.

Socialism and Capitalism

Socialism describes an economic system where the state, on behalf of society, collectively owns and operates the means of production and distributes the proceeds. Capitalism describes a system where individuals own and operate the means of production and benefit personally from the proceeds of their efforts.

Great economies include elements of both.

No country has a market-based court or military.  Societies need socialized legal and defense services.  On the other hand, decades of price fixing in Eastern Europe caused rationing and created a massive black market.  Creativity, innovation and industry flourish with freedom and property ownership.

Healthcare Socialism and Capitalism

Great systems have some state organization of services but also competition, choice and innovation.

Socialist ideology has no mechanism to match the creativity, innovation and progress of market forces flowing from consumer choice.  Free market capitalists have no room for ‘free care’ or helping those who cannot help themselves.

It strains one’s imagination to come up with a free market system for heart transplantation or organ donation that didn’t beggar all sense of generally accepted ethical principles.  So too, it infuriates providers when bureaucrats who don’t know the difference between an IV and an IVP tell clinicians how to practice their profession, at patients’ expense.

Stalemate

Canadian Medicare is frozen by extremes.  Socialists resist any whiff of market thinking.  Free-market capitalists want to scrap Medicare and start over.  Stalemate leaves politicians spending more to buy votes without substantive change.  They prop up a mired system that rewards hospitals and providers for providing great service to governments, regulators and guidelines instead of patients.

What do you think? Do we just need more of the same – more spending, more control, tighter systems?  Do we need to start over with a completely free market approach?  Or do we need something in the middle, something that includes the best elements of socialism and capitalism?

photo credit: pando.com

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