February 15, 2010

Revising the Art of Medicine

For physicians, the nearly instantaneous availability of evidence-based information and protocols is a real game-changer, says Dr. Brian Nester ’04 (EMBA).


After practicing medicine in the emergency room for more than a decade, Dr. Brian Nester ’04 (EMBA) realized he wanted to be part of his hospital’s decision making. To make that transition he came to Columbia Business School. After his first year in the program, he became senior vice president for Physician Hospital Network Development at Lehigh Valley Health Network (LVHN), overseeing business and strategic market development. The Pennsylvania–based healthcare group has nearly 1,000 beds and three campuses.

Nester is a strong advocate for the shift to evidence-based medicine as a way to create greater value in healthcare, and he sees LVHN’s use of a computerized system for physician order entry as a key driver. “Our health network incorporates a team approach to ordering,” Nester says. “Our pharmacists are as involved as the doctor in making decisions about antibiotics, for example. The orders reflect the most recent knowledge of the appropriate drug for the appropriate problem. There is an intersection here of standardization and cost, which we need to pay attention to.”

As someone with a foot in both the provider and physician camps, what challenges do you see for evidence-based medicine in each of those areas?

“The real art of medicine today is still the doctor-patient conversation. The rest, frankly, can now largely be standardized.

From the hospital provider perspective, it depends on the environment. My hospital is a hybrid where we have a large employed physician group as well as an academic focus. These factors, along with our size and the volume of patients we see, require us to pay far more attention to evidence-based medicine in order to reduce unnecessary practice variations. For physicians, the nearly instantaneous availability of evidence-based information and protocols is a real game-changer. I believe that as physicians become more technology-dependant, they will by default adopt more evidence-based information. The challenge for them will then be less about which test to order and more about translating complex conditions and difficult situations to patients. The real art of medicine today is still the doctor-patient conversation. The rest, frankly, can now largely be standardized.

If the art of medicine is about managing relationships, then what role does evidence-based medicine play?

A doctor can’t hide behind the idea that his or her own personal recipe of tests and medications is the only right way to go. The art of medicine is about how to translate results, follow up with patients and make sure they understand what’s happening with their bodies. In evidence-based healthcare, we’re paying more attention to what we can standardize, like the tests and treatments that are proven to be helpful to patients. It’s the over-utilization of resources, and variability in the delivery of care, that contributes to out-of-control healthcare costs nationwide.

Healthcare costs are spiraling. How does evidence-based medicine address the issue of value?

Evidence-based medicine is at the heart of healthcare value, where value is equal to quality over cost (V=Q/C). On a national level, we have complication rates that are not acceptable. We have outcomes that are below par, and they include both morbidity and mortality rates. We need to enhance the value we provide to our communities by increasing quality while we reduce costs. The reality is that we need to address over-utilization as well as inappropriate utilization. It’s not the doctors’ salaries that are at the tip of the spear; it is the pen that is in the doctor’s hand. What an individual doctor chooses to do has tremendous impact on healthcare expense. Unfortunately today, most of what doctors order or prescribe is based on what they learned during their training, rather than current, evidence-based protocols. A computerized physician order entry system with up-to-date, standardized pathways, like the one our health network has, starts to address that issue. It’s a real advantage for physicians and patients.

But haven’t patients come to expect tests and lab work as part of good healthcare? Is there a problem with patient perception?

Yes, I believe that the doctor-patient relationship has changed substantially over the last 10-15 years, unfortunately not necessarily for the good. Rising costs and declining revenues for medical practices have forced physicians to see more patients for less money in many areas — especially in primary care. This commoditization of medical practice has negatively impacted the doctor-patient relationship, often pushing the doctor to say ‘Let’s get some tests and I’ll see you next time’. Over years, the expectations of patients have changed to; ‘testing is a good thing and the only way the doctor decides what is wrong’. What’s worse is that, during this same time, some inadvertent [and even perverse] economic incentives may have further contributed to over and inappropriate testing. Consequently, nationwide, we have trained an entire generation of patients to expect aggressive testing as the new norm.

So, how do you have that conversation? It’s really hard to suddenly explain to the patient who has had 10 years of high-utilization testing that we don’t need another one right now. That conversation takes time and effort in an era when doctors already feel squeezed. My hope is that as we move more towards standardized protocols and evidence-based medicine on a national level, the option to have more meaningful discussions with patients about what’s really necessary becomes more of a reality.

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