The good-old-days fallacy occurs when we remember fondly those times when we did not have to face the endless frustrations of insurance forms, authorizations and peer-review forms. Unfortunately, getting paid in direct proportion to what services a clinician delivers also directly rewards unnecessary and even harmful interventions.
The Marcus Welby fallacy particularly applies to family physicians and is the most important one to correct. Named after the TV doctor who cared for only 1 patient per week, this fallacy refuses to let us acknowledge that (1) patients have a life outside of our offices, and (2) there are patients outside of our practice who are nonetheless affected by what goes on within our 4 walls.
All clinicians must recognize that always choosing to maximize care for individual patients places these patients, not only in conflict with society, but, ultimately, in conflict with themselves. For example, even though the incremental cost of an expensive versus inexpensive antibiotic for a respiratory infection seems minimal at the time, each of these decisions takes away money in the system that could be used by the same patients later in their life for truly life-threatening infections. In essence, beneficial yet unnecessary care mortgages the patient’s—and society’s—future.
The True Mission
If we fix overuse or misuse problems, we improve quality and reduce costs at the same time. Overuse is ubiquitous in American medicine.1
Evidence-based medicine, and our derivation, information mastery, evolved as a way to make sense of the incredible amount of information available to practicing physicians so that they might improve their delivery of medical care. Lately the use of evidence-based/outcomes-based medicine techniques have been met with suspicion, especially because nonmedical professionals have embraced this approach.
The true goal of evidence-based medicine and information mastery is to provide effective and efficient care to patients via a health care system that allows all people to receive basic care. To meet this goal, this system has to be reconfigured so that existing resources are used in a way that is fair and equitable to all persons (and not just patients). Costs must be considered.
Improving quality and decreasing costs
The value of health care services can be improved either by improving quality or decreasing costs. This relationship can be conceptualized by the following equation:
Value = Quality Cost
If we decrease cost and compromise quality in the process, we gain nothing and may lose value. This is many clinicians’ greatest concern regarding cost-cutting efforts. If we can raise quality and decrease costs, however, we can significantly improve value.
Improving quality can be accomplished by reducing underuse, overuse, and misuse of medical care. Most current efforts to improve the quality of health care are focused on reducing underuse and are aimed at ways (practice guidelines, peer-review reports, and so forth) to get clinicians to do things they should be doing but are not. The problem, however, is that doing more is expensive and raises costs, thus reducing the amount of value gained as a result of the increase in quality. As a result, the gains are usually minimal and do nothing to lower the costs of health care or to make access universal.
However, it is estimated that we can safely eliminate almost 20% of the things we do in medicine and no one will be harmed as a result.20 The question is: which 20%? The best way to improve quality in the system is to address misuse and overuse of resources by focusing on using interventions that are less expensive, more effective, or both. Protecting our patients from overuse of services prevents them from being exposed to the risks of unnecessary interventions. This process starts by paying attention to what the evidence is telling us about our care. The concept of Patient-Oriented Evidence that Matters grew out of a need to identify information that tells us what treatments allow patients to live longer or better. As valid POEMs accumulate, practices must be changed according to this new and better information Table 2.
Using POEMs as our guide to which services to provide and which to leave out can eliminate waste in medicine, and in so doing, may result in a more fair distribution of resources. This will occur only if free market competition resulting from industry payers or legislation prevents the additional savings from becoming more profits for shareholders. A focus on POEMs will fit into any health care system concerned with proportioning limited resources. Many clinicians and laypersons in the United States connect the idea of rationing with the long waiting lists for health services in Canada and the United Kingdom. Even countries with universal health care access would benefit from eliminating useless or marginally helpful services.