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2-1 MANAGED CARE, MANAGING UNCERTAINTY
Uncertainty is a fact of life in medical practice. We
usually do not know unequivocally the full extent of a
patient’s disease and even less often do we know the
best single approach to diagnosis and treatment even if
one were to exist even in theory. Physicians practice
within a broad range of acceptable practice that is
based, in large measure, on uncertainty.
Appropriateness is a continuum, not a simple dichotomy
between appropriate and inappropriate; what is
appropriate will change with clinical circumstances.
Archives Int. Med. February 24, 1997; 157: 385-88 2-1 MANAGED CARE, MANAGING
UNCERTAINTY
It is important to understand what is managed. The
implied object may be the budget, the physician, health
care resources, or more optimistically, the care of the
patient. In this essay— "We suggest that one
object that is managed is uncertainty".
Uncertainty is a fact of life in medical practice. We
usually do not know unequivocally the full extent of a
patient’s disease and even less often do we know the
best single approach to diagnosis and treatment even if
one were to exist even in theory.
Uncertainty results from:
- 1) Biological
variability
- 2) Concomitant
disorders.
- 3) Incomplete
knowledge of the basic pathophysiologic
characteristics and mechanism of action of
therapies.
- 4) Lack of knowledge
of what works and what does not work
Because of this, it is
unreasonable to expect that a single path for diagnosis
or treatment exists for all patients. Uncertainty will
remain. Diagnostic tests yield probabilities rather than
certainties. Many treatments are based not on scientific
principles, but on learned practices, assumptions, and
other nonscientific formulations. We have limited
knowledge of the outcomes of what we do. We know the
precise value of only a few tests and the exact benefits
of a small number of procedures and treatments.
What are the consequences of uncertainty? The essayist
suggests that the key consequence is the existence of a
range—rather than a single point of acceptable
practice. The uncertainty hypothesis suggests the reason
for the wide variability of practices in different parts
of the country. Variation results from differences in
physician’s decision making when facing diagnostic
and therapeutic uncertainty in clinical practice.
Professional uncertainty, rather than consensus about the
scientific basis of clinical practice is emerging as the
dominating reality.
The result may be depicted
on a scale:
- To the far left are a
minimal number of tests and treatments that are
widely accepted as being necessary for a given
condition. Not to provide these services would
result in inadequate care and underutilization of
resources.
- To the far right are
tests and treatments that are accepted as not
being appropriate. (Appropriate means that the
application contributes in a meaningful, positive
manner to improving the health of the patient.)
To offer these tests and procedures results in
over- utilization of services.
- Between the 2
boundaries is a range of practices characterized
by doing all that is necessary and only those
things that are appropriate.
But what determines where
within this acceptable range a specific patient lies?
Some determinants:
- Age and gender of the
practitioner (ordering patterns do differ).
- Training. Primary
care clinicians use fewer resources than
specialists.
- Place of training.
- Availability of
technology. This may drive practitioners to do
whatever they have the ability to do, regardless
of the benefit/cost ratio or value.
- Physician’s
personal gain. (Physicians alter practice
patterns in relation to fees.)
- Inability of
physicians to deal with inherent uncertainty. (We
have assiduously woven the goal of minimizing
uncertainty into the fabric of clinical practice
and teaching.) This can lead to over testing.
This is enhanced by an instinctive bias that
assigns greater seriousness to errors of omission
than to errors of commission and the charge to do
all that may benefit the patient, regardless of
how little the possible benefit or how great the
cost.
Uncertainty of benefit
leads to greater use of resources. This need not, and
usually does not, result in unacceptable practices. The
range of acceptable practice, based on what is known or
not known by medical science, is broad enough to allow
substantial variations in practice patterns. Thus the
existence of even major differences in practice does not
necessarily indicate good or bad practices, only
different practices.
Physicians practice within a broad range of acceptable
practice that is based, in large measure, on uncertainty.
Appropriateness is a continuum, not a simple dichotomy
between appropriate and inappropriate; what is
appropriate will change with clinical circumstances.
Many of the practices of managed care are also rooted in
uncertainty. In order to reduce costs organizations try
to shift practice patterns to the left of the acceptable
scale (toward only necessary tests and procedures) as
long as it remains in the acceptable range. The care that
results, is by definition, acceptable. If the
conservation incentive is so strong as to induce
underutilization, unacceptable care results. For
physicians, uncertainty drives practices to the
right—to attempt to reduce uncertainty and to
maximize potential benefits. What is not known to be
inappropriate may be considered necessary.
The key issue is not what practices are supported, but
who determines where practice lies on the axis. A final
and long-term challenge is for both groups to work to
reduce the level of uncertainty in practice.
Archives Int. Med. February 24, 1997; 157: 385-88
Commentary from Univ. Of Tennessee College of Medicine,
Memphis
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