Thursday, March 20, 2008

Why have doctors lost out to bureaucrats ?

Medicine was much simpler in the past, when doctors made decisions in consultation with the patient, to do what they both felt was in the patients' best interests.

Today, this autonomy and freedom has been taken away - from both the doctor and the patient. They are told what they are allowed to do - and what they are not - and this has become the norm for many areas in medicine.

An excellent example is my specialty - IVF. Today, in the UK, doctors are allowed to transfer upto a maximum of only 2 embryos for IVF

We all understand that the best outcome of an IVF cycle is a singleton healthy pregnancy ( though twins are a welcome bonus for many infertile couples !) However, IVF technology still has a long way to go and it's extremely inefficient today. Even perfect embryos have only about a 30% chance of becoming a baby. While SET ( single embryo transfer) is the holy grail we should aim for, the fact remains that we are a long way of from reaching this stage.

This means that while this policy is sensible for a 30 year old woman doing her first IVF cycle, it does not make much sense for a 41 year old woman who has already failed 3 IVF cycles.
In her case, her best option would be to transfer more embryos, to maximise the chances of at least one of them implanting successfully.

Common sense says we need to individualise care for each patient and formulate a personalised treatment plan for each patient, depending upon their history , clinical circumstances and personal choice. In fact, this is exactly what doctors are meant to do even today !

However, this right , privilege and responsibility is gradually being taken away - by bureaucrats, who want to tell doctors how to practise medicine.

The modern view is that doctors cannot be trusted to make the right decisions; and that they need to be monitored and policed. This is why they need to be regulated by bureaucrats, who can decide what is best for everyone !

Unfortunately, the problem is that one size does not fit all. Bureaucrats treat everyone as a number - and because they are nameless and faceless, while they excel at dealing with groups, they are not very proficient at handling individuals.

Like all good officials, they do take advise from medical experts when drafting their guidelines - but as anyone who has been part of the process will tell you, this is just a sham. Since they decide which experts to invite, they selectively stack their committees with doctors who toe the party line - and tell them what they want to hear. They are masters at manipulation; and since they are the ones who do the final drafting, they conveniently leave out everything which is inconvenient for them.
The treat doctors as puppets - and since most doctors are too busy taking care of their patients , they get easily manipulated !

Bureaucrats think in terms of numbers only - they think " big" ! However, this means that while they are good are creating rules, they are terrible at dealing with the exceptions to their rules. They ignore the exceptions - or are happy to sacrifice personal desires, at the altar of a greater " social good. " They treat everyone as part of a homogeneous whole; and for them, the inconvenient square pegs need to be forced into the round holes they create.

Doctors deal daily with individual patients who are hurting on the inside. They are extremely good at solving an individual's problems one-on-one - but because they do not have the skills to tackle bureaucrats, their ability to do so has been gradually eroded.

Bureaucrats specialise in creating hurdles - in telling people what they cannot do. Doctors , on the other hand, are experts at solving problems - in helping patients to achieve their personal goals.

This sad state of affairs means that doctors have lost their autonomy . They can no longer practise medicine the way it should be - to maximise their patient's personal best interests.
This will hurt all patients - and all doctors.

The sad reality is that by abdicating their responsibility, doctors have failed themselves; future doctors ; and their patients.

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