No Best, Only Better Practices—Lessons from the Olympics

Simplistically put, the current thinking on the healthcare overhaul enjoins us to “identify the “best” practices and just have everyone follow them.”

There are at least two major flaws with this concept. First, there are no best practices. There are only better practices, everyday.

Second, everyone is different. No two patients are going to need the same “practices.” Now, I know that you are all saying, politicians don’t mean the patients when they say “everyone.” They mean the doctors. But the point is that they’re missing the point. The patient is the subject. The patient is the central character in the drama of medicine and healthcare. And everyone is very different.

Now for the “best practices.” It’s worth repeating. There are no best practices. There are only better practices, everyday. If there were best practices, we would still have only sulfa drugs or penicillin to treat infections. We would not know that a bacteria, H. pylorei, is the cause of many, if not most gastric ulcers. The discovery of this fact and the development of the mega-anti-acids, called proton pump inhibitors, have all but eliminated the many complex abdominal surgeries, the best practices of their day, that I learned as a surgical intern 30 years ago.

What is best for me, a woman with a specific medical and surgical history and a cultural/social context and point of view, is not best for you, a man or a woman with a similar medical profile. Even if we both have the same medical “disease.”

Best practices are only fleetingly best. Practices need to change with every new important piece of information brought forth in the medical scientific literature which is full of contradictions, and rightly so. People are full of contradictions, especially their biology, their beliefs, their politics, etc., all of which impact their medical profile and therefore their medical care.

As for the “everyone,” physicians are supposed to enter into a very special and unique relationship with each and every patient. The relationship is defined primarily by the patient and his/her needs. The physician brings her medical bag of knowledge and skills to the encounter, and then pulls out the right set at the right time in the right order to fulfill (many times after a prolonged journey of exploration) the needs of that patient. And every patient is different, very different. Even if the recommendations for care may look the same.

So where are the lessons from the Olympics? The Olympic Gold Medal for Men’s went to the US contender, Evan Lysacek. The first American to be the World Champ and get the Gold since 1984! The first American to stand with the men’s Gold Medal for skating since Brian Boitano in 1988. And he did it without the quad! He did it by being the best he could be with all the tried, true and perfected tools in his skater’s box. And he was brilliant. (I chose this link b/c you can watch again and again these two incredible athletes.)

The quad is a new, more daring jump. Not everyone has mastered it, much less perfected it, enough to make it a reliable jump at the mother of all competitions, the Olympics. But take heart, Evegeni Plushenko, eventually the quad will become the “best” practice in skating and therefore the standard practice, if you are going to be the best. That is until the next great move is invented and perfected.

Medicine, like Olympic skating, skiing, and snowboarding, is a sport in a constant state of reaching towards being better and better. It’s usually an evolution but occasionally there is a revolution. But if we are stuck (against our will and natural inclinations) in the “best practices” of today which must rapidly become those of yesterday, why bother to find better practices for tomorrow?

Politicians need to be careful about how they characterize your healthcare overhaul. They might not truly understand the real consequences of what seems to you to be a simple solution where none exists. A solution, yes. Simple, no.

If you, dear reader, are interested in this topic of best practices, I recommend you to a far more in depth and eloquent discourse by Dr. Jerome Groopman. Jerry Groopman has emerged as a voice of the physician who knows how difficult quality medicine is to develop and deliver. He is a colleague and a friend who has courage to stand up and say what needs to be said.