The alchemy of care variation

I regularly speak to groups of physicians about clinical practice and leveraging technology to improve patient care. I have learned that certain words or phrases can derail a great conversation, and hence, I try to avoid those terms. Sometimes there is a questionable rationale behind the negative reaction. For example, the dreaded “P-word.” Yes, you know what I mean:?provider. Many physicians rebel against this word, believing that it somehow demeans or minimizes their role as the head of the healthcare team. Other doctors think that it is just a word that makes it easier to refer to groups of professionals who care for patients. Either way, I find it easier to use other words instead and avoid unnecessary detours.

While the jury may be split on?provider, in my experience, there is consensus on a different phrase:?avoid clinical variation. This is a definite no go when I am in front of physician audiences. Just mentioning these words can bring catcalls and hisses. I get it; I understand where the discontent is coming from. Cookbook medicine is the pejorative term applied to the idea that once there is agreement on proper assessment and treatment, every patient must follow the identical pathway – almost without exception. I would argue that most chief medical officers or chief quality officers do not see it this way, but many attending physicians perceive the “avoid clinical variation” mantra as often being forced to stick a square peg in a round hole.

To acknowledge this concern, I add an adjective. Oh, the difference that one little adjective can make. I always say that we should be avoiding?unnecessary?clinical variation. That stops the cookbook medicine crew in its tracks. If we all agree on the best course of action, and perhaps we even have evidence to support said course, then we should follow those recommendations unless we have a good clinical reason to do so. Ay, there’s the rub.

Patients are not made in a factor (yet!)

If there is a good clinical reason to not follow the general best practice recommendations, then physicians should not hesitate to do so. Patients are not made in a factory (yet! ). We are complicated animals, and often, one size does not fit all. That is why the word?unnecessary?is so important. Doctors should follow clinical practice guidelines unless they have a good reason not to.

A recent?Health Affairs blog post ?expanded my horizons about the benefits of avoiding unnecessary clinical variation. The authors skillfully point out that there is a good reason to increase necessary care variation: to improve evidence-based pathways and inform care transformation. By considering valid reasons to veer from recommendations, physicians can add to our understanding of the varieties and complexities of human disease. Of course, this is easier said than done. Simply not following guidelines when they do not fit the patient’s specific course will not move the needle forward. Organized and thoughtful research is required to advance our understanding of how best to treat the wide spectrum of disease.

While evidence-based medicine and the care guidelines based on it are undeniably good things, there is always room for improvement. The authors note that factors that can justify moving away from a recommended best practice must be explored in more detail. They mention social determinants of health (SDoH) which often were not considered as care guidelines were drafted. We now acknowledge that?SDoH ?can be much more responsible for both good and bad health outcomes than any medicine doctors prescribe or surgical procedure they perform. Further,?shared decision-making ?must also be considered when weighing the pros and cons of necessary care variation.

The authors have masterfully conveyed the hope that practicing necessary clinical variation can improve patient outcomes and physician satisfaction with their work. They say that “…variations must be identified, celebrated, and reinforced as core to our professionalism. In doing so, we uncover the previously ignored magic in balancing the yin and yang of necessary and unnecessary variation in care. Celebrating necessary variation will help physicians concede that best practice pathways are not a tool to crush autonomy, but rather a guideline that makes good sense for most patients most of the time.”

I could not have said it better myself.