Wednesday, March 4, 2009

Is Vendor Supplied Care or Disease Management Too Many Cooks in the Kitchen?

At the conclusion of its presentation at the National Medical Home Summit in Philadelphia, the Disease Management Care Blog was asked an important and telling question: is the introduction of outside care management vendors into the doctor-patient relationship akin to letting too many cooks in the kitchen?

Prior to sharing the answer in this post, the DMCB confesses to pausing at the cooking shows while it’s annoying the DMCB spouse with its click-click-click channel surfing. Favorites include Bravo’s Top Chef and Food Network’s Iron Chef America. Watching those skilled professionals’ creativity in the midst of all the ingredients, chaos and pressure is great fun. Or maybe the DMCB likes how both shows pit teams against each other and how the judges are insufferably fussy. Note that America’s newest gastronomic pal gal Carla came so close to winning the title after being paired up with Casey, while each Iron Chef literally has a supporting cast of slicers, choppers, boilers and fryers.

Too many cooks? Nonsense, says the DMCB. It suspects the kitchens of all our better restaurants rely on a similarly arrayed Top/Iron Chef-style teaming with the appropriate division of labor. What works is the chief cook (or a physician) who presides over an array of smart hard working helpers (or non physician professionals). Getting the helpers to work together is key ingredient when it comes to plating a great meal (or care plan).

The DMCB believes the decision by a physician to make use of an external care management vendor should not depend on the number of cooks in the kitchen. We need several cooks. It should depend on the additional value that particular cook brings to the patients. The DMCB predicts many head-chef physicians will calculate that the value is high.


But it doesn’t stop there. While at the Medical Home Summit, the DMCB heard a deeply respected, oft quoted and famous if unnamed (and tiresome) senior statesman of the chronic care model also raise the food preparation allegory in another context. 'Cookbook medicine,' he declared, is clinical excellence writ large. Pretending otherwise disrespects decades of science, brings dishonor to physicians and kills patients.

Nonsense again, says the DMCB. It believes that’s only true when the evidence is good and generalizable to the patient at hand. To take the culinary twist further, the DMCB asks you to contrast soufflés versus spaghetti sauces and diabetic ketoacidosis (DKA) versus dizziness. Success for each of the former (soufflés and DKA) depends on carefully following a defined protocol. The latter (sauces and dizziness)….well, depend on the circumstances and are largely an art. Excellent chefs and physicians can handle both ends of the spectrum. And by the way, hopefully, these Institute of Medicine guys will understand that and why some variation will never go away.


And while the DMCB is examining parallels outside of medicine, it doesn’t really buy the Cato Institute’s naïve simplistic notion that the coordinating physician caring for patients with chronic illness has duties akin overseeing subcontractors that are ‘building a house.’ Rather, it’s more like rehabilitating This Old House, only the foundation is cracked, there’s a lot of dry rot, much of the plumbing is lead, none of the wiring is even close to code and you don’t have the option of bulldozing it and putting up a new dwelling. The DMCB agrees that there is a role for the lead doc overseeing the subcontractors (just like Norm, Tom, Richard and Roger). While many of the individual myriad tasks of This Old House have a right way and a wrong way to perform them, there’s much of an art to this and the outcome – especially in real life - is rarely perfect.

No comments: