The Next Generation is a BWH Clinical & Research News (CRN) column penned by residents, fellows and postdocs. This month’s column is written by Kyle Morawski, MD, a research fellow in Implementation Research in the newly-formed Center for Healthcare Delivery Sciences (C4HDS).
Healthcare is (rightly) viewed as an evidence-based profession, yet not all practices are data-driven. I can recall sitting in my outpatient practice office during residency and reviewing my schedule only to find that nearly 50 percent of my patients that day were being seen for follow-up of chronic disease, oftentimes well-controlled ones. Maybe it is just me, I thought, so I perused the schedules of a few other doctors and found a similar situation. Perhaps due to good traffic or plenty of coffee, I found myself with a moment to ponder how one decides on the proper follow-up. Why is it that a patient with hypertension is seen every six months, despite years of good control? How do we decide when a well-controlled diabetic should return to the doctor’s office? Is four months too soon, is 10 months too late?
For me, I was following the practice of my preceptor. But the more I thought about it, the more I realized that many of my decisions each day are not based on evidence but rather on imitation. When I choose to listen to someone’s heart and lungs in clinic, it isn’t because I read a review from JAMA’s Rational Clinical Exam, but rather because I always listen to the heart and lungs. When I recommend a four-day burst or a 10-day taper of steroids for asthma flare, it is because that is what my mentor taught me rather than what the medical literature says. These “judgment calls” are sometimes referred to as the art of medicine, and I would argue that the intricacies of these decisions are what makes it impossible for computer algorithms to fully take over medical care.
At the same time as I honor the art of medicine, I contend that the search for evidence in medical practice is critical for the field to move forward. This is why I decided to join the Center for Healthcare Delivery Science (C4HDS), which is designing and rigorously testing interventions to improve the lives of patients. This was not an easy choice for me. I was told more than once by my fellow residents that they were surprised by my decision to not pursue a career of 100 percent clinical practice. I was surprised about my decision as well. What swayed me was that C4HDS was as close to affecting clinical practice as research could get. Where some studies are performed on large databases that improve the knowledge of practitioners, I wanted to be involved with research that will improve patients’ lives. The apposition of the researcher’s conference room and the doctor’s clinical room is what I am interested in.
While trying to reconcile what I see in The New England Journal and what I do in clinical practice, I hope to assist C4HDS in continually keeping the Harvard Medical School goal of “alleviating human suffering caused by disease” as present as possible. I hope to keep asking, “Why?” while I am in clinic, and optimize our health care practices to find the most efficient system through innovation If this means I see a patient for well controlled blood pressure every 12 months instead of every six, then that is what I should do. If I can assist with managing a patient’s diabetes over the phone rather than have them come in to the office without compromising care, I need to have that practice. Getting to the essentials in health care to achieve optimal health is what I want to do.
Through my fellowship with the Center for Healthcare Delivery Science, I hope to gain the skills necessary for rigorous evaluation of the everyday activities that patients and providers do in order to guide both parties to optimal practices for achieving health. Making research more applicable and widely usable so that patients’ lives are positively affected will be the goal and metric for success.