Identical care isn't best for all patients

Blacks with diabetes fare worse than whites, even when they see the same doctor who orders the same tests, visits, and referrals to specialists, a new study has found.

Some will surely assume that the doctors were - perhaps unconsciously - racist, and so may have sent their black patients different messages than their white ones. But what if the problem was that the doctors treated all their patients precisely the same way?

Dr. Thomas Sequist, the Boston doctor who conducted the study, published in the Annals of Internal Medicine, said he thinks the doctors might have failed to consider cultural differences when they, for example, assigned the same low-carbohydrate diet to all their patients, regardless of their traditional foods.

In today's medical climate, we doctors are expected to standardize our care. We're graded every quarter by insurance companies and hospitals who criticize us if any officially sanctioned tests are missing from a patient's record. We're supposed to do whatever it takes to get the tests done.

But what if my diabetic patient doesn't care about her score on a A1C test - an indicator of how well her blood sugar is controlled - because her husband is dying? Or what if, because of her cultural background, it's simply not realistic to ask her to quit eating rice? Or what if, knowing her options, she'd rather have that piece of cake than live until age 85?

Maybe I wouldn't be providing the best care for that patient if I simply told her what her A1C scores were, told her to eat fewer carbohydrates, and sent her on her way - even though it would earn me a good grade for her care.

I'm concerned that the current standards of care encourage doctors to check boxes on a form rather than tune in to the needs of their patients. Sure, it's helpful for me to know whether a diabetic's blood sugar is under control, but if that's all I know about my patient, I won't have served her or him well.

When I first started working at a city community health center with a large Hispanic population, I talked to my young patients about sexual activity the way I had talked to my suburban ones - I assumed that our common goal was to help them avoid getting pregnant. But when I began listening instead of talking, I realized that some of the girls actually wanted to get pregnant so they could accompany their girlfriends who already had babies on walks through town.

To be an effective doctor, I had to delve beyond simple birth control issues and explore with them what it means to be a parent while in school.

Another lesson I learned early: To discourage my teenage patients from smoking, it didn't work to lecture them about how smoking causes lung cancer. I needed to focus on what they cared about. When I began telling them that smoking would stain their teeth and make their clothes smell bad, I got more traction.

And some patients need me to explain to them in great detail why I have chosen specific medications, while others just want me to hand them the prescription on their way out the door.

Unfortunately, the structure of medical care today discourages care that's tailored to a patient's individual needs. Doctors have 20 minutes or less to get to know their patient. Poor quality scores are handed out only for failing to conduct a test or follow a protocol, not for failing to connect with the person in the johnny.

I am reminded of a young patient of mine who takes medication for her Attention Deficit Disorder. The ADD protocol indicates that I must see her twice a year. But I know this family: They come from a long distance, the mom is a single mother who works, and the child is doing well. Having her come in twice a year is an unnecessary inconvenience.

As Sequist, a primary-care physician at Harvard Vanguard Medical Associates, learned when he reviewed the medical records of nearly 7,000 black and white patients with diabetes, uniform care is not always the best.

We all want to improve healthcare, but if we try to get there by oversimplifying treatment, by assuming that if we say the same thing to the same patients we're delivering "quality," we're wasting our time, and likely doing our patients a disservice.

Dr. Victoria Rogers McEvoy is chief of pediatrics of the Massachusetts General West Medical Group and assistant professor at Harvard Medical School. She can be reached at mcevoyvicky@gmail.com.