cookbook medicine

The standardization of medical practice forces physicians to follow a script to achieve cost effectiveness and efficiency, but at what price to the patient?
Think about the last time you visited a medical office. The nurse ushers you into the examination room. He or she then proceeds to ask you questions from a checklist on a laptop while simultaneously typing in your responses. The nurse barely makes eye contact with you. After the checklist is completed, an algorithm in the computer generates a "to do" list based on your responses.

The physician enters the room, diagnoses your symptoms based on the computer algorithm, perhaps puts in a request for laboratory testing, writes a drug prescription for you and sends you on your way, all in a span of 10-15 minutes. This process is known as "cookbook medicine"-a set of generalized clinical guidelines dictating how physicians should approach patient care.1

"Cookbook Medicine": The Standardization of Medical Practice

Historically, physicians enjoyed professional autonomy in practicing medicine.2 They had the freedom to make informed decisions based on their own knowledge, expertise and judgment on what the best course of treatment was for each individual patient. This personalized treatment used to be the norm in the practice of medicine and, as a result, the practice patterns of physicians varied from one another.2

In recent years, medical practice has undergone a metamorphosis. In response to the variation of medical practice, the medical and health insurance industries have developed protocols and specific procedures to establish a "standard of care" that physicians are required to adhere to for all patients.3 There are several reasons for the streamlining of medical practice. In a report published in the Archives of Internal Medicine, the author Marshall B. Kapp, JD, MPH writes...
This push for formal explicit clinical standards emanates from a variety of sources for many purposes. Third parties, both public and private, that pay for health care want to assure that the care they purchase on behalf of their beneficiaries is appropriate and efficacious. Physicians, institutional administrators and other health care providers have a professional and ethical stake in assuring the quality of care. Clinical standards may be used for such quality assurance purposes as licensure, privileging and other credentials review. Additionally, the setting, dissemination and enforcement of clinical standards may be relevant for legal purposes, especially as evidence of fault or lack of fault in medical malpractice cases; this naturally attracts the interest of potential malpractice defendants and their insurers."2
The standardization of medical practice forces physicians to follow a script to achieve cost effectiveness and efficiency, but at what price to the patient?

The Pitfalls of Streamlining Medical Practice

Focusing on efficiency may very well prove beneficial from a business perspective; however, there is a major problematic assumption underlying the standardization of medical practice. The "cookbook medicine" approach operates on the false assumption that patients are not different from one another but simply belong to a homogeneous group and can all be viewed and treated the same way. This "one-size-fits-all" approach results in missed symptoms and misdiagnosis, as well as unnecessary testing.4

It is estimated that "cookbook medicine" unnecessary testing contributes to $210 billion in additional health care costs.4 Hemal Kanzaria, MD, lead author of a study published in Academic Emergency Medicine states:
So many physicians acknowledged that they ordered tests for no medical reason, which makes it clear that physicians feel enormous pressure to behave in a way they may not want to.4
In an opinion piece published on the National College of Physicians website, one physician expresses his frustration with the standardization of medical care...
I wouldn't do it again, and it has nothing to do with the money. I get too little respect from patients, physician colleagues, and administrators, despite good clinical judgment, hard work, and compassion for my patients. Working up patients in the ER these days involves shotgunning multiple unnecessary tests (everybody gets a CT!) despite the fact that we know they don't need them, and being aware of the wastefulness of it all really sucks the love out of what you do. I feel like a pawn in a moneymaking game for hospital administrators. There are so many other ways I could have made my living and been more fulfilled. The sad part is we chose medicine because we thought it was worthwhile and noble, but from what I have seen in my short career, it is a charade."5
Moreover, physicians are bound by contracts that are based on pay for performance, which usually means they must adhere to strict metrics, testing and treatment standards.6 According to an article in The New York Times authored by two physicians, Pamela Hartzband, MD and Jerome Groopman, MD:
For example, doctors are rewarded for keeping their patients' cholesterol and blood pressure below certain target levels. For some patients, this is good medicine, but for others the benefits may not outweigh the risks. Treatment with drugs such as statins can cause significant side effects, including muscle pain and increased risk of diabetes. Blood-pressure therapy to meet an imposed target may lead to increased falls and fractures in older patients.7
They further add that, "These measures are clearly designed to coerce physicians to comply with the metrics. Thus doctors may feel pressured to withhold treatment that they feel is required or feel forced to recommend treatment whose risks may outweigh benefits."7

Mandatory Vaccination Policies Mimic "Cookbook Medicine"

The principles of "cookbook medicine" are very evident in mandatory vaccination policies enforced in the United States and in other countries. The U.S. Centers for Disease Control and Prevention's (CDC) current vaccine schedules for children and adults take a "one-size fits all" approach and do not acknowledge an individual's current state of health, personal or family health history, nutritional status and genetic predispositions prior to receiving vaccines. Mandatory vaccination policies assume all human beings are part of a homogeneous group and do not have individual genetic, biological or environmental differences.

Arguments have been made that decisions regarding an individual's vaccinations are not one-size fits all since exceptions to the schedule are sometimes made by doctors who have concluded there is a reason to delay or omit a vaccine to protect the person from being harmed by vaccination. However, the truth is that the CDC and American Academy of Pediatrics (AAP) consider very few medical conditions as a reason to delay or omit a vaccination and 99.99 percent of children do not qualify for a medical vaccine exemption under narrow federal vaccine contraindication guidelines.8,9

The federally recommended and state mandated vaccine schedules do not factor in an individual's susceptibility to vaccine adverse reactions, which the Institute of Medicine has pointed out cannot be predicted ahead of time by doctors, in part, due to gaps in vaccine safety.10

While "cookbook medicine" may serve a specific purpose for corporations and insurance companies operating health care systems, as well as for government health officials implementing "no exceptions" mandatory vaccination policies, this standard of care approach often fails to lead to better health outcomes for individuals.

References
  1. Reese S. Will You Be Pressured to Perform "Cookbook" Medicine? Medscape July 30, 2013.
  2. Marshall B. "Cookbook" Medicine: A Legal Perspective. Archives of Internal Medicine 1990; 150(3): 496-500.
  3. Rastegar D. Health Care Becomes An Industry. The Annals of Family Medicine 2004; 2(1): 79-83.
  4. Park A. Your Doctor Likely Orders More Tests Than You Actually Need. TIME Mar. 24, 2015.
  5. Jauhar S. Is Physician Autonomy Dead? National College of Physicians July 1, 2016.
  6. Goodman J. Are You Ready for Cookbook Medicine? Forbes Jan. 12, 2015.
  7. Hartzband, P, Groopman J. How Medical Care is Being Corrupted. The New York Times Nov. 18, 2014.
  8. U.S. Centers for Disease Control and Prevention. Conditions Commonly Misperceived as Contraindications to Vaccination: Recommendations and Guidelines. CDC.govOctober 2013.
  9. Fisher BL. Blackmail and the Medical Vaccine Exemption. NVIC Newsletter May 18, 2015.
  10. Institute of Medicine Committee to Review Adverse Effects of Vaccines. Adverse Effects of Vaccines: Evidence and Causality: Evaluating Biological Mechanisms of Adverse Events: Increased Susceptibility. Washington, DC: The National Academies Press 2012.