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Can She Make A Cherry Pie, Billy Boy?

March 23, 2014

My parents have always made their own bread, a skill I have never been able to master.  The other day my dad was showing off this beautiful loaf of bread he had made, and I asked him how he did it.  He said “I don’t know.  I followed the recipe and then added more flour until it looked right.”  Huh.  So the recipe was wrong?  “Well, not really.  It just needed more flour.”

As I was reading our dear leader Brad Wright’s policy wonk piece from March 12 I clicked on John Goodman’s piece on personalized medicine and it occurred to me that my father’s approach to bread baking is a good analogy for how doctors confront protocols and guidelines.  Goodman has a great blog, by the way, over at the National Center for Policy Analysis.

Let’s start with the recipe itself.  You think you want to make, say, a pie.  You don’t know what kind of pie, just “pie”.  But you’re an experienced baker, you’ve been baking for 20 years.  You look in the index and find the directions for “pie”.  You follow the directions exactly.  You end up with something that looks like pie.  But it’s not quite right, it doesn’t fit exactly.  There’s no filling.  You haven’t decided how to personalize the pie, make it yours.  According to our analogy, the baker is the doctor.  He’s very experienced, and has been practicing medicine for a long time.  He sees a patient whom he decides has, say, diabetes.  He looks in the index of his protocol manual, as he has been told to do by the administrators of his EMR, and follows the directions for “diabetes” exactly.  But the patient doesn’t get better.  The doctor hasn’t found out what kind of person his patient with diabetes is, so he can tailor the recommendations to the patient, that is, he can personalize it.

To extend the analogy, say this baker makes his pie according to the directions but because of his experience, knows a few ingredients are missing, so he adds them.  Like my dad, an experienced bread-maker, adding flour.  The results are much better, and he is able to charge more for his superior bread.  But the doctor does this for his diabetes patient, and the patient’s insurance company calls him saying it won’t pay for the added items.  They aren’t in the recipe.

Now someone comes to the baker and says: “Baker I ate your pie and I got sick.  What did you put in it?”  The baker replies that he followed the recipe, but when pressed admits he added a few things, but nothing that could make the pie-eater sick.  The pie-eater doesn’t believe him but the worst that he does is no longer buy pie from the baker.  The patient comes to the doctor and says: “Doctor I did what you said but I got sick.  What did you do?”  The doctor says he followed protocol, but when pressed admits he added a few things, but only things that would improve the patient’s care.  Doctor is sued for 10 million dollars.  Conversely, a person buys a pie and says to the baker: “This pie tastes terrible.  What happened?”  And the baker answers that someone got sick from a pie he made with additions, even though it wasn’t his fault, so now he just follows the recipe.  The patient says to the doctor:  “This treatment isn’t working for me, what happened?”  And the doctor says:  “I got sued for personalizing care, so now I just follow protocol.”

Tired of this analogy?  Me too.  Here is the problem with cook-book medicine.  You’ll come out with something that looks like quality care, but doesn’t really satisfy anyone.  It’s nice to have guidelines, so you know in general how things are done by other doctors and experts in the field, but if you don’t have the freedom to use judgement gained by experience to adjust care to the patient at hand, the end product doesn’t work.  I guess my point in all this is that quality care cannot be legislated and measured with strict guidelines.  Quality health care is like good pie; you know it when you see it, and you leave it to the professionals.


From → Healthcare

  1. thetinfoilhatsociety permalink


  2. johnbennett70 permalink

    Thanks Sherie
    Yes, old fashioned medicine has its place. Going by intuition, and not by the book, although, as you said, you are playing with fire, if put on the stand. I love computers and what they can do, but is one thing they will ever replace; the “feel” of something, not measurable. There are so many variables that will be difficult to capture that the brain spontaneusly makes, in the snap of a second.
    When I was working in the ER, there was a nurse’s aid (Not even a nurse) who had the “look” and “feel” down. When she would come to fetch me to see a patient, and she would say, “Doc, this patient just don’t look right”, she was dead on, even if all the variable, including vitals, were stable.

    • John – yep. We call it “not passing the look test”. You know something isn’t right, you can’t pin it down. On the stand, everyone has the benefit of hindsight.

    • It’s the intangibles that make the difference. That’s what you learn in residency.

  3. Bettercareelsewhere permalink

    Being a baker, this was really good. I enjoyed this, love medicine and cooking/baking. Here are a few “pointers”:

    some of us “amateurs” are good enough to be “pros”. Some of us can do better than or equal to the pros in less time, effort, and money. With ALL due respect.

    some of us “amateurs” can read the cookbook too and figure out that the > 100 year old method of going by 1) what I learned in med school, 2) learning from my experience, and 3) learning from my peers, just doesn’t make for good care unless you have a cold or a wart or the flu. To put this to medicine, I’ve seen doctors for 20 years, 30, or 10, miss some major things because I read the medical research and even stuff published 3 years ago they didn’t know about. So I’m paying for … “pie” but I went to reading the “professionals cookbook” and did it better myself.

    last but most important, very few people sue, even fewer win. That’s a fact. Way too many stories I see, one of the worst was a MD/MD couple who had to go to 3 ER’s before they got the right care for their child. They weren’t looking to sue but they sure are looking to tell. The problem is that the “pros” think that every patient is a lawsuit when they’re aren’t, and some of us just want good care or the doc to apologize, fix it.

    Look for Dr. Ring and the hand surgery. I’m not the only one who said I would take this doc in a second because he trusted the patient and the courage to tell the truth.

    Its the docs who don’t care and who don’t want to learn (or throw tantrums, I’ve had that) that are a bigger danger to the medical profession than we are. It would help if doctors would be willing to learn from those patients that aren’t worshippers at Dr. Oprah’s feet. I am a data nerd, and I can read UpToDate and ClinicalKey and just asked a day or so ago if the local medical school had the Amer. Assn. of Clinical Chemistry mags. I don’t watch TV. I love documentaries. You’re going to get a research answer from me and maybe working together, we might just make a handy dandy pie better than anyone alone.

    Btw, one of my docs and I agreed upon the “pie ingredients”. Unfortunately, some of those effects from the pie ingredients in the pie we made, might not be so great. I don’t blame the doc. I tell everyone I know go to him and give him glowing reviews, even to his admin. See we made the decision together, and used all of our knowledge of all the other cookbooks and cooks to do so. Sometimes due to flukes (like the way the “oven heated” or whatever), things happen. I can deal with that. See I know my “pro cook” is behind me. He’s got my back and will help me when things go south.

    That’s a real cook and most of all, a real human being I can trust.


    • I agree that the internet makes it a lot easier for patients to be informed. I also agree with you that most patients with a bad outcome do not, in fact, want to sue, they just want answers. It’s when the stuff on the web and the stuff in the protocols overrides intuition that we get into trouble. Thanks, as always!

      • Bettercareelsewhere permalink

        True. Of course the other bad thing is “amateurs” who think they’re “pros” because Dr. Oprah said so. I’ve had a few docs who said they’d not trust the frat, they’d trust me, the amateur.

        That said I understand the “look” and “see” analogy. I had a good doc do that. It worked a lot of times, but sometimes, um the stench from the “burned pie” … you would have thought he’d be better at medicine because when I was a cook for that long I didn’t screw up that much. LOL course a pie and a human … Grand Canyon difference. 🙂

        Oh and it helps when the docs don’t have egos and have a sense of humor. 🙂

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