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Editorial: A Science and an Art; Pondering Health Care Delivery

We’re having a little trouble thinking of doctors and nurses as health care deliverers, in the same way that it sounds odd to call reporters, photographers and editors “content providers.” It all seems a little reductionist, but this is a battle probably already lost.

Anyway, we got to thinking about the whole subject over the weekend after reading staff writer Chris Fleisher’s story in Saturday’s Valley News about the first class of 45 health care professionals completing its studies in Dartmouth’s new master’s program in health care delivery science. The curriculum was designed by faculty at the Tuck School of Business and researchers at The Dartmouth Institute, with the idea of combining the insights of the business world with those derived from the pioneering research the institute has undertaken over the years, and bringing them to bear on how health care is delivered to patients. The point is to improve the quality of care while saving money.

As an example, Dr. Kevin Curtis, director of Dartmouth-Hitchcock Medical Center’s residency program in emergency medicine, sought to address this problem: Nearly a quarter of the patients who come to the emergency department do not have a primary care physician. Curtis and his classmates in the master’s program developed a system to match ER patients with a primary care physician, with the result that about 300 people have been successfully referred during the past year. Presumably many of those patients will now get routine treatment they need in less costly settings than the emergency department, while freeing doctors and nurses there to concentrate on true emergencies.

It seems clear that many of those enrolled in the master’s program deal with health care in the macro sense, where they can make good use of business acumen in financial management and running complicated organizations. As Fleisher reported, Robin Lunge, who is spearheading Vermont’s health care reform effort, used what she learned to set premium costs and deductibles for insurance plans that will be offered beginning next year on the state’s new health insurance exchange.

This all makes good sense on the face of it, but we do have a couple of reservations. One is that while business has much to offer to medicine (as it does to politics), they are far from identical enterprises. Companies generally have a free hand to institute needed changes, while hospitals and doctors operate under strictures that make it impossible to pick and choose which patients they serve, or, in many cases, to set the amount they will be paid for the care they provide.

The second is that the practice of medicine (or health care delivery, if you prefer) is an art as well as a science. Yes, it’s vital for a doctor to have at hand all the patient data she needs and a knowledge of what research indicates are preferable courses of treatment. But in that personal interaction with a patient, the physician’s judgment and intuition must also play their role, as well as the patient’s informed preferences. This all takes time to sort out, even though time is money. And sometimes these considerations may combine to recommend a less “efficient” or more costly treatment plan. Any health care system that doesn’t make allowances for this cannot be said to be truly serving the best interests of its patients or its professional staff, no matter what the science says. And that’s all the content we can provide for today on this subject.