Transcription:
Cookbook Medicine Versus Standardization

Melanie Cole (Host):   Clinical practice guidelines can be potentially valuable tools. However, if mishandled can become a hefty skull-crushing medical cookbook while standardization affects many areas of medicine and is continuing to expand with the growth of evidence based medicine and efforts at measuring, reporting and improving quality for patients. My guest today is Dr. Vijay Trisal. He's an associate clinical professor in the Division of Surgical Oncology in the Department of Surgery at City of Hope. Welcome to the show, Dr. Trisal. We're talking today about cookbook medicine versus standardization. Will you define these two terms for the listeners first please?

Dr. Vijay Trisal (Guest):   Hi, Melanie. Thank you for having me, first of all. It might sound to everybody that this is dry and this is boring, so I don't want people to get put off. I think this is at the crux of what is ailing and physicians where this struggle with how to do it. Let me try to define it in a simpler manner. Let us say 40 years back when we started understanding more and more of disease processes, especially diseases like cancer which is what we do primarily here City of Hope. We did not have enough information as to how does the biology of this disease, how does the cell behave, how does this cell behave in a particular patient, and what the treatment options would be. A lot of research was done, both at the cellular level then as case reports and patients came in and doctors said, "Oh! Look at this melanoma which was this big and had this outcome and we should do this." Slowly, we got more and more data and we wanted to see which of these different treatment options were the best treatment options. So, more elaborate and substantiated research that came about which are called “randomized controlled files” and they said, "If it is this sized tumor, this is what we should do." So, standards started forming and these standards were applied from a huge swaths of populations to individuals. On one hand, it took away this guesswork from the physicians that “What we are going to do with this tumor? My experience for three tumors is that I should take a two centimeter margin but this data that is based on 1000 patients tells me, ‘No, I just need to take a one centimeter margin.’” So, standards became applied and that is the standardization. Instead of the doctor saying, "My experience is that I want to do ‘X’", the standard said, "No, you should do ‘Y’ because that is what works." So, those are the standards but it also came with this dictum that now if you have a 1 cm tumor, you're always going to do a 1 cm margin and that becomes cookbook. Standardization and cookbook are basically two sides of the same coin and how we apply it and in which scenario we apply it, and how we become individualized and, at the same time, use the benefit of standardization is what we're talking about here today.

Melanie Cole:   What a wonderful definition. Dr. Trisal, since guidelines are written as you say for average patients but very few patients fit that description, are those strict adherence to practice guidelines, can there be a substitute for clinical judgment. I mean, if each patient is individual and you as the expert are the one making the decision on the margin, whether it's two centimeters or one, who do we as patients to be our own best advocate, who do we want to trust? Do we want to trust those standards that had been set and based on 1000 patients? Or, do we want to look to our doctor because we are an individual and our doctor knows us?

Dr. Trisal:    If it were based on just the standards or just the doctor, it would be simple. So, let’s put this into perspective. So, these are two arrows that are going in different direction. If a patient comes with a breast cancer to an institution A, and if that institution A, based on this patient who has family history of breast cancer, who has a certain centimeter tumor, and has a lymph node, if that whole institution treated this individual patient and had the same standard or came up with the same treatment, I would say then we’ve got to base it on the individual. But, what is happening today is that when this patient comes, it is the luck of the draw. If this patient comes and sees Dr. “X” versus Dr. “Y” versus Dr. “Z”, if the same patient is getting three different treatments, there's something wrong with the system. However, if you have 100 patients coming in and all of them, because their tumor is 1 cm, are getting the same treatment, there's something wrong with that system also. Individual factors, whether those factors are related to a patient's personal values or whether they're based on an individual’s circumstances, if we don't take that into account then we're missing the boat. I think that--and this is a rough number. I'm just throwing this out there--that if we are having 80% standardization or 70% standardization where we take a population and say all of them had a 2 cm tumor and all 80% of them got this treatment, we would think that we are applying in the right area. If we're using 100% standardization, something is wrong in that. If we are having 30% of patients who have the same tumor and are getting different types of treatment, there's something wrong with that. The balance is somewhere in the middle of that where personal values, individual circumstances, individual tumors become important but if doctors do not agree that a certain tumor with a certain the receptor would demand this treatment and the treatment becomes different, then there's something wrong with that also. Let me give you an example of how we look at that. Let us say that I have colon cancer and I go to one doctor and I say, "What would you do?" The doctor said, "You should get chemo first." Then, I go to another doctor and he says, "No, that other doctor is crazy. You should get surgery first." This is similar to—and I give this example to my patients a lot--I am bad at understanding cars. So, I go and I take my car to a mechanic and the mechanic says, "Your fuel pump is broken and you have something in your carburetor and you have fuel injection needs to be changed and that is going to be $5000 for repair." I say, “It’s fine. You're the expert. Let us do whatever you do.” Then I go to the next mechanic and the mechanic tells me, "There is nothing wrong with your car. Just put a patch here and there you go, and here is a $10 voucher that you need for this." That doesn't lend you to have confidence in that system.

Melanie Cole:   Absolutely. See, that's the thing now and I've heard this a lot with prostate cancer specifically, Dr. Trisal, because some doctors say surgery remove the prostate. Some say no let's watch and wait. I know that could be a confusing one because you have so many tools for prostate cancer. However, I want to throw a little wrench in here and ask you where does in this spectrum the health insurance company come in to this cookbook versus standardization because it would seem that if they're contributing to making a determination on coverage or treatment and they are the ones making money off that decision. Does that come into terms for you doctors?

Dr. Trisal:   Melanie, that it is a circular argument and I agree with you that is how guidelines get somewhat made. So, NCCN, an organization in this country that actually formulates national/international guidelines on different tumors, which is the National Comprehensive Cancer Network. City of Hope actually is a founding member of the NCCN. What this body said is that we're going to get the top fifty cancer centers in this country and we will sit down together whenever algorithms change or at least twice a year, and we want to say what should we do with this tumor and we will come up with algorithms. They come up with these standards and they also are scared that if they don't put it in the standards then the insurance companies will deny it. Insurance companies look at these guidelines and say, "Okay" and see some guidelines say, "No, you don't need the CT scan." So, if a doctor now, because of the patient's specification or because of something individual in the patient, orders a CAT scan, it gets denied. We're caught in this conundrum where these guidelines are made somewhere in the backdrop of “will the insurance company approve this.” So, we should say consider a CAT scan. On the other hand the insurance companies look at this and try to find out flaws where if this guideline says, "No, you don't need a CAT scan" then they're not authorizing that. Unless that gets resolved to the point that insurance companies don't make decisions on treatments and the doctors are not willy-nilly all over the place, until that time, this debate is going to continue back and forth.

Melanie Cole:   What do you want patients to do about this debate and this question because we're the ones that are looking to you as experts and we are saying, “What do you think that you should be doing for me to be my best partner in health care?” What questions should we be asking when we are getting these different opinions because we are supposed to get second opinions, right? So, what questions should we be asking you doctors that will help us to make the decision based on what you're telling us?

Dr. Trisal:   Being prepared is very critical. The two things that I look at and I'll give you the mechanic answer again and I look at this same way is that number one, I need to be educated about my car. My total lack of knowledge about my car is going to hurt me. So, I need to know at least some basics and I am so glad that a lot of the patients are coming into my clinic today with basic knowledge. They sometimes have fake news knowledge which I need to correct but they have basic knowledge when they come in. So, that's one thing. The second thing that is so critical is this relationship between the patient and the doctor. If I don't feel comfortable whether that is because this mechanic is telling me all the good news and if I don't feel comfortable with this as a person and there is something to be said about gut feeling—and I'm throwing out all the standardizations out of the window by talking about gut feeling--but if you don't have the relationship with the doctor and you don't trust the doctor or you feel that this is to mechanical, I don't think this is going to work. I think it is much more important to feel that the physician and the patient understand each other, understand each other's values, understand where they want to get. I think those other things will become simpler. The question that you asked about prostate cancer is very relevant because you go to a medical oncologist, they'll give you a different treatment. You go to an urologist and they'll say do surgery. You go to a radiation oncologist, they'll say that radiation is as good if not better. I have this great quote of one of the doctors. His name is Khalid Alekhtiyari. He is a radiation oncologist. He said, "You go to a barber, you get a haircut. You go to a radiation oncologist, you get radiation whether you need it or not." They look at it as, “This is my hammer. That is the nail. Anything looks like it, gets a nail.” So, you look at it that way. I think what we're doing and what most institutions should do is have a multidisciplinary team. In all of oncology, all of cancer, you want to put the patient in the middle and have these four doctors around the station and say, "Let us discuss what is the best treatment for this patient” and not your standards; not use "This is my way" but let us come up with a common algorithm. So, in these areas where there's a debate as to what is the right treatment, there are some areas where they are very clear. I have colon cancer, I'll need treatment. If it's nodes, I need chemotherapy. Those algorithms are very clean. It is these penumbra areas where there is an overlap that you want to put these doctors around a table with the patient in the middle and then say, “How we apply these standards to this patient?”

Melanie Cole:   That is a great wrap up but I would like to ask you to please just kind of bring it all around with evidence-based medicine so that it doesn't take out the individuality out of your case management and doesn't stifle innovation and this ability of you at City of Hope to try these new and exciting things. Wrap it up for us, Dr. Trisal, and tell patients what you want them to know about what's going on in the health care industry today.

Dr. Trisal:   I think health care industry, it is this the story arc that it is the best of times and it's the worst of times. It is the worst of times because we are in this uncertainty about what is going to happen to health care and insurance and what is going to happen to all this expense that is so overwhelming to patients and causing bankruptcies on one hand, and it's the best of times because there is so much advancement in research that we will know on a molecular basis is for this tumor that has this mutation and has this receptor, this is the treatment. There's not going to be any if’s or but’s. There is not going to be this doctor that says, “My tumor will respond to this treatment.” You will have actually material evidence based on the pathology of the tumor and that's what we're doing here. Our partnership and relationship with T-Gen, which is a molecular based treatment company that just joined City of Hope, is focusing on how do we have confidence in this decision. Not just say, “This standard came from a thousand patients in a certain community whether they match or not match my patient,” but really look at the tumor because at the basis of it the markers of the tumor and the receptors of the tumor and the molecular biology of the tumor, there is no debate around that. Then, we apply on top of that the personal values, the individual circumstances. If there's a patient who has no support at home, I'm going to treat that patient differently and that no standard is going to pull that into their algorithm. I want patients to understand that the advancements in the basic science world are going to make their decision making easier and the doctors decision making easier. There's not going to be this amount of hedging as to what how I'm going to treat this patient. So, they should feel confident about that.

Melanie Cole:   Thank you so much, Dr. Trisal. It's absolutely fascinating topic. You're listening to City of Hope Radio. For more information you can go to www.cityofhope.org. That's www.cityofhope.org. This is Melanie Cole. Thanks so much for listening.