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Sunday, May 24, 2015

Population Medicine: The Other "Dismal Science"

All of medicine is based on population health. Indeed, the medical wisdom we've gained from the time of the ancient Greeks has been an amassing of population data over centuries. All the clinical trials we've performed to date seeks to gain more knowledge about populations of patients that's why we seek larger trials, multi-center trials, even inter-continent trials. And it's why we do meta-analysis and Bayesian statistics in order to understand the meaning of this data in the true state of the world. Afterall, understanding everything possible about a particle of sand still does not help one to be aware that they are standing on a beach. I wish we would stop making this an issue of population health vs individual health. We are humans first and Sara, William and Carlee second. To contend otherwise is really about ego rather than science. The value of population health is to better understand and respond to individuals. It supports individualized care by reducing unnecessary variance and increasing necessary variance. Necessary variance is patient-centered, i.e., it allows deviation from population data because the patient's own condition so dictates. Unnecessary variance is not patient centered--it is deviation from appropriate care because of non-patient driven variables--and may place the patient in harm's way. For instance, Sara comes to the ER with a fever of 102.5, cough with rusty colored sputum and shortness of breath of 2 days duration. She is allergic to azithromycin. She is given prescription for ciprofloxacin and discharged home. She follows up with her PCP two days later where symptoms are persisting and is given a prescription for moxifloxacin. She subsequently improves over the next 72 hours. Population health tells us that Sara most likely has Streptococcal pneumoniae pneumomnia. Ciprofloxacin does not cover Streptococcal pneumoniae while moxifloxacin does. Population health tells us that ciprofloxacin should not have been prescribed, and that it was is an unnecessary variance. While prescribing a medication other than azithromycin is a necessary variance based on an individual's history of allergy to azithromycin. Here is a seamless marriage of population health and individual health that's practiced every day to help individuals. Population health is to individual health as the foundation is to a house. The house atop a solid foundation may all be highly varied--Colonial, Mediterranean, Tudor, ranch, etc--but the foundation is similar. A danger of not recognizing this relationship clinically is that when a patient presents for medical attention we unintentionally take a jackhammer to the foundation then try to build a house atop. This latter approach increases unnecessary variances. Let's build a future of patient-centered care with the conjunction 'and' rather than 'or'--population health AND individual health.
from Rajesh Harrykissoon, MD

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