Quadrant IV healthcare system (1)
Beginning around World War II and until the early 1990s, the American healthcare system resided in Quadrant IV of the healthcare universe. Medical decisions were made, for the most part, by individual doctors and their patients, based on what was perceived to be best for the patient (or sometimes, we must admit, for the doctor). But healthcare decisions were not driven by high-quality, data-guided reasoning. The decisions were generally of low quality. A system of low-quality decisions made by individual doctors and their patients planted us squarely in Quadrant IV.
Medical decisions were generally of low quality during the Quadrant IV era for several reasons:
1) Until recent years most medical decisions were not based on rigorous clinical science, a fairly recent invention. That is, the information that doctors used to make medical choices tended to come from personal experience, anecdotal case reports, or the opinions of medical gurus instead of from large, controlled, randomized clinical trials.
2) Doctors have traditionally had the ethical and professional imperative to place the needs of the patient first. But at least in the era before managed care, the more stuff doctors did, the more they got paid. So they tended to do more than was necessary. This tendency was enhanced by the general dearth of evidence. Without hard evidence doctors relied on a synthesis of soft data from many sources of their own choosing; it was easy for them to shade their decisions, often subconsciously and more or less in good faith, in the direction of doing the things they got paid for.
3) Overt, old-fashioned, in-your-face medical paternalism (which persists to this day to some extent) was the rule during much of the Quadrant IV era. According to this paternalistic viewpoint, patients are supposed to rely on the opinion of the experts, that is, their doctors, in sorting through the complex nuances of medical decisions. Patients aren’t at all capable of understanding this sort of thing themselves, the reasoning goes; after all, this is why their doctors spent all those years in training.
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