“Eminence-Based Medicine” versus “Evidence-Based Medicine”
Speaking of improving medical practice, COL (Dr, Ret) Gary Davis, my predecessor four times removed, has an apt description of Afghan medical practice in previous years: “eminence-based medicine” versus “evidence-based medicine”. When we ask some of the ANA physicians why they may have, for example, prescribed five antibiotics for a cold, the answer is usually “That is how my teacher did it.” The younger physicians are much more interested in reviewing journal articles in order to practice more evidence-based medicine. That is very encouraging. What is also encouraging is that ANA medical leadership is actually asking for advice in providing more structure to hospital staff practice. To that end, we are in the process of updating and fleshing out the 2006 Ministry of Public Health hospital standards of care. Specifically, we are developing standards for nursing, medical records, and internal medicine. The best thing about this effort is that these will be true Afghan standards of care. In case you missed my previous comments about Afghans holding themselves accountable, these standards will also come with requirements for Inspector General HSI-like assessments that will start with ANSF MTFs and spread to MoPH facilities. They are not quite ready for Joint Commission standards, but this project will set them on their own quality improvement odyssey.
Lastly, how do we know if we are making the system improvements we intend? You guessed it: metrics. In November, each ANSF hospital started documenting patient encounters on standardized forms that become a permanent part of the patient record. That in itself is a paradigm shift. Many providers had gotten away with only documenting a general diagnosis, if even that. Clerks then transfer key information from the form to a patient database. At the end of each month, we will have actionable data that ANA senior leadership can use to allocate personnel and supply resources to meet demand as well as focus future preventive medicine and medical education efforts to more common conditions. It is not quite AHLTA and P2R2, but they are well on their way to having the tools they need to provide adequate command and control over their medical system. Eighteen months from now, those systems will provide the proof of our successes.
This has been an incredibly challenging and rewarding year for me. I have worked with some amazing US, Coalition, NATO, and Afghan personnel. Many times, it feels like we are not making much progress. I am confident, though, that the systems we have put in place, especially in medical education, will be the tipping point that carries the government of Afghanistan to provide self-sustaining security for its people.
