I find myself in a unique position. I recently retired as an orthopedic surgeon and my wife and I moved out of my practice area. At the same time, my wife was diagnosed and started treatment for breast cancer. So I got opportunity to interact with the health care system both as a provider and as a family member of a patient receiving long-term care first from providers I knew very well, then from providers who I did not know at all.

From the time I started practice I observed that many providers had a tendency to treat labs instead of patients: the idea that if a lab is abnormal then the patient must be treated. In medical school, we were taught that lab values were the result of statistical analysis and somewhat arbitrary with the understanding that this the best way to do it. This creates the problem of trying to define the boundary between normal and abnormal.

Take total cholesterol. A level up to 200 was accepted as normal, above which it was declared abnormal. This puts the provider in a somewhat difficult position if they have a patient with a total cholesterol of 205. In the past, the main concern was liability risk. Today, the pressure to get it right is worsening as health care moves toward the efficiency of the assembly line and providers are being judged more and more by the quality of the care they provide and how well they follow protocols.

In other words, the pressure is on to treat “by the book.”

Take hemoglobin levels. Years ago, I noticed that many patients who broke their hip came in with abnormally low hemoglobin levels that could not be accounted for by their fracture or subsequent surgery. Upon close inspection, it was found that many of these patients were low for years. In other words, their abnormal low hemoglobin was normal for them. My goal became to get them back to their abnormal level, not normal.

In the past, this was rarely a problem. However, over the years I came under increased scrutiny because I supposedly was discharging patients with an abnormal hemoglobin. At best, I found myself having to spend more and more of my time defending my reasoning, particularly annoying when I had to repeat myself over and over again. At worst, I know of several patients who went into CHF because someone tried to force these patients hemoglobin levels back to normal. At this point, I am just glad that I don’t have to face the possibility of being hit financially for making decisions that were proven to be in the best interests of my patients.

When my wife first moved into the chemotherapy phase of her treatment, I did not know her oncologist because the cancer care in our area had just been taken over by a large outside hospital system that had a reputation for being “by the book.” The oncologist, who had been in practice many years, knew me by reputation and by the fact that I knew the nursing staff. I also was very familiar with my wife’s breast surgeon, pathologist, and internist. Like most physicians, when a loved requires care you tend to do more research, especially when the condition is outside your field of expertise.

Around the time my wife was supposed to start her chemotherapy, evidence was surfacing that a proven less toxic protocol was just as effective as the standard protocol that was still considered the standard of care. To his credit, the oncologist was the one who first clued us into the new protocol. During this time, my wife developed some medical issues that delayed starting her chemotherapy which made us very leery about the standard protocol. After she recovered, we returned to her oncologist who said that my wife would be starting the standard protocol.

I could tell he was uneasy. When I told him that my wife and I had discussed it at length and we wanted the new protocol, his demeanor immediately changed, expressing great enthusiasm for our decision. It was as if we had given him permission to change from the hospital employee back to the physician. Lesson learned.

We are now in a new area, with new providers and an even bigger health system. My wife is continuing the treatment she started, getting all the recommended tests and procedures, including an echocardiogram to make sure her cardiac function is not affected by the chemotherapy. Her last echo was read as 50 percent ventricular function, borderline low indicating that if it went any lower her chemo would be stopped.

When we inquired about the result, we received an “it is fine” response. Her next echo is next week and if it is 49 percent it will be declared abnormal and therefore no longer fine.

Being a physician, I understand what is happening but I can’t help wonder about those patients who are not as familiar as I as to how contemporary health care is functioning. I do know that if at one visit they are told “they are fine,” but at the next they are told “they are not fine,” that questions will be asked as to what changed. Will their providers be prepared to give a reasonable and understandable answer?

Does a 1 percent change in a test really justify converting to a radical change in the direction of care? Is the confusion that this creates one reason why patients are so frustrated with our health care system? From what I can see, all of the not very well-thought attempts to make things better have inadvertently made things worse by forcing more and more providers to practice “by the book.”

Thomas D. Guastavino is an orthopedic surgeon.