Posted on 02/22/2014 7:50:33 AM PST by Kaslin
People who worry about death panels are missing the forests for the trees. Yes, people with expensive-to-treat conditions may someday be denied life-saving treatment because of ObamaCare. But there is a far greater danger for ordinary mortals: government and its health insurance proxies telling doctors how to practice medicine.
In treating patients with various symptoms, doctors are increasingly pressured to follow guidelines or protocols. This "cookbook" approach to medicine is the opposite of personalized medicine — an approach which aims to tailor the therapy to the characteristics of the patient, including her genetic makeup.
Before criticizing it, let me say something good about the "cookbook" approach. I think a doctor would be foolish to ignore protocols. Being aware of how other professionals have treated conditions and what outcomes they have experienced is part of being on top of what is happening in the medical profession in general and the doctor's specialty in particular.
In MinuteClinics and in other walk-in primary care retail clinics around the country, nurses are doing a superb job of following computerized protocols. In fact they seem to follow best practices better than traditional primary care doctors. They also seem to pretty good at recognizing when a patient's condition is outside their area of expertise and referring that patient to a specialist or to an emergency room for more complex treatment.
But things will go wrong if the cookbook becomes a master rather than a servant; if it becomes a book of orders rather than a book of suggestions; and if complying with endless checklists takes valuable time away from patient care. Yet that is exactly what is happening in American medicine.
The cookbook that MinuteClinic nurses follow is a cookbook created in the marketplace for the purpose of meeting the needs of cash paying customers. MinuteClinic has an incentive to weigh costs against benefits in doing what it does. If a nurse has to type too much low-value information into her computer terminal, she will be able to see fewer patients and earn less revenue for the clinic. The cost of information overload will be judged not worth the benefit.
Contrast that with what is happening to doctors dealing with impersonal bureaucracies, which do not bear any of the costs they impose on doctors and their patients. Dr. Virginia McIvor, a pediatric physician at Harvard Medical School explains the problem as follows:
…[T]he quality police demand that for any child who comes in for a physical whose body-mass index is above the 85th percentile, I must comply with certain measures — what we call box checking. I first need to check a box stating that the child is overweight. Then I must acknowledge that I entered "overweight" in his problem list. Next, I need to check a box stating that diet and exercise counseling were provided. Finally, I need to be sure that the counseling is documented in the patient note. If this patient has asthma, I need to check more boxes for an asthma action plan, use of an asthma-controller medication, and flu-shot compliance.
When a healthy child visits, I must complete these tasks while reviewing more than 300 other preventative care measures such as safe storage of a gun, domestic violence, child-proofing the home, nutrition, exercise, school performance, safe sex, bullying, smoking, drinking, drugs, behavior problems, family health issues, sleep, development and whatever else is on a patient's or parent's mind. While primary-care providers are good at prioritizing and staying on time — patient satisfaction scores are another quality metric — the endless box checking and scoring takes precious time away from doctor-patient communication. Not one of my patients has lost a pound from my box checking.
In Priceless, I made the following observation:
Over all, health care is a field that can be described as a sea of mediocrity punctuated by islands of excellence. The islands always spring from the bottom up, never from the top down; they tend to be distributed randomly; they are invariably the result of the enthusiasm, leadership and entrepreneurial skills of a small number of people; and they are almost always penalized by the payment system.
Now if you think like an economist, you will say, "Why don't we reward, instead of punish, the islands of excellence and maybe we will get more of them?" But if you think like an engineer you will reject that idea as completely unacceptable. Instead you will want to 1) find out how medicine should be practiced, 2) find out what type of organization is needed for doctors to practice that way, so 3) you can then go tell everybody what to do.
Atul Gawande is the author of The Checklist Manifesto, in which he argues that doctors can improve the quality of medicine by following a checklist similar to the ones that have reduced airline accidents. Here is his explanation of how medicine should be practiced:
This can no longer be a profession of craftsmen individually brewing plans for whatever patient comes through the door. We have to be more like engineers building a mechanism whose parts actually fit together, whose workings are ever more finely tuned and tweaked forever better performance in providing aid and comfort to human beings.
Here is Karen Davis, explaining (in the context of health reform) how medical care should be organized:
The legislation also includes physician payment reforms that encourage physicians, hospitals and other providers to join together to form accountable care organizations [ACOs] to gain efficiencies and improve quality of care. Those that meet quality-of-care targets and reduce costs relative to a spending benchmark can share in the savings they generate for Medicare.
The Affordable Care Act (ObamaCare) was heavily influenced by the engineering model. Who, but a social engineer, would think you can control health care costs by running "pilot programs"? What's the purpose of a pilot program if not to find something that appears to work so that you can then order everybody else go copy it? Pilot programs are a prime example of the social engineer's fool's errand. And by the way, there is no evidence whatever that pay-for-performance schemes improve quality or reduce costs — either in this country or abroad — either in health care or in education.
Social engineers invariably believe that a plan devised by people at the top can work, even though everyone at the bottom has a self interest in defeating it. Implicitly, they assume that incentives don't matter. Or, if they do matter, they don't matter very much.
To the economist, by contrast, incentives are everything. Complex social systems display unpredictable spontaneous order, with all kinds of unintended consequences of purposeful action. To have the best chance of good social outcomes, people at the bottom must find that when they pursue their own interests they are meeting the needs of others. Perverse incentives almost always lead to perverse outcomes.
In the 20th century, country after country and regime after regime tried to impose an engineering model on society as a whole. Most of those experiments have thankfully come to a close. By the century's end, the vast majority of the world understood that the economic model, not the engineering model, is where our hopes should lie. Yet health care is still completely dominated by people who steadfastly resist the economic way of thinking.
“A pharmacist’s mandate includes dispensing the correct drug for the patient’s disease, and the pharmacist is both ethically and legally liable if a drug is dispensed for an inappropriate indication.”
It is legal in all 50 states to prescribe drugs for “off-label” indications.
These indications are usually supported by medical research of which the pharmacist may often be unaware.
An example is beta blockers, originally approved for treatment of hypertension, but widely used to control tachycardia in atrial fibrillation and hyperthyroidism for many years before that indication was approved my the FDA.
Thus, it is not up to a pharmacist to pass judgement on the indication.
There is a difference between “off-label” and “inappropriate.” If a drug is prescribed that seems inappropriate to the stated indication, or could endanger a patient, it is the pharmacist’s duty to check, and indeed refuse the prescription if his or her concerns are not satisfied. Pharmacists can and have been held liable when they failed to do so and the patient was harmed.
Do you mind sharing which type/brand you are using? I have been researching this topic lately and I would value your input. Thanks very much.
We started with Sovereign Silver, which was reliable but expensive. I am playing with a colloidal silver generator. We’ll see.
Thank you, sir.
Glad it is helping you — best of luck.
bookmark
I will tell you that there is no more art of diagnosis.
Two friends had gallbladders removed in the past year.
Both got very ill afterwards and were ill for a years.
Sludge in the duct of one woman
The other one just died of same symptoms as the first.
Had a 30 year old acquaintance go to the ED, with l quadrant pain. A slam dunk for appendicitis.
Undiagnosed until it burst.
I am shocked by the level of poor medical care in highly regarded facilities. No diagnostic capabilities.
“If a drug is prescribed that seems inappropriate to the stated indication, or could endanger a patient, it is the pharmacist’s duty to check, and indeed refuse the prescription if his or her concerns are not satisfied.”
I understand.
However, the intrusion of insurance company-run drug plans where there is usually a non-pharmacy trained clerical staff reviewing doctors’ orders, not having the benefit of medical history, patient interviews or lab data is far different from a neighborhood pharmacist who knows his patient or a hospital Pharm D who makes rounds with the medical team and advises therapeutic options.
It is especially ridiculous when I am advised by the insurance co. drug plan that there are drug-drug interactions when I combine isoniazid, rifampin, ethambutal and pyrizinamide to treat tuberculosis.
That this generates the need for a phone call or faxes is truly idiotic.
“Cookbook” medicine is rapidly becoming the norm.
That is what is taught in med school now. One must
follow the “standard of care” meaning if someone
presents with symptom X or history Y you order tests
A B and C. If you believe you know what is wrong and
do not order those tests and your are incorrect you
cannot defend yourself in court...you failed to meet
“standards of care”. This phenomenon leads to doctors
who don’t do good physical exams, who do not take a
complete history and who merely rely on technology to
provide them an eventual answer....even if they have
to bankrupt the patient and give them leukemia from all
the lab and radiology exams they subject them to.
True doctors who practice medicine are becoming increasingly rare.....med schools and the legal
climate are producing physicians who are not doctors,
they cannot practice medicine, they are merely proctors,
they oversee massive numbers of expensive tests.
Strongly agreed.
It is especially ridiculous when I am advised by the insurance co. drug plan that there are drug-drug interactions when I combine isoniazid, rifampin, ethambutal and pyrizinamide to treat tuberculosis.
*facepalm*
Be careful with that colloidal silver. It can make you turn blue. Once it gets in you, it doesn’t get out. Google “argyria”.
Good grief, don't you think that every manufacturer of that product doesn't address that question? It takes a huge dose.
My wife had appendicitis at one point. After a day of not feeling well, I googled her symptoms, and got her to call our doctor, who told her to go to the ER.
At the ER, I said the magic words "Our primary care doctor told us to come because he thinks it's appendicitis". The ER triage nurse is not doing to second-guess a doctor, so she sends us into the ER for tests. Got it taken out that evening.
"You say that like it's a bad thing."
Disclaimer: Opinions posted on Free Republic are those of the individual posters and do not necessarily represent the opinion of Free Republic or its management. All materials posted herein are protected by copyright law and the exemption for fair use of copyrighted works.