When Quality Is Core by Pat Conrad MD

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In the post-modern, pay-for-dumbing age washing over practically every aspect of life, medicine is being, like, y’know, Kardashianized by the amorphous collective of Big Academics-Big Insurance-Big Government cronyism. Pay-for-performance, core measures, and evidenced-based medicine are all faces of the monster we first met in training when schooled on how to be “good stewards of scare resources.” The monster is collective thought that is forcibly substituted for training, experience, ethics, and judgment. It makes something less than an individual of both patient and physician, trundling them along through mass transmogrification into parts and technicians.

California physician Karen Sibert, MD knows what I’m talking about. She has an excellent piece, “Today’s “Evidence-Based Medicine” May Be Tomorrow’s Malpractice”, in which she breaks off just a chunk of the rotting self-importance that is today’s medical establishment.

Lowlights:

  • The Justice Department has encouraged CareFusion Corp. to pay the government a $40.1 million settlement after learning that the company was boosting sales of ChloraPrep by paying kickbacks…$11.6 million to Dr. Charles Denham, then the co-chair of the Safe Practices Committee at the National Quality Forum. Another, ahem, colleague pushing Chloraprep was Dr. Rabih Darouiche who wrote for the NEJM extolling the “significantly” better CareFusion product. Was Dr. Douc-, sorry, Darouiche likewise on the take?
  • Dr. Should-Be-Prosecuted Denham resigned – no word on any other legal action. And why should the damned government get any money, when they abetted this corruption by creating a legal and fiduciary environment that allows crooked vendors to intimidate subjects into buying their product?
  • The Surgical Care Improvement Project (SCIP) has defines beta-blocker use as “a core measure” hospital quality for surgical patients, despite the absence of any study demonstrating any benefit. Hilariously, the SCIP does not track whether the patient’s blood pressure or heart rate are maintained within a normal range. Funnier still, a 2013 review and meta-analysis demonstrated pre-op beta-blockers were associated with a 27 % risk increase in 30-day mortality. Dead patients cost nothing. That’s a golden twofer, reaching quality goals and reducing expenses with one cheap med.

Dr. Sibert: “Sadly, the federal government has seized on adherence to “evidence-based guidelines” as a way of demonstrating “quality” in health care…This system will include payment bonuses or penalties based on a composite performance score. Patients as well as physicians should be frightened at the prospect that the government’s version of guidelines for care will forcibly replace physician judgment and experience in caring for patients as individuals.”

I only disagree with Dr. Sibert’s tense. Physicians, many of who believe in the rightness of institutionalized compassion and the rightness of quality claptrap, are already forced daily into decisions that are against their best clinical judgment. Several years ago, a staff colleague of mine, a board-certified pulmonologist and critical care specialist, saw a patient for pneumonia in the office, obtained sputum cultures, and began empiric antibiotic therapy. The patient was later admitted as the pneumonia worsened, but fortunately the sputum cultures confirmed that the offending bacteria was very sensitive to the chosen antibiotic, and the patient began to improve. Armed with collective-approved Medicare guidelines a nurse, unburdened with the pulmonologists extraneous training, informed the physician that the antibiotic must be changed to conform with the core measures or the hospital would not be completely paid. So the doctor was forced by the quality collective to choose between providing the best care for the patient, or the best care for the hospital. That she chose the former is no comfort at all.

 

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