Great stuff on this site, I read it daily!

First quote from the article:

“In too many cases, the quality measures have been hastily adopted, only to be proven wrong and even potentially dangerous to patients.”

I would like to see some facts here. “In too many cases”. Is one too many? Is two? How many cases have been ‘hastily’ adopted? The authors in fact list two. These two cases ‘tight glucose control’ and ’statins for esrd patients’ are making headlines (not that they shouldn’t). But 2 cases in my opinion does not ‘many’ make.

Next quote:

“These and other recent examples show why rigid and punitive rules to broadly standardize care for all patients often break down.”

Again, “often break down”. Please give me some real numbers. If you are going to write a piece in the Wall Street Journal be prepared to come with some facts and not anecdotes.

Its not that I don’t share concern over the potential that a quality control metric can be misused, or implemented inappropriately. Its just that I don’t agree with making inflammatory statements without some facts. What can be said is that we are seeing instances where punitive measures are being brought against physicians and/or medical institutions without having put in place a system of due process. This is concerning.

Here is my favorite quote from the article which referenced Dr. Sackett:

“Half of what you’ll learn in medical school will be shown to be either dead wrong or out of date within five years of your graduation; the trouble is that nobody can tell you which half”

Really? Half of what I learned is dead wrong? This is an outlandish statement of pure rubbish. In my opinion Dr. Sackett should retract this statement with an apology. Period. No need to spend another neuronal synapse thinking about something so incredibly wrong.

Finally to quote Kevin,

“demanding that doctors follow stringent guidelines without room for flexibility doesn’t seem to be the answer either.”

Please note that guidelines are by definition flexible. They are ‘guidelines’, not rules. Guidelines are filled with ‘weasel words’ such as low blood pressure or elevated temperature. Doing so in fact allows for variability.

Algorithms and Protocols are more stringent and bring definition and uniformity to practice, while still allowing for appropriate variability that is able to be adjudicated. This is what my group advocates in medicine. However, it is extremely hard to achieve, and needs to be refined at local levels due to the myriad of factors that appropriately influence the practice of medicine in any particular area.

Once you institute more structured practices of medicine (especially utilizing computerized clinical decision support) then you have a basis to draw conclusions on the validity of your treatment methods, because you are able to reduce (or even control) the variables and increase the ability to examine your outcomes.

JFS

Doctors have to obtain prviliges, answer to quality committees, licensing boards, and always have the threat of malpractice.

Forcing them to add a statin to an 85 year old demented man’s medication regimen acomplishes little.

Patients, nurses, pharmacists and other physicians have ample opportunity to complain about the care a physician provides (right or wrong, valid or invalid complaint, this is the simple truth).

I would rather doctors, even ones I have never met before my acute illness, decide how to set my ventilator, what medications to pump into my veins, and what surgery (if any) I need. At least they examined me; the policy wonks don’t even know what I look like.