Clinical guidelines in healthcare reform

While DrRich is a conservative American, and has made plain the difficulties he has with the Progressive program in general and with Progressive healthcare reform in particular, at times he is forced to admit that, on occasion, the Progressive way of looking at the world has certain merits. And as DrRich contemplates a question that has been bothering him lately, a question that no doubt plagues many American physicians who (unlike DrRich) are still toiling away in the trenches, he finds that this is one such occasion.

That question is: Just who are the people writing all those clinical guidelines – the  “guidelines” physicians are now expected to follow in every particular in every case, on pain of massive fines, loss of career, and/or incarceration?

DrRich is quick to say that the act of creating clinical guidelines is not inherently evil, and indeed, back in the day when guidelines were merely guidelines (instead of edicts or directives that must be obeyed to the last letter), creating clinical guidelines was a rather noble thing to do.

But today, we have physicians clamoring to become GOD panelists (Government Operatives Deliberating). These aristocrats of medicine will render the rules by which their more inferior fellow physicians, the ones who have actual contact with patients, will live or die. Clearly positions of such authority will be very desirable, and so, as one might predict, they are being vigorously pursued. And we are seeing candidates audition for these panels with efforts ranging from amateurish to ruthless. It puts one in mind of the early-season contestants on “American Idol.”

We see them vociferously extolling, in every public venue they can find, the idea of “fly by wire” medicine, whereby every decision physicians make will be determined not at the bedside but by the best and the brightest experts, acting at a distance. The experts will distribute rules of action based on only the best scientific evidence (“best” being determined by those selfsame experts). The directives they hand down will be models of actionable simplicity,spelled out so unambiguously that even doctors born, raised, and trained in the Midwest or the South will be able to follow them.  (And if the doctors refuse to cooperate sufficiently, non-physician medical professionals will be able to do the job.) We see them writing scientific papers that spin the evidence in such a way as to generate conclusions which will be soothing to the Central Authority. We see them editing medical journals in order to make certain that the correct conclusions are published, and the incorrect ones are not. We see them taking control of professional organizations, and using their positions to promulgate changes in medical ethics that advance the Borg-ification of medicine, and to formally endorse Obamacare on behalf of American physicians who, for the most part, were against doing so.

These people have gained great prominence within our healthcare system, and practicing physicians will be dealing with them and the consequences of their actions for many years to come. While the natural impulse of us typical American doctors may be to simply marvel at the wonder of it all, shake our heads resignedly, and go about our increasingly distressing business, it may behoove us to take a closer look at these individuals, to attempt to understand them a little better. After all, their activities in the near future promise to greatly impact our lives, our fortunes, and our sacred honor.

So – who are they, anyway?

This, dear reader, is where the Progressive mode of thought comes in handy. DrRich refers, of course, to the Progressive doctrine of Diversity.

Diversity, for those who pretend not to know, is perhaps the chief mechanism by which Progressives attempt to control the behavior of the population.

Recall that the Progressive program is to create the perfect society. The Progressive elite know just how to do this, of course, but individuals within every population throughout human history have insisted upon acting in their own self-interest, which is counterproductive to the collective goal. In past efforts to perfect human societies, such individual recalcitrance has been dealt with by means of concentration camps and pogroms and the like. “Diversity,” we all should admit, is a much kinder and gentler approach to curing the problem of individualism.

Specifically, the doctrine of Diversity defines the range of permissible behaviors and thoughts for a given group of people within a society. The numerous celebrations of Diversity we see all around us invariably turn out to be strategies to reinforce those allowable ranges of thought and behavior. In this way, members of a particular group who begin behaving and thinking outside the allowable range can be quickly identified and dealt with, either through correction (which brings them back into the group), or through vilification (which marginalizes them). It is easy to become confused about this, since classically “diversity” means something other than “conformity.”  (As a general rule, if you want to know what Progressives are really up to, listen to what they say and then look to see if their deeds are actually working toward the opposite thing.  DrRich thinks that much of the time you will find that they are.)

In any case, while in general DrRich does not approve of Diversity as it is being practiced today, he finds that the concept might be useful in attempting to answer the question at hand.

Specifically, DrRich refers to his theory that physicians (like any humans) tend to end up in careers that best suit their underlying personalities and proclivities, and so physicians in a given specialty will tend to think and behave like other physicians within that specialty, and unlike physicians in other specialties. If this theory has any merit (and let us call it the Diversity Theory of Physicians), it will allow us to make some generalizations about the characteristics of individuals who have chosen specific kinds of medical careers. DrRich stresses that he is aiming to make generalizations only, and while those generalizations might help enlighten us to a modest degree regarding, say, what sort of physician will end up on the GOD panels, they can tell us nothing about particular individuals.

With that annoying disclaimer out of the way, let us examine some ways in which the DTP reveals Truth. An obvious example is the specialty of psychiatry, which tends to attract doctors who are, perhaps subliminally, concerned that they are just a little crazy themselves. As it happens, it often turns out they are correct. In DrRich’s experience, and in the experience of just about anyone who has encountered more than a handful of shrinks, these fine physicians, on average, display an astonishing degree of off-the-wall psychopathology. (Not that there’s anything wrong with that.)

Emergency room doctors have short attention spans and are afraid of commitment.

Endocrinologists get their jollies by sitting alone in cramped offices, parsing tremendous volumes of laboratory data from blood tests, which they claim reflect moment-to-moment variations in hormone levels, and from this arcane evidence are able to parse out (so they say) subtle glandular difficulties. If endocrinologists were not physicians they would be accountants; the more aggressive endocrinologists (who are identifiable by the dirty glance they give you if you happen to interrupt their lonely cogitations) might be forensic accountants. (How anybody could specialize in any organ that just sits there, perhaps secreting various invisible substances, but otherwise not doing anything whatsoever,  DrRich will never understand.)

Orthopedic surgeons are former jocks, or wish they were, and the ones who end up replacing hips in old ladies instead of patrolling the sidelines at college football games are often very frustrated individuals.

Party animals who manage to gain entrance to medical school often end up as anesthesiologists.

Cardiologists like to envision themselves (and would like others to envision them) as living on the edge. After all, they put catheters into damaged coronary arteries in patients on the brink of heart attacks, and, through their skillful manipulations, open those arteries and save lives. They are the extreme sportsmen of medicine, so they believe. But really, their jobs are ones of relative security, predictability and instant gratification. What they do in the cath lab actually is pretty rote, and it provides them with immediate, concrete results. They can even show the “before” and “after” pictures to the person they just saved, who will then heap praise and shed tears of gratitude upon them. But any time fixing a particular artery looks a little too risky, they call a cardiac surgeon right away. This pattern of behavior suggests to DrRich that their aggressive personnas and glory-seeking activities are actually masking an underlying insecurity.

It would not be fair of DrRich to psychoanalyze all these other specialists – who have done nothing to provoke him – without also doing the same for electrophysiologists. All electrophysiologists started out as cardiologists, of course, so they have that going for them. But to really understand electrophysiologists, one must invoke the principle of sublimation. To sublimate is to channel an underlying negative tendency to some activity that partially gratifies that tendency, but that is considered worthwhile by society. So, for instance, people with a tendency toward pyromania may become volunteer firefighters. People with sadistic tendencies may become prison guards. Foot fetishists can become shoe salesmen. Compulsive liars can become novelists.

Who, then, become electrophysiologists?

Back in the 1980s and 1990s, when DrRich was practicing, what electrophysiologists mainly did was to try to prevent sudden death in patients who had a high risk of dying suddenly from cardiac arrhythmias. And in order to find the optimal therapy for these patients, it was necessary to induce, intentionally and repeatedly, cardiac arrests under controlled conditions. This was done in an effort to find an antiarrhythmic drug that would prevent the induction of cardiac arrest. This behavior we euphemistically called “serial drug testing.”  Fortunately, this procedure is no longer necessary, since the implantable defibrillator has been perfected and is now widely available for high-risk patients (if you can get it paid for).

While it has been widely remarked that those early-day electrophysiologists were a very strange group indeed, most of us who did this serial drug testing ended up successfully absorbed into normal society, and today (as far as DrRich can tell) we are for the most part generally pretty harmless. But DrRich sometimes finds himself wondering what might have become of some of us (some in particular more than others) if we had not had this remarkable opportunity to sublimate what one might speculate to be some rather unpleasant tendencies. And what is to become of that young person today who has whatever those unfortunate tendencies might be, and who, 30 years ago, might have found release as an electrophysiologist? One must not think too deeply about this.

Let us now turn our attention to those would-be GOD panelists, and see if we can decipher what kind of people these might be. Admitting that what follows – and, for that matter, what has just been said – amounts only to an educated guess, DrRich submits that the GOD panelists are people you already know well, if you have worked within the American healthcare system.

These are the kids you knew in college who studied all the time and got straight A’s in all the hardest courses, buttered up their teachers, then aced their MCATs. For them the hardest part about applying to medical school was in deciding which of the many schools that accepted them they should attend. Likely, they chose one of the Ivy League ones. Their first two years of medical school – the didactic years – were much like their college experiences. They studied hard, aced all the exams, and were generally acknowledged by both faculty and peers to be at the very top of their class.

Then they reached their clinical years, and things changed. They still knew more information than anyone else, and in fact their information base continued to expand. They read all the journals, and could always quote new research findings chapter and verse. They could conjugate the Krebs cycle on demand (or whatever it is you do with the Krebs cycle), and could recite precisely which enzyme that new drug inhibited, and could say why doing so made it OK to eat pizza again.

But what they could not do was be a good doctor. They had no instinct for it; no ability to get the patients to tell them the important information; no ability to read a patient’s facial expression, or phraseology, or body language, those signs that reveal the real truth. They had no ability to discern useful information from the flood of partial and contradictory clinical evidence that is always pouring in from several sources. When time was of the essence, they had no capacity to figure out what was going on or what they should do about it. They could not adjust to changing clinical situations on the fly. In an emergency they were paralyzed, trying to match the quickly evolving situation in front of them with the static words on the printed page. And often they were klutzes.

They were perfectly cut out to learn medicine, but lousy at actually doing it. What was worse, some of their colleagues who were mediocre in the book-learning department suddenly blossomed into highly competent clinicians on the wards, and quickly became recognized as rising stars by attending physicians, while they themselves were repeatedly chastised, or ignored.

And it just wasn’t right. It just wasn’t fair. They had worked harder than everyone else, had twice the brains as those others, and had learned the material three times as well. But the way God set it up, they just weren’t good doctors.

Many of these unfortunate souls quickly left clinical medicine, and branched off into research, academics, or administration. Most of them did quite well for themselves, because they really are very smart. But they never really got over their frustration and anger over their unjust  failures on the clinical wards, a place where their obvious inferiors lorded it over them. They have now spent years engaging in cognitive dissonance, convincing themselves that their apparent failure was an illusion, merely a sign of having been subjected to the anti-intellectual, shoot-from-the-hip, do-it-quickly-and-make-more-money environment that is American healthcare. After all, how could they be sub-optimal physicians when they are clearly far more intelligent and knowledgeable than the supposed “stars?” If the healthcare system had been arranged differently, in such a way as to make the cowboys behave the right way, they would have proven themselves to be the best clinicians in the land.  It is a bitter, bitter pill.

These are the guys, DrRich thinks, who are chomping at the bit for the opportunity to sit on the GOD panels. They would dearly love the chance to utilize their superior intellectual firepower, to distill the clinical research data, to digest it painstakingly and thoroughly (not haphazardly and on the fly like those others), to put down on paper the RIGHT way of practicing clinical medicine -  and to have the authority to do it in such a way (backed up by the full force of the Central Authority) that those lesser doctors will HAVE to do it their way, at long last.

The point of all this psychoanalytic guesswork is to suggest that the GOD panelists, even the GOD panelists who are physicians, will have no sympathy for the idea that the practice of medicine should be individualized to any degree whatsoever. The idea of individualizing medical care, rather than practicing by formula from a book, is what caused these people the most uncomfortable moments in their professional lives. Far from being sympathetic to the idea, they will probably be more hostile to it than the non-physicians on the GOD panels. When somebody on the panel suggests that, perhaps, we should give the doctor a little more leeway on this particular issue, these physicians will speak up and say, “Listen. I’ve been there and you haven’t. These doctors don’t need any more rope, unless it’s to bind them even tighter.” They were themselves shown no quarter, in the tough arena of clinical medicine where outcomes (and not process or book knowledge) is the only mark of success, and they will offer none in their turn.

DrRich cannot prove any of this, of course. He is just theorizing, based on his own personal observations and prejudices, having observed many of these whiz-kids in his 25 years of teaching medical trainees, and watching where they wound up. He could, of course, be wrong.

In any case, for allowing him to carry on in this manner DrRich owes one more expression of gratitude to his Progressive friends, whose doctrine of Diversity supplies the necessary substrate, and the ethical “cover,” for mercilessly stereotyping selected groups of what otherwise might turn out to be individuals.

Richard Fogoros is a cardiologist who blogs at The Covert Rationing Blog.  He is the author of Fixing American Healthcare – Wonkonians, Gekkonians, and the Grand Unification Theory of Healthcare.

 

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  • pcp

    Check out JAMA Feb. 16 “Sudden Acceleration of Diabetes Quality Measures:”

    “This case study indicates that the quality INDUSTRY’s (my caps) process of developing performance measures is broken and that steps need to be taken to restore accountability . . . Only when those who promulgate measures are held personally responsible for their decisions should they hold physicians on the front line personally responsible for their implementation.”

    • stitch

      This is what nurses have been dealing with for years: increasing burdens of evaluation without clear evidence as to benefit, leading to decreasing time spent with the patients in favor of spending it with the chart.
      We physicians really need to be speaking up about the problems of measuring “quality” by assigning measurable “values” to what is essentially the low hanging fruit. Whatever happened to treat the patient, not the number?

  • JPB

    Bravo!

  • Marc Gorayeb, MD

    Brilliant! A deep, solid foundation for our contrarian (dare I say Randian?) manifesto. The Federalist Papers pale in comparison.
    By the way, did you catch the latest JAMA article on the use of ICD’s? JAMA went ahead and published it, despite the fact that the “registry” is really not all that it could be. But the government is about to cure all that, because soon we will all be required to upload every last detail about our patients to that wonderful cloud in the internet sky.

  • http://fertilityfile.com IVF-MD

    I love guidelines as in “Let us summarize for you the available evidence and logically argue why option X is better than option Y in this situation. Then you can take this information to heart and let it influence your management decisions appropriately, as you see fit within your role as a doctor”

    I despise guidelines as in “You must do as ve say or ve vill crush you”

  • http://onhealthtech.blogspot.com/ Margalit Gur-Arie

    Echoing the Bravo!!
    …and I consider myself progressive….

    And it’s even worse because “guidelines” are a precursor to “quality measures”, which are a precursor to reimbursement policies and other “we will crush you” strategies for ensuring “compliance” with guidelines.
    In addition to the concern about who is developing the hundreds upon hundreds of quality measures, I have a concern about who selects the subset to be “enforced” and the process by which the selection is made. Right now, it seems that the technology folks at ONC are selecting measures based on what can be measured with HIT (in all fairness, there are some folks with MD degrees on the various panels). This entire process seems a bit odd to me as I wrote at some length a while ago http://onhealthtech.blogspot.com/2010_09_01_archive.html

  • PAULMD

    Very good piece.

    I seem to remember similar “best and brightest” issuing the Gene Stoner M-16 black rifle without cleaning kits. The new rifle was so advanced, no cleaning was needed….it was “self cleaning” said the best and brightest from a safe far away place, let’s say….the pentagon.

    As the weapons failed in combat, many American soldiers died and there was an outcry for M-14s or cleaning kits lest our boys continue to use captured enemy AK-47s. As OUR body count mounted, a new directive including cleaning kits and new propellants were finally issued from the “best and brightest” and things did get better for our soldiers and marines.

    I wonder what our body count (both patients and docs) will be before this diversity is deconstructed.

    The validictorian of my med school class was the most ineffective student I ever shared a rotation with. A boyish, lumpy teenage “Rainman” from Long Island, incapable of parallel parking let alone participating in any true patient care. He was basically placed in a chair in the OR so that we wouldn’t trip on him. He matched in radiology but, as a kid never picked for kickball, I’m sure he would be a perfect addition to the star chamber.

    More and more, an “MD” after your name means that you are in fact in possession of a medical doctor degree but that you are not necessarily a physician.

  • http://www.foodandhealth.com doctorjay

    First off I share much of Dr Rich’s concerns about GOD panels and paricularly the GOD MD panelists. Progressive ideology and diversity are indeed evil and anethma to a free an open society. But let’s deal with an example where there is reason to question Dr Rich’s belief based on the scientific data and what impact GOD panelists might have on interventional cardiologists. DrRich stated:

    “Cardiologists like to envision themselves (and would like others to envision them) as living on the edge. After all, they put catheters into damaged coronary arteries in patients on the brink of heart attacks, and, through their skillful manipulations, open those arteries and save lives.” DrRich

    This appears to conflict with the growing consensus that putting stents into narrowed coronary arteries does not in fact save lives. It does not appear to reduce the risk of MI and at best in most patients transiently reduces angina. Of course, taking away a patient’s only symptom their dit is killing them might reduce compliance with a diet & exercise (perhaps combined with statins/niacin/etc.) program that could get rid of their angina by stopping and reversing the atherosclerotic process – something angioplasty has no capacity to do. It seems to me Dr Rich may be concerned such data may threaten his livelihood if the future GOD panelist reject elective PCI (except perhaps in cases of severe dibilitating angina), which clearly would save the US healthcare system tens of billions of dollars with little or no impact of CVD mortality. Could it be DrRich excellent article reflects this coming predicament for DrRich

    • http://covertrationingblog.com DrRich

      Doctorjay,

      You do not give me enough credit. First, when I practiced I was not an evil stent doc. I was an evil electrophysiologist, a much higher form of being.

      Second, I have written plenty of articles that reflect the truth about stenting, such as: http://covertrationingblog.com/cardiology-topics/the-proper-syntax-for-the-god-panelists

      Third, I have also skewered some of the foibles of electrophysiologists plenty of times as well, but I refuse to provide those particular links.

      Rich

  • horseshrink

    Impressive! Nice! Nodded my head repeatedly in resonance.

    And, I’ve thought the same about the rule writers. They niche thus because they aren’t as good as their peers at actually practicing the field for which they write the rules.

    ,,, Joint Commission auditors … Inspector general employees … DOJ emmissaries … Administrative code writers …

    Necessary evil? Blunt, slow hindrance?

    Another problem with guidelines … The field of medicine changes too rapidly now for bureaucratically written guidelines to keep up. Such currency is even difficult within professions! The APA guidelines site is a good example of this.

  • gzuckier

    I came into this pretty antagonistic, but persuing DrRich’s previous writings, I see he makes an excellent case, at least re the “reasoning” centered around the JUPITER study. But isn’t it a matter of thresholds? Reductio ad absurdiam, what about a doctor who amputates somebody’s leg as a cure for migraines, defending himself on the grounds that there are no guidelines identifying the practice as wrongheaded?
    The much-loathed malpractice industry thrives in the fuzziness of practice standards. The establishment of standards of practice, although as political and error-prone as any other human endeavor, is preferable to the essentially random-walk establishment of quasi-legal standards of practice by random juries which is poised to fill the vacuum.
    But, yes, it is both frustrating and troubling to have one’s individual talent, intelligence, and initiative constrained by a distant bureaucracy.