Cookbook medicine can make doctors clinically lazy

Juan Gonzales, (not his real name), is a somewhat demented elderly Hispanic male, who I met last week in an intensive care unit. He spoke little English, and I spoke limited Spanish.  His devoted family was at the bedside, and fortunately his daughter was able to provide some history. He was admitted with palpitations and dizziness and atrial fibrillation with a rapid response.

His family had just moved him from Miami, where they said he had three prior strokes. As I went over his medications, all seem appropriate except for two antibiotics ordered from the ER, azithromycin and ceftriaxone. He had no fever, a normal white blood cell count, no cough or dyspnea, and benign urinary sediment. His lactic acid level was also normal. His chest x-ray did show heart failure and the report also said “cannot rule out lower lobe pneumonia.” By all clinical and objective criteria, this man did not have an infection that needed to be treated. However, the ER team is so sensitive to missing sepsis that I guess any reason to give empiric antibiotics is not missed.

I have witnessed this trend before, and have to wonder how much this over use of antibiotics has contributed to drug resistant bugs in the hospital.  As a physician in training, we had a fraction of the drug resistant problems encountered in most hospitals today. I can’t believe that our hand washing and sanitizing was that much better in the “old days.” I am no infectious disease or public health specialist, but I do believe that the unintended consequences of this, and other mandated core measures and protocols, have created as many problems as they have solved.

There certainly is a role for guidelines and workflows. I am sure that more post-MI patients are discharged on aspirin, beta-blockers, and statins, than before they were instituted. Yet, the cookbook approach to medicine also makes us clinically lazy and treating problems where none existed. I have had to wage a campaign at some of my local hospitals to educate the coding folks, (not so fondly referred to be one nurse as the “clipboard people”) to not say a patient has congestive heart failure, because his BNP level was 102 (normal being 1-100).  And therefore I don’t need to order beta-blockers, ace-inhibitors, or an echocardiogram.

Speaking of echocardiograms, if the patient had one last month and returns again in heart failure, he really doesn’t need another one, unless of course he has had an MI. Probably one of the most abused and over-ordered cardiology tests, doctors and coding staff seem too rushed to even look if the patient has had an echo in the recent past. And oh by the way, Medicare won’t reimburse us for reading more than one every six months, without an appeal and extra documentation.

Another time I was approached by a core measure nurse, to ask why a patient had not gotten aspirin within 24 hours of his admission. The answer, which of course I had to document in the chart, was because the poor soul was in shock and on a ventilator, and his enzymes did not turn positive until 36 hours after admission.

The Joint Commission has now recommended no less than 14 different National Hospital Quality Measures, ranging from myocardial infarction to tobacco treatment. So expect the ranks of the clipboard team to swell in the future. Some of these make sense and are useful, like a “timeout” before surgery or an invasive procedure, to make sure the correct patient and site of operation are confirmed. But do I really need a timeout before I administer a treadmill stress test?

All of these policies are well intentioned. However, once Medicare started supplying financial incentives, and disincentives, and the Joint Commission penalized hospitals for poor compliance, you knew abuses weren’t far away. I suppose as doctors, we had this coming for not remembering to do all those little things that make patients better, and avoiding those that make them sicker. It just seems that common sense has once again taken a back seat to bureaucracies and insurance companies.

I do what I can, albeit small, to make application of these guidelines more rationale. But sometimes, I feel like Don Quixote, tilting at windmills. As for Mr. Gonzales, I stopped his antibiotics, treated his atrial fibrillation, and he did just fine.

David Mokotoff is a cardiologist who blogs at Cardio Author Doc.  He is the author of The Moose’s Children: A Memoir of Betrayal, Death, and Survival.

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