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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  • http://www.facebook.com/obinna.akunna Obinna Akunna

    Cookbook “clinical” algorithms are one of several ways medicine is being automated. I predict than in ten years, most doctors other than a few specialists will be easily replaced by NPs, PAs or other midlevels. It is no wonder doctor salaries are stagnant….some nurses are making more. Face it we have dumbed down our profession by being scared of the joint commission, lawyers, patient satisfaction surveys etc etc EHR was the last straw for me.

  • http://twitter.com/DavidGelberMD David Gelber MD

    The cookbook approach helps level the field, bringing all doctors to the same level o mediocrity. I don;t know how many times I’ve been called by the ER to admit a patient with “Small bowel Obstruction.” The patient has not ahd previous surgery, does not have a hernia, has had nausea, vomiting and diarrhea, with fever. The diagnose is invariably based on CT report which describes all the classic findings, except that the patient’s clinical history and exam clearly suggest gastroenteritis. Of course, that doesn’t matter. Once it is committed to paper, the diagnosis is carved in stone. The proliferation of “Protocols” with reimbursement tied to their implementation has led to a cookbook approach that borders on insanity. do I really need to be called at 3 am to ask about stopping the antibiotics on the octogenarian who had emergency surgery 24 hours ago for a perforated colon and is still septic?

  • http://www.facebook.com/people/Steven-Reznick/100000549195050 Steven Reznick

    At 8-10 million dollars per inspection the Joint Commission has become part of the problem not part of the solution. The fact that insurance companies can now refuse to pay a facility for care rendered if the Joint Commission flunks them is a conflict of interest and absurdity that results in more non care giving persons in white coats running around with clip boards to monitor core measures than individuals in white coats providing care. There is little or no common sense applied by the Joint Commission ( requiring doctors to sign the bottom of each page in a continuous hospital progress note and write ” turn to next page” and trying to sell that as a safety measure). During the Joint Commissions reign of terror the number of safety issues, accidents, development of drug resistant bacterial infections has not declined. Is it possible that the resources needed to fix these problems are being devoted to hiring ” clipboards” to see if we signed the bottom of our progress notes and wrote ” Turn to the Next Page.” Or could it be that Joint Commission Reviewers are reading the progress notes and get to the bottom of a page without directions and are sitting there endlessly trying to figure out what to do next?

  • drd

    All that seems to matter now are labs and test results. Which of course leads to action of some sort—like another profit making procedure.

    No thinking is allowed. Remember when Brave New World was just a book?

  • Ann Waters

    On behalf of coders, forgive us. I’ve attended workshops where the speaker has given tips about your above (non-existent) CHF or SBO. I’ve cringed, knowing the queries coming your way in short order will be more invalid than valid.
    The best coders are the one who have taken the initiative to not only learn about disease processes and treatments by constant reading, but also find the physicians who are willing to take the time to teach us. I’ve been quite fortunate through the years to have had wonderful clinicians willing to spend the time. In turn, I’ve been able to work on large projects because I know what I’m reading.
    So there are some of us out here who know what we’re reading. I’m sorry for those of us that drive you crazy. And, hey, thanks to all of you who have wonderful documentation – not just for reimbursement, but taken the time to teach

  • lauramitchellrn

    To me, decision trees/algorithms/clinical pathways should be a guide. What I’ve seen over the last ten or fifteen years (for nurses too) is that instead of being an adjunct to treatment, the decision tree/algorithm/clinical pathway BECOMES the treatment, no matter what. Where’s the critical thinking?

  • http://www.facebook.com/profile.php?id=100000077801405 Jay B. Ham

    I think of checklists and algorithmic based medicine rather fondly. As the proud owner of a somewhat disorgainzed, mildly ADD mind, the enforced structure can be very helpful. Certainly the downsides are apparent, most importantly the “is it time to deviate” from the checklist. Some personalities have no difficulty stepping off the checklist, mine is one of them. Others are so respectful of law and order, that it can actually cause anguish to not follow the pathway. Worse, the lazy brain doesn’t care. I suspect a formalized curriculum for dealing with algorithmic based medicine will be developed to help with lazy brain syndrome or law and order worship. As long as we don’t canonize the algorithm, we’ll be ok.