That’s where the American healthcare system is heading, and barring a massive outcry from both physicians and patients, I don’t see any chance of stopping it.

Here’s a story in the Washington Post about how doctors around the country are being penalized by inaccurate rating systems which 1)  don’t collect data correctly, or 2) measure fake outcomes, or 3) measure outcomes for which there is no evidence. For instance: patients who’ve had a heart attack are supposed to be on beta blocker medicines. Ok, fine. That is well-documented (in studies funded by the drug companies, but we’ll set that aside), and accepted clinical practice. But how is one of the high-school educated clerical workers reading through records to determine compliance going to know that the family physician decided to use a different method of blood pressure control in a little old lady who can’t tolerate even the lowest dose of beta blocker because she develops postural hypotension and has been falling because of it? It should be documented, but it might be written in a way that our clerical worker (lowest common denominator here) can’t understand, or perhaps the documentation was made a couple years ago, not in the chart that’s being reviewed right now.

That’s just one example. We could go with others: such as that there is little research backing the concept that patients with community-acquired pneumonia benefit if antibiotics are started a couple of hours earlier in the ER, although this is now such a key quality measurement that I’ve seen several elderly patients’ charts with colored notes from the efficiency folks inquiring about whether antibiotics were started early enough. Or how about heparin for DVT prophylaxis in surgical patients? Accepted surgical standards state that for young patients or those with low-risk surgery, methods such as aggressive ambulation, TED stockings, or SCDs (sequential compression devices; half my patients hate them, half think they’re getting a free massage) are sufficient to protect against DVTs and pulmonary embolism. Nevertheless, Medicare guidelines now require heparin use, pre-op, in all surgical patients. This can be circumvented by mentioning in your op note why you chose not to use heparin (fear of bleeding, etc). But why do we have to document a useless statement about a criteria for which there is no evidence? Why do we have to waste our time jumping through these hoops trying to make bureaucrats understand how we think?

It’s going to take nine years for me to learn to think like a doctor. And we have bureaucrats and medical coders judging us on this? When did they get their medical degree? We worked hard to get here. They come into their offices at nine o’clock, and sit down in comfortable chairs to pick holes in our decisions. What do they know about it? (I got a lecture today about how any plan of action which involves a surgery intern arriving at the hospital later than 5am on any day of the week has to be flawed.)

Reading Sabiston’s surgery textbook is actually useful. I’m kind of handicapped because I decided to do surgery relatively late in medical school. I didn’t spend the time soaking up their practices the way most medical students on this career track do. But today I discovered that the first fourteen chapters in this huge volume explain all the lore that I keep getting tripped up on. It’s complicated, you know. There are all kinds of risk assessments for patients with any kind of pre-existing medical disease that you’d like to name. There are a million different possible complications to be aware of and plan ahead to avoid. And this is all before we actually start doing any cutting.

You folks out there want bureaucrats practicing medicine, or would you perhaps prefer that those of us who were trained for the job, do our jobs? It’s your health. You are the consumers. If only you  knew what was happening, you could have a strong voice.

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