Clueless

Someone named Ronen Avraham, a professor at the University of Texas School of Law, wrote an Op Ed piece in the NY Times (3/28/11) about the Obama administration's plan to invoke clinical guidelines as a solution to frivolous malpractice litigation. The good professor apparently had spoken with enough people to know that the problem with clinical guidelines is they are often written by the wrong people, and sometimes by people who have ulterior motives, e.g. to promote profit for the people the authors of those guidelines are working for. The other problem with the guidelines is they are too often written by people with the time to write them, faculty members at medical schools, who, perhaps surprisingly, are not the sharpest blades in the drawer.




I recently regaled a conference at my own hospital by simply reading from the clinical guidelines for the in patient management of diabetics which said, among other brilliant things, if the patient you are treating is terminal, i.e., if he is expected to die within a short time, then controlling his blood sugar, lowering it to normal ranges by the use of intravenous insulin may not be required, or at least it may not be as important as this practice would be for people who are expected to survive their hospitalization. Which is to say, if you are dying of widely met static lung cancer, if you have it growing in your brain, getting your blood sugar into normal range may not be your highest priority.



Ya think?



So who should be writing guidelines? And, more basic, is it really possible or wise to attempt to write guidelines at all? Is medical practice not in a constant state of flux, adjustment and re examination and is it not so complex that writing a single manual is impossible? Is this not what we go to medical school, residency training, specialty conferences to learn? It's like that old saw where the author is asked by the radio show host, "So what's your novel about, in a sentence?" and he replies, "If I could tell you that, I wouldn't have had to write the novel."





Some things are complex enough to defy simple dictums.





Then there is the case of "Medical Economics." The Obama people have their hearts in the right place: They want to provide health care for all, and they want to do all this at the lowest possible cost. But, understandably, they don't know where the hemorrhaging is. If you don't know the anatomy or the physiology, you are not going to find the bleeding point.





Not that the Republicans have any idea. What they have is fantasy. And fantasy is, at least, coherent--it makes a good story: Just let the market drive down costs. Get the malpractice lawyers out of the picture, driving up costs as they do. Stop all the regulation. Private enterprise will save all. Republicans love living in denial. They will cleave to these fantasies with ferocity, because they want to believe all this.





The Obama people, Peter Orszag in particular, have their own fantasies. They wanted to believe economists could tell them where the savings can come from. And they wanted to believe Atul Gawande had done a bone fide piece of medical economic analysis in Texas, showing the way as he described one Texas town where the billings to Medicare were very high versus another where they were close to the median as if these two towns held some sort of key. In the expensive town, it was all about greedy doctors, bilking the system by doing unnecessary tests.

So that's the answer! Search out those bogus, unnecessary tests!





Nice fantasy.





The real problems, of course, are much more pervasive and more difficult to fix because so many people are making so much money and they vote and they spend that money to hire elected officials.





A colonoscopy makes a local hospital $3400 and that's not even including the doctor's fee. This is a test which could be done by a technician for, reasonably, taking into account the overhead for equipment, cleaning equipment and staffing support, say $250 a pop and you could screen a lot more patients at far less cost. But colonoscopies are the cash cow of the gastroenterologist: he learns the procedure in a few months, masters it in a year and then supports his family and his boat payments doing this procedure which can be scheduled and is never an emergency, and he can be on his boat by 4 PM. You think the GI docs are going to give up that without a fight?





Similarly, you could replace 95% of dermatologists with technicians who could do excisions and biopsies at a small fraction of the cost people with MD's charge. This is another group which works 9 to 5 and profits are so enormous dermatology residency training programs are now the most competitive residencies out of medical school. Everyone wants that life and income.





Well, not everyone. Just the people who had really high SAT scores in high school, really great grades in college and who learned how to play the game to their own advantage. These are not people who dreamed of being heroes, saving lives in the middle of the night, leaving their warm beds in the middle of the night and driving into the hospital where a distraught family awaits, holding the hand of their stricken mother.





No, the dream of some medical students is a big house, nice cars and maybe a boat.





Truth be told, that hero dream is not much to be found in medicine anywhere. Just look at the TV programs now if you want to see the screen writers' fantasies about the possibilities of a medical career.





And with the advent of shift work in the hospital, with hospital doctors now just employees and with doctors in the community no longer self employed in private practice, medicine is becoming or has become not an ennobling profession, but just a job.





Medical practice has been deconstructed into its parts: Much of it is now being done by nurse practitioners, "procedurealists" , laceration technicians, physicians' assistants and other people who never went to medical school but took a short cut to the white coat and the stethoscope.





Not all of this is bad, but none of it saved money to the total system and the important part of medicine, which never paid well, is now often not done at all. That's the part where you listen to a patient's story, told in a fractured way by a person who does not have a clue what may be relevant and you tease out a coherent whole which tells you what test to order and to which specialist or for what procedure to send the patient.





One thing which looks pretty clear is the economists who do medical economics at Princeton, or MIT or Harvard or Chicago have no idea which rock to look under. Their approach, their tools are simply incapable of finding the truth, or any meaningful answers. They simply do not know how to do ward rounds and to gather the right information or to organize it into a meaningful analysis.