And more about marketing….

It’s frustrating that hospitals and administrators have become increasingly involved in the delivery of medical care by physicians in an attempt to manipulate the institution’s public statistics.  It’s also frustrating that this approach is being driven by the ‘so-called’ groups that advocate quality.  Where groups such as the JCAHO, Institute of Medicine and the States that publish ‘Quality Measures’ purport to aim to improve quality, all they do is cause the degradation of quality medicine by forcing physicians and hospitals to focus on ensuring the ‘data looks good’.  Published Data about hitting targets for treatment of certain medical conditions (DVT prophylaxis rates, Health Care Associated Infection Rates, Influenza Vaccination rates, etc) do nothing to indicate whether a Physician is a good one, whether they can actually make a diagnosis and treat a patient at a high level.  Now, individuals who make sure that the ‘data’ looks good will be considered the ‘good ones’ even if they couldn’t take care of my dog.

Hospitals have become expert at manipulating Ventilator Pneumonia rates, Line infection rates, Mortality, etc.  Did you know that in many hospitals in NY, NJ and PA there have been ZERO Ventilator Associated Pneumonias in the last 5 years…..and despite this there have been quite a few!!!!

The quality measure that tracks the ‘Time from Admission Decision’ in the ER to transfer out of the ER has led to patients being diagnosed and admitted with ‘bridging orders’ even though the diagnosis isn’t close and the bridging orders merely say ‘admit to floor’ with no diagnostic or treatment orders…..but, although the patient will languish on the medical floor awaiting real orders and a real diagnosis….the quality is excellent because the patient made it out of the ER in less than 90 minutes.  Gotta love the priorities!!!!!

Then there is the push for the almighty Electronic Medical Record (EMR) and Computerized Physician Order Entry (CPOE), which are also supposed to improve quality.  How, I’m not so sure, but it’s supposed to.  Now we have Emergency Physicians sitting at computers typing instead of at the bedside diagnosing and treating.  Next up…..the same in the ICU’s…..which will lead to very cursory discussions of patient issues and treatment plans because it takes forever to type it all out.  Now what you’ll see is just a list of problems without any discussion of the issues and plans.  So much for quality through improved communication and discussion.

I recently received a note from the Electronic Record of a Cardiologist at the University of Pennsylvania, a quality institution.  The note included list of Assessment diagnoses and a list of Plans,  all generated by clicking off the correct boxes, and not a thing was discussed about what the clinician thought and why…..I have no idea what he thought.  I already knew the list of diagnoses but wanted to know what his thoughts…..and nothing!!!!  So much for the record being a place to discuss your thoughts and plans in a detailed fashion.  I will say, it was a perfect note….had all the components and Systems Review to receive the highest level of coding and billing!!!!

As for order entry….in an attempt to create uniformity, it has become impossible to individualize treatment on a daily or minute to minute basis, unless you want to jump through major hoops to do so.  And when you have 30 patients to see, who is going to sit and spent 20 minutes typing orders when the hand written version would have taken 3 minutes……and would have been more to the point and detailed what you actually wanted to have happen.  Ahhhhh….cook book medicine (or should I say ‘evidence based medicine’).  I do understand the intent….now you don’t have to be smart and well trained, or experienced and talented, to practice medicine….all you have to do is click the right boxes and we’ll all look the same!!!!

Now, I’m all for Evidence Based Medicine, in fact I’ve been practicing that way since before it became in vogue, it’s just how I was trained at the U of P…but….no two patients are the same.  And therefore, no two treatment plans should be same, not even close!!!!  Too bad, but now you merely have to click the ‘Pneumonia order set’!!!!!

Well, that’s my rant for today!!!



It’s all about marketing…

It’s just a shame that medicine and healthcare has come down to what ‘looks good’ in the reports and statistics but requires abandonment of what’s best and most ethical for the patient.  I have a patient in my ICU who recently underwent a cardiac surgical procedure but has been very slow to recover after a myriad of complications.  He didn’t really want to undergo the procedure but agreed after pressure from family.  He’s been slowly recovering but recently was set back by some kidney and respiratory issues.  He is fully awake, aware and capable of deciding his treatment and has begun refusing certain treatments.  Unfortunately, the cardiac surgical team has been fixated on the 30 day mortality target to get the patient ‘off the books’ after a discharge to a lower level of care.  And they’ll do anything to get there.  This poor man has been asking to be left alone and allowed to die in peace if that’s what happens and has been ignored.  He’s been placed on a respirator against his wishes, has had procedures against his wishes and been treated for kidney failure against his wishes.  Nursing and other staff that wish to advocate for the patient have been told to go away and mind their own business and family have failed to step in.

It’s really a shame.  The first ethical principle of patient self determination and their right to govern what happens to their own body has been completely abandoned by those whose primary interest is self-promotion through good outcome statistics.  All that seems to matter these days are mortality statistics and complication rates with no interest in how these outcomes were achieved, and at what cost to the poor patient.  And I’ve seen this repeatedly….every time there is a complicated case or poor outcome the goal becomes the 30 day survival time frame and discharge to an appropriate level of care for the DATA, not the patient.   In addition, the patient is kept in a critical care environment to ensure the outcome at the added cost, added risk of secondary infection and delayed rehabilitation.  Then comes the transfer directly to a nursing facility with minimal skilled nursing care after the patient was supposedly too sick to transition to a lower lever of in-hospital care.  And we want to know why healthcare is so expensive but it keeps expanding with online apps for healthcare and other new tools.

Sadly, so much emphasis has been made of these ridiculous outcome statistics that surgeons will pick only cases that make them look good to the exclusion of those more complicated and need the treatment.  Then god forbid there is an irreversible complication, the patient is tormented until they can come off the surgeon’s ‘books’.

Unfortunately, we all know who these physicians are.  I just don’t understand why the ‘system’ doesn’t care and move to eliminate these types of behaviors????  I can’t imagine it’s that difficult……