What the heck am I doing here? Why am I here? More specifically, why have I agreed to participate in a blog?
Because in medicine, there are a large number of subjects that everyone thinks about and talks about, but no one writes about. As a group, these subjects are too social for our journals, and too political for our organizational newsletters. The scientific front-story of medicine receives excellent coverage in our journals, as do the explicit economic issues in our various societal newsletters.
The back-story, the issues surrounding the social construction of health care at the individual, group, hospital, and societal level, has no venue for conversation. We all wonder: where is this going? We talk about it, but there is nowhere to read about it. The result is highly local, mostly poorly informed and poorly formulated discussion. So what? It matters. The truly radical changes in medicine today are in its social structure as much as in its scientific underpinnings and clinical practice. As a group, physicians are uninformed about these social issues. Worse, we are untrained to think and write about them. There’s a lot to know about the social construction of health care, and physicians don’t even know where to begin.
The decision to avoid a conversation about the social engineering of medicine has been made explicitly or implicitly by every major medical journal. Why? Because an honest discussion of these issues is difficult, far more so than discussing the correlation between telomere length and mole count. Like discussions of other very delicate topics (think race relations and gender issues), honest discussion can give offense even where none is intended. There are two reasons for this. First, the conversation is had so rarely that its participants can be legitimately completely unaware of where the sore spots are. Second, and far more importantly, is that some questions, and some ideas, are themselves threatening to those with social agendas. Overtly subversive. Think about it. I think and write a lot about safety and failure. In medicine, patient safety has become like motherhood and apple pie: you can’t question anyone who advocates anything intended to advance it, no matter how foolish, stupid, or poorly conceived their proposal might be. The sad truth is that the vast majority of patient safety ‘experts’ aren’t and haven’t the slightest idea of what they are about. What they are doing is engaging in social engineering, making changes to healthcare whose consequences are usually substantially different than they believe. For instance: protocols for final verification are now universal as a consequence of a JCAHO mandate. The dirty little secret? There is no evidence that they are of any benefit. Indeed, there have been large trials of more stringent protocols than those mandated by the JCAHO, to my knowledge, none of them has worked (and I know for certain that several have been convincing failures). Who could oppose these? I suppose I could write an editorial about what a colossal waste of time and money they are, but where would I send it?
The editorials that accompany many manuscripts are often more
illuminating than the articles that motivated them. Highly educated
though we may be, we all benefit from listening to an erudite
discussion of the implications of developments – whether it is of basic
science (see the NEJM’s excellent ‘clinical implications of basic
research’), or clinical investigation. Of the major journals, Critical
Care Medicine’s surfeit of editorials differentiates it from its
competitors, and is one of its major draws. Regrettably, the quality
of their editorials varies wildly. More importantly, none establishes
requisite conversation with its readers; and almost all ignore the
Major news columnists – pick your favorite – help us understand the news and integrate it into our understanding of the world. The best commentators provide real analysis, the backstory that enhances your understanding of what’s happening and what it means. While we prefer to read commentators whose views are in line with ours, we are likely to benefit more from reading a well reasoned opposing view, especially if that commentator paints a clearer or more coherent picture of the world. If we had a forum for such commentary, it would have a readership that would at least rival the major journals.
Where does all of this leave us? Living in a world that is rapidly changing as a consequence of scientific progress, clinical innovation, and social engineering. It is the social engineering of medicine that is the real uncounted force shaping its future. Who is driving the social engineering? A number of actors, including various government agencies (CMS, FDA, NIH), various regulatory agencies(JCAHO), third party payors (Leapfrog), industry forces (HCA, Pharma, ‘patient’ advocates), vendors (pharmaceutical and equipment) and of course, the political parties themselves. In general, those behind the social engineering of medicine have hidden their agendas, and are reticent. Be certain, they will neither tell you what they really think nor what they really want. We can only guess at where they want this to go, and can only do so by engaging in a conversation which they will discourage from happening, take offense from at every turn, and may use every means at their disposal to derail or stop. As in any high stakes game, your reward for harming the interests of these players can be an avalanche of trouble, including personal attacks, hate mail, and regulatory scrutiny…. Does this mean we should shut up and go along like good sheep? That’s what everyone else hopes for.
The social context of medicine is frequently more clearly visible to outsiders than insiders. An excellent book about the politics of breast cancer is:
Breast Cancer Wars : Hope, Fear, and the Pursuit of a Cure in Twentieth-Century America (Hardcover) by Barron H. Lerner (Author)
If you read it, it will open your eyes to the political agendas that have shaped the research and recommendations for care of what is and should be fundamentally a medical issue. It will also make clear how tolerant those who engage in social engineering can be of dissent (answer: they’re not).
My aspiration is to write about what everyone is talking about. There is no other venue, and it may be that the other venues are inferior. My hope is to inspire a civilized conversation about what all of this means, not to start a brawl. But even a civilized conversation is likely to threaten the agendas of some of these players (and thus provoke angry responses and personal attacks). I’m not an answers guy, I’m a questions guy. There are lots of people who know all the answers. I spend my time trying to find the new and important questions. I believe that it is worthwhile to expend substantial effort in finding and phrasing the questions, the social questions, correctly. If, at times, it seems as if I’m struggling with an idea, it’s because I’m struggling with an idea.
So let me end with a few questions that pertain to the content of this site:
1. Was there any explicit discussion in the world of medicine
before the JCAHO expanded its purview from the setting in which health
care is delivered into the actual details of that care? Is patient
safety the lever that the JCAHO is going to use to attain control of
the delivery of health care?
2. Do you believe that the JCAHO is especially competent to determine how health care is delivered? Is it more competent than individual physicians or their professional societies? This matters, as it is endorsing care strategies that professional societies did not. Progress in medicine is slow, because it entails convincing a very large percentage of smart people that you are right (Wise men point out that all of us are smarter than any of us). Conflicting studies frustrate those who would ‘improve’ the quality of health care. Is conferring the power to mandate these changes upon a regulatory agency going to increase ‘progress’ in medicine?
3. Is the evidence behind these recommendations proportionate to either their force or their scope? In specific, is there any evidence that final verification protocols have reduced the incidence of wrong site surgery? The answer is no – but the cost associated with them is enormous. Bet on this: we will still be talking about wrong site surgery in 3 years – and likely at exactly the same rate that we are now.
There is conflicting evidence about MET/RRT. No matter, the JCAHO has decided to embrace the concept. Once again, the cost will be enormous. The force of their recommendation is completely out of proportion to the evidence they cite.
Aside: the benefit of any change in medicine seems to be diluted with time and additional study, regardless of its nature. All interventions seem to degrade in benefit in this way. Explanations for why vary. Practitioners with a sense of history are skeptical, and many await the publication of multiple confirmatory studies before they change their practice to incorporate any change about which they have doubts. This conservatism is likely to have helped our patients more than it has hurt them over time.
4. Should this discussion occur? Does the JCAHO want it to happen? Is questioning the wisdom of that organization or its creeping power subversive?
5. Do you aspire to be a sheep?