Everyone does it, but no one writes about it

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 social back-story. 
    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:

http://www.jointcommission.org/PatientSafety/

   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?

Comments

[jnkdg]

Since you are a questions person, here is one for you - how important do you find the litiginous atmosphere in the US as a contributor to this social engineering process and the thought process of the JCAHO?

jnkdg

[mkeamy]

So, let me answer for my buddy, Mike. Firstly, from a political perspective, (and I WAS a politician) doing something, even the wrong thing, gets more support than doing nothing. Rule #2 - when you're holding a hammer, everything looks like a nail. The Joint commission people aren't nefarious; they are just trying to make things better using the limited tools at their disposal; they have a big stick (medicare, medicaid and other reimbursements) but inadequate manpower to do real evaluations. And privately, they know it. Hence this superficial bean-counting (and I have shepherded my hospitals through six JCAHO surveys in jobs ranging from Chief of risk management to Chief of staff...)
To the extent that the core motivation of all these activities (litigation, accreditation) is to protect the vulnerable (patients) from the powerful (aggregated provider interests-"the machine"), they all derive from the same source. But of course, litigation is driven by individual consumer/attorney financial interests, and accreditation derives from societal/political motivations, and is potentially much more stifling in the long run. (at least I think so) Of course, our only recourse is self-regulation, which has never really worked in any industry either as an effective quality mechanism (read Arrowsmith or The Citadel) or as a political alternative. Thanks for visiting. We like your blog.

[Mike O'Connor]

First, I want to apologize for the delay in response.

As usual, Mitch is correct. That said, let me be clear: there are multiple forces pulling medicine in multiple different directions. They defy neat categorization into the usual classes of economics, regulation, and politics, because most of them necessarily span these boundaries.

An incomplete enumeration (and in no particular order) would include:

- CMS (HCFA)
- 3rd party payors (e.g. United Health Care)

- FDA

- JCAHO
- State regulators (in Illinois, IDPH)

- Consortia (e.g. Leapfrog)

- Large provider networks (e.g. HCA)

- Vendors (pharmaceutical and equipment mfg)

- Litigation

Litigation and the threat of litigation vary in their influence on practice. Fear of litigation drives behaviors more in some settings than others, and perhaps more in some states than others. I'm not aware of any data (but there might be some) that suggests that care is less expensive in states that have tort reform - but my guess is that riskier services are more readily available in those states (e.g. high risk OB, neurosurgery).

[Gibbitt]

Yes, but if JustComingAndHelpingOut ceases to exist, how will those people earn a living? When I label my propofol, which is a white liquid in a transparent syringe, because JCAHO tells the hospital to tell me to, so I won't confuse it with another white liquid in a syringe and inadvertantly inject the wrong drug, that is disingenuous BS. Of course, when they leave, it's back to business at usual with a wink and a nod, and the surprise visit and the 10000 dollar fine for me drinking coffee in the OR never seems to happen... etc etc. And my laptop comes back out, and I respond to this blog. JCAHO is OSHAs mutant spawn, grown from the early days of slaughterhouse health hazards, with metastasized tentacles into the modern day operating room. The resentment born of JCAHO leads to retaliatory disobedience, which negates any benefit of the unproven dictates anyhoo. Now, back to the hip.

[cpap]

Yes, litigation is driven by individual consumer/attorney financial interests, and accreditation derives from societal/political motivations, and is potentially much more stifling in the long run.

Sam Nisbett