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Tuesday, June 07, 2005

More coercive guidelines,a surgeon fights back and The Borg

A Florida physician is fighting back against what he perceives to be more interference with medical practice. I could not tell from the news article the exact nature of the requirement or who was imposing it but it appears to be a Florida state requirement to report some aspect of antibiotic use in surgical patient. I applaud the neurosurgeon for fighting back.
This news item was pointed out by Kevin,M.D. and I am reminded of comments made in Medical Metamusings in March this year. The following comments borrow heavily from that blog's comments as well as thoughts expressed in the two articles that are referenced by it.
Guidelines and lack of adherence to them should not be used as a basis for determining the quality of medical practice.One of the articles mentioned above is by Dr. Mary Tinetti in which she addresses the issue of how RCTS often exclude patients with coexisting diseases and guidelines based on those trials may not apply to real life situations.
Tinetti makes the following points:1) guidelines are typically based on RCTs that often have relatively small improvements in relative risks and have eliminated subjects with other illnesses and who take certain other medications and who are too old and have relatively short periods of observation. On, the other hand, real patients tend to get old, have multiple illnesses and take the medications for longer periods of time. 2)Multiple drugs have multiple interactions 3) patients that are older and have multiple illnesses may not have the same priorities as the trial authors or the guidelines authors and may opt to not take all of the drugs or undergo all the procedures that the multiple guidelines recommend or take the drugs for a while and decide to stop.
All of which leads up to : Disease specific guidelines may not apply to patients with multiple diseases and to patients whose characteristics are not similar to those in the trials.
With all the increasing talk of conformity," quality" based on adherence to guidelines and now the specter of state mandated reporting , I am also somehow reminded of the borg who may represent the penultimate in quality improvement programs. I quote from the above Wikipedia reference regarding them. "According to themselves, the Borg only seek to "improve the quality of life in the universe" and add to their own perfection. To this end, they travel the galaxy, improving their numbers and advancing by "assimilating" other species and technologies, and forcing captured individuals under the control of the Hive mind..."


Nick said...

Resistance is futile.

Anonymous said...

What's the big deal? As I read the article, Florida simply required an explanation when a guideline was not followed.

Why do doctors want to resist? MEdicine is, in fact, the last cottage industry; it has not evolved as a modern, scientific endeavor. And, given you guys kill between $100-200K a year through your negligence/laziness/indifference, you should want standardization.

Bizarre claim? Just look at the atlas of medical procedures that published by that guy from Dartmouth. http://geiger.dartmouth.edu/ReadMe.asp

The regional variations in the type and number of procedures that are performed in this country is astounding. IF medicine is based on science, it should be relatively law-like in its application. Such drastic regional difference suggests that you guys are just practicing quaint local lore--or, at least, not practicing in a way that's best.

Ah, and what about the aneasthesiologists? They got sick of being sued and rather than cry to the state legislatures, they adopted standards--and guess what (with a little help from new technology), aneasthesiologists have among the lowest premiums of any doctors. Standardization probably works.

james gaulte said...

I am a bit surprised that a non-physician would read the shotgun rantings of a retired doc let alone take the time to comment.I am not surprised that I have not yet convinced everyone of the argument " conformity does not necessarily equal good care and non conformity does not necessarily equal bad care" I will likely slog on with that effort.

Anonymous said...

Anon7:19 was not arguing against the claim: " conformity does not necessarily equal good care and non conformity does not necessarily equal bad care" Of course, complications complicate and render difficult cookbook medicine.

Nonetheless, doctors paint themselves into a box when they claim their actions are so unique, so case specific that they elude any standardization. If that's the case, then what they do has nothing do with science, which, as I'm sure you recall from K. Popper, requires reproducibility and falsifiability. If medicine cannot generate rules capable of these things (which you're in fact claiming), it's simply voodoo.

Speaking of science, what does the empirical evidence tell you? Does anyone have evidence that standards-based medicine produces worse outcomes in any circumstances? No.

Anonymous said...

MEdicine is, in fact, the last cottage industry; it has not evolved as a modern, scientific endeavor.


Some guys can always be funny.

Even when they don't intend to be.