Friday, November 16, 2007

I was not the only one taken back by comments on the beta-blocker peri-operative mortality morbidity issue

Here the Happy Hospitalist had the same reaction I did to recent comments made in Dr. Robert Wachter's blog regarding the disappointing results of a clinical trial with beta-blockers ( the Poise trial). The Happy Hospitalist sums up Wachter's entry by saying "Oh Well".

Wachter enlisted the comments of his colleague, Dr. Andrew Auerbach who, in regard to the study that demonstrated increased risk of stroke from peri-operative use of beta-blockers said in part"

"So I agree with Bob – it wasn’t unreasonable to include them as a quality measure at the time. We were wrong, but at least we are in good company (can anybody say estrogen replacement therapy?). "

That comment may appear to be more flip and radiates more hubris than was intended . There is nothing flip about a stroke. Being in good company will do little to improve a hemiplegia or aphasia and I am sure Drs. Wachter and Auerback would not belittle the seriousness of the unfortunate events that seemed to be more common in the beta-blocker treated group.

Quality measures to a greater or lesser extent often drive care and influence the way physicians care for their patients. If a physician should exert great care in deciding what to do for an individual patient it would seem a greater level of concern and contemplation should be expended in writing "rules" that will influence the care of many patients.

I do not mean to imply that physicians who author quality rules take their responsibility lightly but events such as the beta-blocker saga should perhaps make us insist on a very high standard of proof of efficacy and safety be shown before we presume to tell others physician what they should do particularly when those rules are "enforced" by economic carrots or sticks. Further when an intervention is to prevent something, i.e to decrease the risk of a bad outcome, the level of certainty should be higher than in the circumstance when the physician is treating a certain medical condition. In a seriously ill, patient you often have to act, even to use treatments that lack super solid proof or efficacy; when you are in the prevention mode, you had better be more sure.

The individual docs not only have a fiduciary duty to do what it right for the patient but they are held to a legal duty.

The individual physician deals with the stroke patient and has to answer to him and the family, and perhaps to the family's attorney while the quality rule writers have to answer to whom. The individual physician strives to do what it the right thing for his patient and hopes that what he does is right, the quality rule makers seem presume to know what is good for everyone. Obviously, they frequently do not.

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