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Thursday, June 22, 2006

'Unanticipated" effects of the quality movement-JAMA commentary

Dr. Robert M. Wachter, of UCSF, is well known in medical circles for his writing and activities in the hospitalist phenomenon. In the June 21, 2006 issue of JAMA he writes about the quality and IT "revolutions".

His comments about the unforeseen effects of the quality movement resonant with me and likely many real life physicians who may have found the quality activities impeded their work as doctors.I quote:

" More typically, individuals and institutions begin to focus on improving their performance on the variable measure, in doing so turning away from others. This "playing for the test" is not only expected; in some cases it is the point of the whole exercise."

He comments on the most egregious examples of IT gone bad with the Cedars-Sinai debacle and the tragic increase in pediatric deaths occurring after the introduction of a commercial computer system.(Han,YY et al,Pediatrics,2005:116-1506-1512.)

With those facts on the table I find the following puzzling:

"Importantly,until the science of guidelines development and quality measurement improves, the systems must preserve physician's' ability to apply the art of medicine when patients do not fit the templates, such as in those patients with multisystem illness or rapidly changing disease course."

Of course, physicians must have the final say in clinical management,they cannot be replaced with computers and algorithms. The individual physician must be able to deal with the unique particulars of the case at hand. Wachter's use of the word "until" makes me flinch. He seems to believe that someday computers and IT system and EBM and algorithms will get to the point when physicians will not have to apply the art of medicine and will not be allowed to do so. We cannot escape the contingencies of life and medicine by all encompassing algorithms and computer prompts. I don't really think that Dr. Wachter thinks we can escape them but I worry about that "until".


Anonymous said...

I think individuals need to be constantly vigilant in protecting their own health and educating themselves as much as possible. I know that some doctors get annoyed when patients question them, and suggest possible diagnoses for themselves. However, there are plenty of people out there who just have no idea about the basics of general self-care and place all their trust in doctors. There are still people who smoke and figure that the doctors will be able to cure whatever illness results from their smoking. Ugh! I'm not a doctor (obviously), and do everything I can to stay out of the labyrinth of medical care, but I have lots of sympathy for doctors.

Anonymous said...

I've heard Dr. Wachter speak on this before. Although I don't know for sure, I suspect that he says "until the science improves" to be polite. It sounds so much nicer than "well there will never be any way to do this with guidelines and EBM and every case is unique."

That way makes it sound like the emphasis on quality is like Ponce de Leon's search for the fountain of youth.

I think he means to say "while the mephasis on quality is important, it does not take precedence over indivdualizing each patients' therapy."

At least I hope that's what he means.