How Big Medicine Will Affect Patient Care

Another P4P metric is, “Percent of surgical patients that received the correct kind of antibiotic.” However, Dr. David Gelber has described a situation when the protocol mandated an additional antibiotic he considered medically unnecessary for his patient’s specific operation.

Dr. Gelber was informed that if he didn’t follow the guidelines, the nursing staff would “get in trouble.” He reluctantly allowed them to administer the unnecessary medication, hoping it wouldn’t cause any adverse side effects. (It didn’t.)

In Dr. Gelber’s words,

Administering unnecessary antibiotics opens the door to potential side effects, some of which can occur after only a single dose. Disruption of normal, symbiotic bacteria by the administration of antibiotics can cause transient diarrhea or severe colitis, while allergic reactions are always unpredictable. ...

Yet, here is an example of the SCIP [Surgical Care Improvement Program] administrators, who are not physicians, insisting on inappropriate antibiotics. Every surgeon learns, as part of their training, the proper way to administer prophylactic antibiotics, which medication to order for which procedure and for what duration. But, surgeons also understand that there are often situations where deviation from the usual regimen is not only allowable, it may be vital and life saving.

These examples illustrate a larger trend of attempting to control costs through standardized practice protocols.

Standardized guidelines and protocols aren’t always bad. Dr. Atul Gawande has written a now-classic essay on how well-devised checklists and practice guidelines can protect patient safety and improve clinical outcomes. When someone comes into the ER with chest pain and a suspected myocardial infarct (“heart attack”), it’s appropriate to utilize checklists to ensure the patient receives his or her oxygen, an IV, EKG, appropriate blood tests, etc. Protocols and checklists can serve as a vital procedural “safety net” to protect against sloppiness or human error -- like an astronaut running through a standard safety checklist before liftoff.

Standardized protocols can be an important adjunct to clinical judgment, but they cannot replace human judgment. Clinical protocols may be fine for 95% of patients, 95% of the time. But not all patients will fit the standard guidelines; there will always be outliers. The art of medicine consists in tailoring general guidelines to the individual patients as necessary, which requires the independent judgment of the skilled physician. This independent judgment is the heart of good medical practice.

As a patient, you want your doctor to be rewarded for using his expertise on your behalf, not punished for it. You don’t want to be the patient receiving too few (or too many) antibiotics because a bureaucrat is overriding your doctor’s best judgment.

As a physician, this is one of my biggest concerns about Big Medicine -- namely government intrusion into the doctor-patient relationship. Your doctor may have to choose between following government guidelines vs. doing what’s medically right for you as an individual. Will he still uphold his Hippocratic Oath, even though it may jeopardize his compliance statistics? Or will he meekly comply with the guidelines? You’d better hope he’ll still be willing to make the right choice.

Finally, “bundled payments” and “pay for performance” likely won’t be the end of government controls over health spending. The state of Massachusetts has already enacted into law “global caps” on aggregate health spending (public and private). The exact enforcement mechanisms are still to be determined, but this will inevitably mean more restrictions on who can receive what medical care. In the New England Journal of Medicine, several prominent ObamaCare supporters have called for a similar national-level binding “global spending target for both public and private payers.” If current cost control measures fail, this will likely be the next phase of Big Medicine.

Next article: The role of electronic medical records and Big Data in Big Medicine.