We are a commune of inquiring, skeptical, politically centrist, capitalist, anglophile, traditionalist New England Yankee humans, humanoids, and animals with many interests beyond and above politics. Each of us has had a high-school education (or GED), but all had ADD so didn't pay attention very well, especially the dogs. Each one of us does "try my best to be just like I am," and none of us enjoys working for others, including for Maggie, from whom we receive neither a nickel nor a dime. Freedom from nags, cranks, government, do-gooders, control-freaks and idiots is all that we ask for.
Yesterday morning's NJ post on "Quality Care" from the WSJ was enlightening, and just gives me one more reason to stay away from Medicare (besides the fact that they pay me peanuts, and that their paperwork requirements are over my head and take more time than my patients take).
I see how government "Quality Care" works: the academic medical experts take a vote, and that becomes "Quality Care." That's not medical care: that's government policy. Forget the individual patient and his or her unique situation, forget the Doc's experience and skills and insight, forget the Doc's judgement, forget the fact that academic Docs aren't always practical, forget that next week's new data will completely alter the information at hand. Just Follow The Rules and stay out of trouble.
I have seen plenty of cases go bad in the hands of young Docs who strictly follow the rules. It's not a good example of that, but when I was a resident one of "the rules" of the time included strict limits on the use of pain-killers, even for terminal cancer patients. Didn't want them to become addicts, you know. They forgot that pain relief remains one of a handful of the greatest blessings medicine has bestowed on humanity (along with anesthesia, antibiotics - and Lexapro).
One of the best things about seasoned physicians is that they are a cranky bunch who do not take orders, who think for themselves, who feel that rules are made to be broken, and who do not like to take crap from anybody - especially anybody in "authority". Your patient comes first, or you are nothing. There is a "House" inside every Doc. In most lines of work, you can't get away with that sort of attitude.
When government gets involved in things, they tend to screw them up. The article's example of high blood sugars in the ICU was a perfect example. Even I, who have not cared for ICU patients for more than a decade, know that tight sugar control for critical patients is insane and dangerous. Not only that, but it doesn't matter: if the patient survives and gets healthy, a few days of higher sugars with a good margin of error will not have hurt them one darn bit. But I am a Doc with a practical mind.
Expertise always has to be taken with a grain of salt, and government-emitted expertise with a tablespoon-full. I am not disparaging expertise, which I respect enormously. I just distrust the combination of expertise with power over others: anointed experts who want power instead of simply to educate give me the willies.
Non-"experts" often have loads of common sense. We take an ancient oath, too.
Dr Joy (and you too Dr BD), pls don't miss this --there's actually some valuable info down a ways --concerning Big Labor's usual sneaky push. I can see the point tho --the Vig off the new bureacracy will be huge for Big Labor's underground ecaponemy.
Right on, BD. When I worked in a hospital, I had my fill of the sacred cow of "Evidence-Based Practice." Not that I'd ever make or suggest an intervention without some rational basis, but how many well-designed Qualitative studies have been ignored, and, conversely, how many poorly-designed "Evidential" studies are taken up by well-meaning hospital committees? I'll have to look into whatever supports the tight glycemic control practices in the ICU; after watching lab results bounce around, I'm with you on practicality and solving the larger problems.
There are two large problems (as well as an indeterminate number of samller ones) with the approach being undertaken.
First, "guidelines" become "rules" and then laws. In my work as a tech specialist in computer software, when my boss was contemplating instituting guidelines that had been emplaced at other companies, I begged him to make sure they were written on toilet paper rather than stone tablets - he agreed, and down the line we dodged some nasty outcomes.
Second, establishing anything beyond guidelines by experts. For one thing, Pasteur would never have been allowed to try anything - even as it was, he had to byass the establishment and risk punsihment for ignoring "rules" of treatment.