Correspondence
Should We Accept Mediocrity?
N Engl J Med 1998; 339:636-638August 27, 1998
- Article
To the Editor:
I find it interesting that all of Manian's DEFs (deficiencies, errors, and frustrations) were due to problems with hospital staff and payers (April 19 issue)1; none dealt with the multiple problems physicians create daily. I have compiled a list of PDEFs (physicians' deficiencies, errors, and frustrations) — the times when a physician's decision results in an adverse outcome for a patient, unnecessary cost, or both.
PDEF 1
I am a family physician, and I refer a patient to an infectious-disease doctor for vaccines required for overseas travel. The infectious-disease doctor finds the patient has dyspepsia in addition to needing immunization against yellow fever and refers the patient to a gastroenterologist. The gastroenterologist sees the patient limp into the office (he took a spill playing basketball the night before) and refers the patient to an orthopedic surgeon, who puts the patient on a regimen of ibuprofen and ice. The gastroenterologist prescribes the same medicine the patient was already taking and charges $146 for an initial office visit. The orthopedic surgeon charges only $92.
The Problem: Each physician thinks only inside his or her own box and does not value the relationship the patient has with his family doctor, hence costing the medical system nearly $250 more than necessary but providing no better care. (Using the Ottawa Rules for determining the appropriate medical intervention, I would have managed the ankle injury over the phone.)
PDEF 2
Physician A wants to check a patient's potassium level because the patient is taking a diuretic for high blood pressure. The physician wants to do some screening tests and therefore orders a 22-test chemistry panel and a complete blood count. The bill for the laboratory tests is $146, but only the potassium test is covered by the diagnostic code on the billing form, so the patient is left to pay the remaining $124.
The Problem: The physician uses a “shotgun” approach to diagnosis and screening because it is easier to circle the SMA22 series on the procedure form than each necessary test. The physician is also under the mistaken impression that the use of screening laboratory tests prevents morbidity and reduces mortality.
PDEF 3
Physician B sits in a box seat at a baseball game and eats a catered meal supplied by a pharmaceutical-company representative. Physician B keeps a well-stocked cabinet of drug samples containing all the newest drugs. Physician B takes a full course of clarithromycin from the sample cabinet for his own upper respiratory infection. Physician B prescribes clarithromycin for patients with bronchitis.
The Problem: Physicians are influenced in their prescribing patterns by the easy availability of drug samples. Physicians treat themselves with drug samples. But the newest, most expensive drugs are not always the best medicines for the patient.
PDEF 4
Patient A comes to the emergency department after four hours of chest pain and with ST-segment elevation on the electrocardiogram. The patient is admitted to the intensive care unit and given oxygen and heparin, and serial cardiac-enzyme levels and electrocardiograms are recorded.
The Problem: Despite years of evidence, a considerable percentage of patients with acute heart attacks do not receive the appropriate treatment with aspirin, beta-blockers, and thrombolytic drugs. Changing physicians' behavior is very difficult, even when the evidence of improved outcomes is clear.
Physicians are just as culpable as the parties Manian blames for creating the quagmire in which medical care finds itself. Physicians have profited for years from expensive and inefficient care. I agree that we should never accept mediocrity, but we must take responsibility for cleaning our own house before we begin inspecting others'.
1 ReferencesJohn M. Westfall, M.D., M.P.H.
University of Colorado Health Sciences Center, Denver, CO 802201
Manian FA . Should we accept mediocrity? N Engl J Med 1998;338:1067-1069
Full Text | Web of Science | Medline
To the Editor:
I would like to add a few DEFs of my own to Dr. Manian's list:
DEF 12
Ever since the radiology department has been transformed into the hospital's “imaging department,” the access the attending physician has to his or her patients' actual films has deteriorated greatly. I dread my daily sally into the imaging department because, in spite of my best efforts, I have only about a 50 percent chance of being able to find a patient's recent films. Thus, half the time I feel foolish for having wasted time and effort trying to be a compleat physician.
DEF 13
Ever since the medical records department has been rechristened the “health information department,” service to patients and physicians has declined. The health information department is now primarily devoted to providing documentation of billable services to payers and various government agencies. Because patients change physicians every time their employers change health plans, nearly every patient admitted is someone I have never met before. Obtaining the old charts of these patients seems to require an act of Congress. It seems more important for billing clerks, nurse case managers, and other bureaucrats to have the charts, rather than the poor doctor trying to obtain a few scraps of reliable information about his or her new patient's history.
DEF 14
Hospital transcription (soon to become “voice processing”?) is so backed up that operative reports take nearly a week to appear on the chart. If I request that mine be processed “stat” they will appear in 24 to 36 hours, but this backs up the system for everyone else. Histories and the results of physical examinations take three to five days to appear on the chart. This is lots of fun when I'm on weekend call and my partner admitted the patient on the previous Thursday or Friday.
What can we do as physicians? Retire early? Find another profession? What we really need is a Hundred Thousand Doctor March on Washington, D.C.
James M. David, M.D.
Idaho Falls Clinic, Idaho Falls, ID 83404To the Editor:
As a patient who happens to have a medical background (albeit in the animal world), I believe that, overall, the quality of actual doctor care (that is, when you get to see one) remains excellent. On the other hand, the quality of office and hospital care seems to be deteriorating as unqualified people attempt the work that used to be done by more highly trained people.
One would like to assume that, as a patient, one should not have to clarify to laboratory personnel what tests were actually ordered by one's physician, explain to one's nurse what the actual flow rate on a total-parenteral-nutrition infusion should be, or monitor the patency of one's own intravenous line. One would also like to assume that an adult patient undergoing elective surgery requiring anesthesia would have signed the consent form before being heavily sedated. One would even like to assume that a patient could use the call button from his or her hospital bed and get a compassionate response rather than being greeted with “Next time, wait and call me after you've finished vomiting.”
Dr. Manian's conclusion that “patients will suffer directly . . . if they haven't already” as a result of “mindless cost cutting” is right on target. The downward spiral that is occurring in our health care system is alarming and should be of concern to every consumer of health care. Unfortunately, many patients are afraid to complain or question those in the medical profession.
Sheila Adenwalla, D.V.M.
Fox Valley Technical College, Appleton, WI 54913To the Editor:
. . . Dr. Manian, like many physicians, views his coworkers as barriers to improving quality instead of as partners with valuable contributions to make in improving care.
The principles of quality management are total employee involvement, data-driven decision making, and continuous improvements in all aspects of quality. Physicians who view themselves as part of a team of providers and part of a larger system of care have the opportunity to make dramatic improvements that will benefit patients and the medical profession. Physicians who assign blame to everyone from those in the boardroom to those in the treatment room for poor quality and remain aloof from improvement efforts erode the system and our profession.
Charles Levenback, M.D.
University of Texas M.D. Anderson Cancer Center, Houston, TX 77030Author/Editor Response
Dr. Manian replies:
To the Editor: Dr. Westfall presents several of his own DEFs but does not seem to disagree with any of the DEFs presented in my article. He suggests that because some physicians have faults of their own (many of which are not new), they have no right to express their frustration with a new system of health care delivery that in many instances has made what was once standard care now a luxury (e.g., orders executed properly and experienced health care workers taking care of patients). However, Dr. Westfall himself admits that “changing physicians' behavior is very difficult,” and to suggest that physicians should tolerate substandard and mediocre care for their patients until the behavior of their colleagues is perfected is absurd. It is interesting to note that three of the four DEFs listed by Dr. Westfall concern the cost, not the quality, of patient care. Such inordinate emphasis on cost is music to the ears of managed-care administrators and is an unfortunate tribute to those who have successfully divided our profession by placing cost ahead of quality.
I have also experienced the DEFs listed by Dr. David, and many other physicians probably have also. These DEFs further illustrate how the basic support system needed by physicians to provide high-quality care to our patients has been eroded.
Dr. Adenwalla's personal experience with inexperienced and less-than-caring health care workers is a vivid example of the way many institutions have underestimated the importance of having competent staff care for patients during what is one of the most vulnerable periods of their lives.
Finally, if this were the early 1990s, I might agree with Dr. Levenback's idealistic views. However, having endured nearly a decade of managed-care policies driven purely by the bottom line, without regard for the suggestions of physicians, I have become more realistic and less sanguine about the prospect of teamwork.
I agree with the principles of quality management as outlined, but the fact remains that as long as these principles can be applied only under what are often arbitrary budgetary rules imposed by short-sighted businesspeople who have no contact with patients, true teamwork is unlikely. If we don't speak up against mediocre patient care, then we don't deserve to be called physicians.
Farrin A. Manian, M.D., M.P.H.
Infectious Diseases Consultants, St. Louis, MO 63141
