03 December 2009

The non-medicine side of medicine

The MI chapter of the American Academy of Pediatrics had an open forum meeting tonight, which I attended. It was interesting to attend a meeting of physicians that really had nothing to do with medicine or providing care. The two hours were spend discussing Medicaid reimbursement, disproportionate share payments and the requirements for re-certification; specifically the quality initiative requirement. I have strong opinions on all of these issues, but the one I will disucss now is re-certification.

Re-certification, which must be done every 10 years, requires four things:

  1. Send in your license
  2. Complete lifelong learning modules
  3. Pass an exam
  4. Complete an approved quality improvement project
An example of an improved quality improvement project is to plug data from 10 patients with asthma into some software which analyzes your management practices against accepted asthma guidelines. It will then suggest areas you could improve. You choose one, change your care appropriately and put the new data into the program. You can then look at how your patients are doing based on the change in your practice. The idea is to continually be evaluating your quality as a practitioner and actively identify and implement potential improvements.

My issue is this: it seems a lot like research without informed consent. The patient does not know they are part of this quality initiative. Their management is not being changed based on an individualized assessment by the physician, but by a national guideline or software program.

Apparently, if the intent is not publishing, it's not "research". I think this is an ethical gray area. Comparing your practices in a systematic way against the national guidelines is a good thing - it can help you identify ways to improve. But altering the treatment of your patients then merits thought about their individual case. I would like to believe that when my doctor makes a decision about my care, he has done so because he thinks it's best for me, not because he needs to meet his re-certification requirements. And as far as I'm concerned, if you run a systematic intervention with the intent of producing altered outcomes - that's research, published or not.

Lastly, patient outcomes are reliant on two (controllable) factors: the ability of the physician and the compliance of the patient. The physician can follow all the guidelines, run the right tests and prescribe the right meds, but if the patient doesn't take responsibility, the outcomes are still going to be poor. We should absolutely measure and track physicians performance, but we have to remember that the doctor cannot be there every day to put a pill in your mouth, put the ice cream away and get you out the door for a run.

For example, the pediatricians were discussing how they are held accountable for vaccination rates in their practices. Some parents simply don't make appointments and don't bring their kids in, so those kids hurt the physician's numbers (which hurts their reimbursement). The docs were seriously considering renting a van and going to the local school, rounding up the kids who hadn't shown for the vaccinations and vaccinating them. Are you kidding? In order to get paid for the services they provide the kids who do show up they have to track down all the rest and accost them at school? I'd rather fine the non-compliant parents. The money would help pay for child health insurance, incentivize care and remind the parents of a little thing called personal responsibility.

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