I am currently reading a fascinating book – 52 Rules of Thumb. This morning I read the above rule.
So what is the context, and why does this appear in a medical blog?
Back in the day, when I was in medical school, most faculty aspired to being triple threats. One really could be an excellent clinician, teacher and researcher. I always wanted that balance in my career. I had role models for that philosophy and job description.
Unfortunately, today our young aspiring academicians are told to choose, especially if they want to do research. Too many researchers avoid the clinical venue. While this trend started with laboratory researchers, it has extended too often to outcomes researchers.
I believe that one problem we have with performance measurement is a poor understanding of clinical medicine. Only someone who really does not care for patients could imagine this performance measure.
In this measure, every pharyngitis patient has required testing, despite all published guidelines recommending against testing patients who have no clincal indications of streptococcal pharyngitis. This performance measure does not allow empiric antibiotics, even though in certain situations they should be given.
This performance measure could only be written by people who know rather than people who do. The performance measure (like most) is rigid, and does not give the clinician appropriate leeway for decision making. It encourages overtesting – in patients with obvious viral infections.
I first heard about this performance measure in the Q&A session after my recent pharyngitis talk to the Alabama Family Practice meeting. When told of this measure I was shocked at first, and then just laughed. I believe this performance measure epitomizes the problem of having researchers develop performance measures rather than frontline physicians.
When I said publicly that I disagreed with the performance measure, I got a round of applause.
While I have more than 80 published articles, I have never left the bedside. I make rounds approximately 150 days each year. For 20 years I had my own patients 2 half days each week, and supervised outpatient clinic at least once a week. I would not take a job that kept me from the bedside.
I hope that everything that I write is flavored positively through those bedside experiences. Caring for patients on a regular basis informs my writing and research. Those who separate themselves from regular patient care lose context (in my opinion.)
Alan Webber, the author of 52 Rules of Thumb, nailed this one (and every other rule that I have read thus far.) Those who make decisions about what others should do are doomed to failure. Of course usually those who do suffer from those who know.
No good physician can care for patients without appropriate context. Seeing and touching the patient are critical in understanding the patient and helping make appropriate testing and treatment decisions.
I wish more wonks and rules makers understood this principle. I wish we did not have a research industry that encourages good clinicians to foresake clinical medicine to spend all their time doing research. We need a return of the triple threat, because the triple threats always kept patient care in appropriate context. And that is true because their knowing came from doing.
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A great summary.
I totally agree with you. We need bedside physicians of greater stature.
I just listened to a module from Mayo Laboratories on Diabetes Mellitus diagnosis using HgBA1C. The idea is to eliminate the term prediabetes mellitus. There are clear limits to what a FBS, PPS, or OGTT can do.
But by eliminating the term prediabetes mellitus, we have to fundamentally re-educate our patients on what obesity, high FBS, etc mean.
Prediabetes was a valuable concept for prevention. Now we have to change the vocabulary of our diabetes (at risk) patient education.
One of the fundamental problems in American medicine is that the bedside is not taken into account. The bedside physician is at the mercy of outside forces that he does not control and thus this has become an unattractive option in medical school and in residency.
Hence, the deficit in primary care and cognitive physicians.
Bohdan A. Oryshkevich, MD, MPH
2 questions:
1. So you’re angry that the measure discourages empiric antibiotics for pharyngitis? Why? Is there a rampant problem with antibiotic under-prescription for pharyngitis, and is this problem caused by physicians who don’t want to test for Strep?
2. Have you considered a vacation? Your postings are becoming increasingly delusional and unprofessional. I urge to you watch Glenn Beck and then re-read some of your rants.
Dr. Centor– Your obvious anger for those who write quality measures keeps you from actually understanding what those quality measures are saying. The measure you link to DOES NOT STATE that all pharyngitis patients require testing for strep A. It simply measures the number of otherwise healthy young patients who received antibiotics for pharyngitis and asks what percentage of those patients received cultures for strep A. A presumed viral pharyngitis should not have received antibiotics, taking them out of the denominator and out of this measure.
Not to bust your bubble, but seeing patients in an academic setting is not seeing patients “on the front line”, even if it’s rounding 150 days a year (which does not really count since you’ve got at least one resident, if not an intern and medical student doing the dirty work) and seeing patients 2.5 days a week. I can’t imaging you seeing much pharyngitis in patients 2-18 years old as an internist in and academic setting.
Everyone like to think they’re the Real McCoy, but perhaps if you saw how often many docs miss obvious things that should have been done, you would see how quality measures could actually improve care. Look at the Medicare PQRI lists– does it not seem obvious that most of those things should be done, and if not then document those deviations? I mean really, you think that it is bad to measure how many people get DVT prophylaxis in hospitals, get ACE-I/ARB’s after LV dysfunction, get treatment for osteoporosis post fracture, etc? With all these measures there is way to remove patients from that measure (allergies, refusal, contra-indication).
Bedside physicians of greater stature is not going to fix medicine. Most of medicine is practiced outside of academia. Triple threats may make better residents and theoretical physicians, but it won’t make better practicing physicians. Attacking policy wonks and burocrats and wishing they would understand is childish. If you realy believe Thomas Sowell’s quote about them, you would stop your anger so that you could actually understand what you are reading.
ErnieG,
I agree with your interpretation of the performance measure. While that doesn’t make it a useful measure, it seems not as bad as Dr. Centor points it out to be.
As for saying that Dr. Centor hasn’t seen much pharyngitis? Um, I’m guessing that’s not the case:
http://en.wikipedia.org/wiki/Centor_criteria
ErnieG is just another example of Gestapo-esque “guidelines writers” who think that they can practice medicine from behind the desk of an insurance company call-in center.
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