Hughesair (Inflection Point)

Retired physician and air taxi operator, science writer and part time assistant professor, these editorials cover a wide range of topics. Mostly non political, mostly true, I write more from experience than from research and more from science than convention. Subjects cover medicine, Alaska aviation, economics, technology and an occasional book review. The Floatplane book is out there. I am currently working on Hippocrates a History of Medicine and Globalism. Enjoy!

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Thursday, January 22, 2009

Treatment Guidelines

Recently a division of HICFA is offering voluntary guidelines for health care providers, consisting of 150 key determinants. The offer promotes physician participation by suggesting a premium for compliance. Reading the guidelines, they follow algorithms already promoted as standard best practices for health care providers. This offering suggests the kind of standardization that will likely come with universal electronic medical records and a National standard of care. There is a problem, however.

No question, our health care delivery system is broken. Ireland now provides better medical care than the US. The Public Health driven solution to correct the problem with standardized federal guidelines has three deleterious and unintended consequences. These consequences should be thought through before going any further down the line of a single National standard.

1. One set of guidelines fails completely to take into account regional differences in both the incidence and nature of disease. The guidelines also fail to account for differences between individuals and fail also to identify the psychological elements of disease. Guidelines will, as they already do, discourage thought, analysis, differential diagnosis and the process of searching for multiple and underlying problems.

2. A single standard, which is almost implicit in a single payer system, is by definition un-scientific in that it excludes the diversity of many research centers competing for knowledge and solutions; it denies diversity of research and is static, inhibiting change by its very nature.

3. A federally directed bureaucratic standard, turns its back on our very source of medical progress which is our numerous excellent medical schools. In fact that negation of medical excellence at the source, our medical schools, is in itself -- self interested. There is an ongoing power play on the part of bureaucracy, insurance, Hospital Association and pharmaceutical industry.

An associate early in the years of my medical practice, once commented, “I find myself in the most trouble when I least know that I am in any trouble at all.” The problem with guidelines is that they never know when they are in trouble. By that I mean, guidelines cannot look past the façade of the obvious; they cannot peel away the layers of the onion and deal with difficult often multiple faceted problems. Guidelines pay you for dealing with one straight forward problem, “according to Hoyle,” and get on to the next case. They pay for diagnostic studies only if you have a justifying diagnosis. All of this stifles thought, promotes false diagnosis and inhibits, delving deeper for multisystem disease. As it is, three fourths of the time a cancer patient is misdiagnosed by the first physician attending. The wide array of cancers and other multisystem diseases are subtle and difficult diagnoses to make. The addition of so called physician extenders working with algorithms only makes the matter worse.

Healthcare available for everyone is to my mind a human resource necessity for America. The regulation of such a system is as essential as having the best motivated and most highly educated practitioners within that system. The regulation should, however, be educational and regional, not punitive and national. The medical school is in the best position to provide all of this but in the weakest position politically and financially to covet that role.

We are in the midst of a quantum revolution in medical knowledge and treatment at the genetic and molecular level. The accelerating change in basic knowledge, and thus the implications for treatment, hardly bodes well for fixed guidelines and central control.

Don’t throw the baby out with the bath. Leave the insurance system in place to compete favorably with the free, public, health care system and give that public system a competitor to surpass. Many will choose insurance for those who can afford it and or prefer the private sector; in doing so the size and scope of the public system will be limited by that choice. This is the approach that worked in Europe, propelling their measures of quality to so rapidly surpass our own. --- Especially Ireland!

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