Editorial Message: Now What Do We Do?

Dear Readers,   Several years ago, a number of well-meaning people began looking into the practice of medicine and decided that they could improve it. With their help and guidance, and, of course, oversight, the quality of medicine could be improved, and certainly the cost could be reduced. We were told there were certain events happening to patients that should never happen if we were providing quality care. Healthcare providers were making too many mistakes in taking care of patients. If we only had more guidelines for practice and rules governing some types of treatment, we would make the practice of medicine what it should have been all along. As a result of these ideas, we have been “blessed” with much wisdom in the form of guidelines, rules, and regulations. For the most part, the medical community went right along with these well-meaning individuals and bought in to the changes.   I would be the first to agree that healthcare providers are only human and the practice of medicine is not perfect. It does seem interesting to me that people who have never attended medical school, nursing school, physical therapy school, or podiatry school, have never gone through any of the healthcare postgraduate training programs, nor have ever taken care of a patient in a hospital, an outpatient facility, or a long-term care setting, could have any real idea as to what is required to take care of patients with acute illnesses, much less patients with chronic or terminal conditions. Yet, they have provided us with instructions as to how to do our jobs better.   Well, how are we doing? We have had the guidelines, rules, and regulations long enough to compare our current practice to practice before this insightful guidance.   In evaluating our performance on just one of the conditions that, according to the new guidelines, patients should never get—venous thrombophlebitis and thromboembolism in the postoperative period¹—some interesting information has been noted. In a recent study, 30,521 operative procedures done from 2006 to 2009 were evaluated for this postoperative complication. Of the patients in the study, 89.9% were treated by the Surgical Care Improvement Program (SCIP) guidelines for the prevention of venous thromboembolism (VTE) and 10.1% were not.² The results were that 1.4% of the patients treated according to the guidelines suffered a VTE while 1.33% of the patients not treated according to the guidelines had the complication. The conclusion was that “compliance with SCIP-VTE prevention measures does not have any measurable association with the events they are intended to prevent.”² An interesting finding, don’t you agree?   Another major issue was mistakes being made by physicians in training because they were required to work long hours and were tired.³ As a result of this, all the residency training programs were overhauled to shorten the working shifts so that all would be well-rested and with a sharp mind when taking care of patients.⁴ A recent study has shown the fallacy of this approach. Even though work hours decreased, no one slept longer and the number of physicians self-reporting medical errors rose from 19.9% to 23.3%.^5,6 I guess we don’t have the answer to tired doctors, do we?   These are just 2 examples of how these well-meaning guidelines, rules, and regulations have not had the desired outcome. So, now what do we do? We need to critically evaluate the benefits of the new guidelines, rules, and regulations to see if, indeed, they are doing what they are intended to do. If not, get rid of them and find what will successfully address the issues. In other instances, we must embrace how difficult the practice of medicine can be and better prepare those who choose the profession to successfully treat patients under all situations and feel fulfilled by it.

References

1. Geerts WH, Bergqvist D, Pineo GF, et al. Prevention of Venous Thromboembolism: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. 8th Edition. Chest. 2008;133(Suppl):381S-453S. 2. Altom LK, Deierhoi RJ, Grams J, et al. Association between surgical care improvement program venous thromboembolism measures and postoperative events. Am Jour Surg. 2012;204:591-597. 3. Ulmer C, Wolman DM, Johns MME. Resident Duty Hours: Enhancing Sleep, Supervision, and Safety. Washington, DC: National Archives Press; 2009. 4. Nasca TJ, Day SH, Amis ES Jr. ACGME Duty Hour Task Force. The New Recommendations on Duty Hours from the AGGME Task Force. N Engl J Med. 2010;363(2):2e. 5. Sen S, Kranzler HR, Didwania AK, Schwartz AC, et al. Effects of the 2011 duty hour reforms on interns and their patients. JAMA Intern Med. Published online March 25, 2013. doi:10.1001/jamainternalmed.2013.351. 6. Struck K. For resident doctors, shorter shifts mean more mistakes. ABC News. March 26, 2013. https://abcnews.go.com/Health/resident-doctors-shorter-shifts mistakes/story?id=18813761 Accessed May 6, 2013.