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Wennberg, J. (00). Unwarranted variations in healthcare delivery implications for


academic medical centers. (Education and debate). British Medical Journal, 5(770), 61-64.


Abstract


Professor Wennberg describes the not so uncommon variations that occur in the practice of medicine. He states that some of these differing practices are unjustifiable since no valid reason exists for these varying standards of care.


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However, the professor does comment on areas in which practices justifiably diverge. Some healthcare providers institute methods proven effective in the literature they read. These practices do not compromise care and do not substitute for basic medical principles. They instead strengthen the quality of care. He also states that in particular cases, two equally-effective treatments might be available. The physician can then allow the patient to make the decision on his or her course of treatment.


Professor Wennberg also analyzes the phenomenon of supply-sensitive care. He cites studies of certain locations where an increase in the number of physicians led to more visits, diagnostic testing, and hospitalizations. He concludes by offering solutions for these various practice methods, placing the responsibility on the government and academic medical centers to prioritize these differences and initiate change to improve the system.


Annotation


The notion that all physicians attending four-year medical schools study the same basic sciences and therefore adopt the same basic practice methods upon completion of residency programs, is actually a complete misconception. The evidence presented in the article is quite alarming since it appears the issue of variation is not a priority and is thus being ignored by the system. Even simple practices such as the prescribing of beta-blocker medications after a Myocardial Infarction are neglected amongst providers. The medical community should consider certain treatments standards of care. Providers must become educated on these issues and continue to learn so their patients are not underserved.


I have often wondered in my own experiences of working for over forty-five Emergency Physicians, just what would have happened with that certain trauma patient or appendicitis case had another doctor been on duty that particular day. How would treatment and diagnosing been done differently and most importantly, would the final outcome have been the same? Physicians, however, do tend to assimilate with the standards of practice of the colleagues they practice with directly. I have personally seen “green” doctors, those physicians right out of residency programs, equipped with all the most current knowledge of procedures and treatments, actually convince hardened, stubborn, “old school” doctors to change their practice methods. Practice variations do certainly exist even amongst providers in the same groups.


With all the proof that increased frequency of use of the healthcare system does not improve health outcomes, the problem of variation must be addressed. Physicians who are delivering equal care with decreased lengths of stay and/or more cost-effective measures must educate the outliers once identified. The common physician attitude that “money is no issue in medicine” has to change.


Perhaps since medicine is not an exact science, standardization is not useful or beneficial in all areas. However, patients as consumers can only hope and trust that their providers are practicing at least what their colleagues consider “best medicine.”


Callahan, J. (16). Social Work With Suicidal Clients Challenges of Implementing


Practice Guidelines and Standards of Care. Health and Social Work, 1(4), 77-8.





Abstract


Professor Callahan discusses the difficulties and ultimate failure of attempting to enact social work standards of care for suicidal patients in one hospital setting. He notes how other disciplines have developed guidelines for liability purposes and that social workers must also protect themselves. He also cites the increased popularity of standards due to quality issues based on variations of practices. These differences can lead to the ineffective and inappropriate treatment of patients and the waste of precious healthcare dollars.


This particular attempt to establish standards proved unsuccessful. The hospital staff of social workers agreed that a cookbook method would be much too simplified and thus ineffective. Individual patient cases were very complex and varied by a number of factors. The social workers all had differing opinions on how to approach suicidal patients; therefore, they were unable to reach a consensus. The staff felt too constrained by standards and emphasized the need of clinical judgment in decision making.


Annotation


The belief that medical practice is an art rather than a science transcends into all disciplines and specialties of the healthcare system. Social workers, therapists, physicians, and nurses all encompass this idea. Most clinicians would probably agree that their daily operational activities and decision-making processes cannot possibly be standardized into steps and made mandatory practice. They would rather rely on their educational background, training, and personal experiences.


The attempt to establish health care guidelines initially stemmed from quality and increasing cost issues. These standards have encountered much resistance from all sides of the healthcare community. Issues over who should write the protocols, mandatory use versus educational tool application, and feelings of confinement among staff members have often been the demise of these standards of care.


Individual patients have different needs and factors involved with their care. For this reason, it would be very difficult to generalize a patient’s case based on a set of standard written protocols. The patient’s management could be misallocated, meaning under- or over-treatment. Misallocation is an example of how guidelines could potentially harm the quality they set out to improve.


The article emphasizes the difficulty of getting a group of professionals to establish a certain practice. Ironically, the only consensus they were able to arrive at was their desire for autonomy, to practice free of restrictions. It is important for healthcare providers to be able to diagnose clinically since they are the ones actually laying eyes on the patient. The presentation of a patient does not always conform to what the textbooks say. Clinicians must thus be able to use their judgment in deciding what is best for their patient. Nothing is for certain in medicine, and perhaps this deduction is why guidelines are not widely accepted “gold standards” of care.


Choudhry, N., Stelfox, H., Detsky, A. (00). Relationships between authors of clinical


practice guidelines and the pharmaceutical industry. (Original contribution). The Journal of the American Medical Association, 87(5), 61-617.


Abstract


The authors conclude that a significant relationship exists between physicians and the pharmaceutical industry. This interactions might control some physician practices. 5% of physicians surveyed who authored 7 different practice guidelines had connections to the pharmaceutical companies of the drugs mentioned in their guidelines.


To reduce potential financial conflicts of interest for authors of guidelines and the companies they endorse, the article offers three suggestions. The writers of the guidelines must disclose potential conflicts formally from the beginning, before guideline meetings take place. Also, if a “significant” conflict of interest exists, such as equity in the company whose drug is mentioned in the guideline, then the author should be excluded. Lastly, the readers of the guideline must have access to full disclosure of the authors’ ties with the industry. The authors of clinical practice guidelines (CPGs) and the pharmaceutical companies they are connected to have a responsibility to appropriately disclose this information.


Annotation


The recent corruption and scandal in Corporate America appears to also be occurring in the highly esteemed industry of healthcare. Though it is happening to a lesser degree, the ethical nature of medicine has long been the reason for the public’s respect of the profession.


The study citing that 5% of physicians had direct relations with the pharmaceutical companies who manufactured the drugs in the guidelines forces one to question the motivations of these providers. Are they authoring these guidelines to promote a drug that they in fact believe improves the quality of their patients’ care or are they merely supplementing their incomes? These questionable motives and relationships only defile the profession and build public resentment. Patients need to be able to trust and have confidence that their physicians are practicing morally.


It is important to note that the writers of this study are quick to disclose that their findings had no financial backing from the pharmaceutical industry. The types of relationships of the physicians to the companies ranged from equity (6%) to travel funding/honorarium (5%) to research support (58%) and employee/consultant (8%). The reason why these connections are of significance is one can only question how much the “kickbacks” drive up the cost of the medications. Are these increases passed onto the patient so the company can maintain large profit margins? There appears to an epidemic of self-interest. The guidelines seem questionably credible and authentic.


The relevance of these ties between the authors of the guidelines and the pharmaceutical industry to health care focuses on possible unethical behaviors on the part of providers and the rising health care costs that result from these actions. It is the fiduciary duty of the authors to disclose this information fully and clearly as to the nature of their relationships. Medicine has long been regarded as a highly esteemed profession. The reputation of the industry itself must be preserved. As long as these relationships are held secret, the healthcare industry is allowing a scandal no different than those already exposed in Corporate America. It would be a disgrace to lose the integrity and credibility of the profession based on those few providers succumbing to the albatrosses of all-inclusive trips to St. Thomas and gratis steak dinners.


Summary


Healthcare is certainly a unique industry. It is highly esteemed and extremely complex. As with any profession, medicine has its share of difficulties and obstacles. One of the problems of the healthcare system involves the standardization of care through guidelines and protocols. As one discovers, this issue uncovers many others as well.


The varying clinical practices of providers seem unexplainable. Why does one physician treat differently than another when the basic medical school education and training appear uniform throughout the country? Though it is important for providers to maintain autonomy in their practices, there must be a system in place to hold physicians accountable for their decisions. Whether this is established with the assistance of the government or medical academic centers, it is evident that the profession needs a foundation for cost-containment and quality assurance.


The establishment of guidelines proves difficult amongst all disciplines. Healthcare providers desire to practice free of constraints. Protocols and guidelines tend to be restrictive. Since practice patterns vary, it is difficult to even get providers to agree on their establishment. Healthcare workers rely on their educational backgrounds, training, and continuing instruction to help their patients. Cases differ and are as distinctive as the system itself. Standardization of care fares difficult if not impossible.


The healthcare field is a highly respected one. When questionable practices arise, these actions only threaten the respected reputation of the industry. Providers have a responsibility to maintain trust and confidence with the public. Such ridiculousness like the study revealing the approximately 60% of physicians with direct ties to the pharmaceutical companies through employment, travel, and kickbacks, only dishonors the profession. It is a travesty that such a noble profession could fall into the same corruption patterns that other industries have recently experienced.


Healthcare is a delicate, unique industry. The standards of care and practices often involve life and death matters. Perhaps protocols and guidelines are not the final answer due to their restrictive nature, but they are a step in the direction of cost-containment and quality improvement. Healthcare is an evolving process with continuously new technologies, research discoveries, and other various changes. The industry must work together to ensure the practice of the “best medicine,” reducing overall healthcare costs and increasing patient satisfaction.





Appendix


Articles referred to in the Annotated Bibliograpy





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