Approximately one year ago, the Public Policy Committee briefly discussed the benefit of assembling a top five list of “avoidable” interventions, physician ordered, that were of marginal value. The goal was to enlighten SHM members as to how we as a society could contribute to improving hospital efficiency, and perhaps patient outcomes. It is the “doing our part” thing.
At the time, an ER doc had published a list that identifies the same, mainly interventions ER physicians should defer due to their, shall we say, wayward nature. The fact I cannot recall the tests, or the citation may be indicative of that effort; well intentioned, but lacking heft. It is the purpose behind this post.
With great fanfare, two recent publications received similarly distinguished attention, one from the Archives of Internal Medicine, and the other from NEJM. They both expounded upon the need for doctors to identify tests or treatments and scale back—for obvious reasons. Whether any effort in this vein is effective, and I am doubtful, is a meritable discussion. However, the two, which the medical press reported correspondingly (and equally) in their behavior changing promise, are vastly different. So much so, that to categorize them both as an actionable “call to arms” is doing one piece a disservice.
Here are clipped recommendations from each:
- Are they different?
- Which one would you distribute to trainees for implementation?
- Which is likely to leave clinicians with a sense of ambiguity?
- Is one likelier to lead to organizational antibody production or promotional incontinence?
You probably guessed that the specificity of the IM over the oncologic recommendations are more accessible and likelier to produce change. I am not dismissive of the NEJM citation however; it is just the “broadness” of the appeal, and its “where do I go with this” character, that convinces me that this list will wilt in the sometimes vainglorious pile of past distinguished explorations (at 2000+ currently).
If you were to envision a hospitalist to do list, compare A & B, and C & D:
A. When non-indicated, avoid gut prophylaxis on the general medical wards
B. Do not order PPI or H2 blockers unless a non-ventilated patient has GERD, PUD, end organ failure, or a coagulopathy. Hard stop.
C. Avoid unnecessary indwelling urinary catheter use.
D. Unless urinary retention, skin breakdown, palliative comfort, or need for urinary output measurement for <24 hours present, indwelling catheter use is potentially harmful and not recommended. Hard stop.
This is an illustrative example, not perfect, but meant to exemplify what may or may not facilitate alteration in behaviors. It will take work to construct directives like those published in the Archives to initiate a coherent effort—but not impossible.
Overall, however, I am not optimistic that pains like these will result in transformation. On one hand, physicians have had years to mull over guidelines, but to no avail.
CER and IPAB like bodies (? with teeth) hold promise, and unless professional societies make hay, and pronto, docs will continue to brandish a less than stellar reputation in the change agent department.
BONUS #1: There are chocolate people. There are vanilla people. There are dog people, and there are cat people.
It is 4PM on Friday. You watch your hospitalist colleague who is on call that weekend greet an innocent clerk leaving on the elevator. The clerk says, “have a great weekend!” The hospitalist responds preeminently, “oh, I am on call this weekend, I will be here!” Or, conversely, the hospitalist says, “thanks.”
Which one are you?
BONUS #2: Anyone who knows me, knows that this, for me, is treif. Reboot. Let me tell you, I had an epiphany this weekend, and heroin has nothing on this stuff. Number one in NYC. Go there. You will hate me for it.