My New England Journal of Medicine still arrives each week. I pay for the subscription so I feel obligated to read two articles from it each week, roughly 100/yr, even in retirement. They tend to be cases of the week or a review of something related to endocrinology, but I am as interested in the changes of how we practice, having lived through it. One element that exploded during my final years as a clinician has been the number of directives and processes that differ from what an experienced physician would likely devise on his own. Now, I may have gotten in on the ground floor of this, starting my post-residency career as a VA physician. These guys didn't have the insight to allow me to receive a flu vaccine in my non-dominant shoulder. One kabooby from the lab ordered, who didn't know what a patient looked like prior to autopsy, ordered that all the lab slips be placed in the chart without having been seen by the ordering doctor first, where they ended up in somewhat random order. They used to transport World War I veterans 100 miles each way for their appointments, paying $700 dollars to the driver of a Ford Pinto that just squeaked by state inspection. I had the transportation director price the cost of a limo for the same trip. For one-third of that, the old warrior could have travelled the breadth of New Jersey in style. He would have to pay for what he took from the back seat bar, but if he drank too much, the VA would dry him out for free and hire the Pinto back to take him home.
On graduation to the university and private sectors, directives declined in number. I am pretty hard pressed to come up with anything that matched the VA encounters. Scheduling made sense. Rules on charting were understandable. We got our own parking spaces and as security became more important, ID tags enabled access to the places we needed to be to provide patient care.
And then came HITECH and the computer. It all changed. In an inner city area, it was common for patients not to keep appointments. Any number of schemes were devised to either reduce the no-show rate or compensate for it, with scheduling bedlam when everyone came. There was a directive to see everyone within seven days of discharge. A schedule does not expand indefinitely, not everyone really needs to be seen sooner that three months by the consultant, and thinking about appropriate post-hospitalization is part of the competence that the residents are expected to acquire. Meetings to discuss quality addressed non-problems to the neglect of what really needed more attention.
Intercepting the asinine seemed hopeless in this era of an expanded middle layer of managers charged with doing things that they don't really have the insight to do because they seemed like a good idea at the time. Once there, they have a life of their own until the hospital is forced to reconsider by either legal allegations or loss of revenue.
It came as a welcome though unexpected surprise to learn that all elements of the inane did not have to become immortal. A NEJM Sounding Board essay described an algorithm that can be computerized to identify and intercept the dysfunction, though not until it has become dysfunctional.
Based on importance, these mavens at NYU targeted processes that had no real basis but were intended to solve a problem. If they didn't solve the problem, they were identified and sent back for rethinking.
Do we really need a computer algorithm for that or would a simple anonymous suggestion/complaint box suffice? The big corporations probably addressed this decades ago. A directive would come by or a customer would complain. The VP's would hire people to address the concerns or deal with an external regulation. Before you know it, you had people with significant salaries tweaking what would be better neglected. Somewhere around the time of the 1992 election, they figured this out and pink slipped the capable high salaried people whose work wasn't worth doing. Medicine has always lagged behind, which is why we are now being pummeled by insurers and product manufacturers. They had their restructuring. We have not. If the algorithm really intercepts the many asinine processes imposed upon us, we might have a chance of catching up.