Keeping Engaged

As I experience some lumbar discomfort in what seems to be the left quadratus lumborum distribution, it is good to have very little running around and some desk time to study some medicine.  There is some pretty good work floating around.  NEJM has some articles on ICU experimentation with glucocorticoid + mineralocorticoid supplementation and different IV fluid options.  I've been through the last six months of the Leonard Davis Institute Blog which has some items on how we practice.  While the NEJM helps determine low value or high value interventions, we still do the things of low value.  An LDI article looked at how docs would look at being penalized for doing things of limited value.  They targeted use of urinary catheters to measure urine output in people not critically ill, use of cardiac monitoring without a preset end point, and use of ulcer prevention medicine in people who were not likely to get ulcers.  I do not see too many catheters at my place.  There are a lot of people on telemetry, mostly play it by ear.  And proton pump inhibitors are now cheap and don't cause a lot of harm so people tend to get them irrespective of risk, though I've yet to see an ulcer develop during hospitalization, maybe because these were used or maybe in spite of them being used.  So they asked if the docs who do these things should incur a financial penalty.  Well, unneeded catheters can cause harm to people.  Monitors cost somebody money.  PPI's short term probably don't cause harm and don't cost much money though there seems to be some correlation of acid inhibition with opportunistic infections so maybe they do.  Like the majority of the respondents, I have relatively little sympathy for the hospital or insurer making less money than they could have, which would be the outcome of less monitoring.  Having insurance premiums go up because of these expensive days is a little more problematic so the societal cost does merit some consideration, as it did to those polled.  And the catheters are a no-no as they harm patients.

However, we all do non-productive things.  The residents order Mg and Phos on everybody and then give IV replacement for trivial variances.  These people will have the same variances at home, undetected by the lab, and do just fine ignorant of those results and absent any intervention.  We do ac and hs glucose monitoring and supplemental insulin on all diabetics.  Probably nobody's microvasculature will be improved from this practice though for some people it does help recommending chronic insulin dosing.  We are just not selective about this.  We have acts of omission too.  I've yet to see a resident include a rectal exam in the initial H&P, irrespective of its value.  Reviews of old records leave a lot to be desired.  These cost nothing, can add a lot of value, sometimes save money on not repeating things that will not have changed and infuse a habit of thoroughness that reaps its rewards later.  We are just not selective enough or thoughtful enough in what we do.

But penalties for excessive care?  Being punitive rarely improves care and probably wouldn't here either.