Generally, I lack the time to follow much TV, so it’s been a while that I watched Lost, but I thought the show’s basic and primordial premise – being lost on an island, where no one really knows how they got there, or how to get away (ok, for those who are up to date on this, people seems to have gotten off the island in Season 4) – seems so befitting our current economic situation. Now, I am a physician and not a economist, but most analysts seems to agree with me that the current world economic situation is quite similar to the TV series: we seem utterly lost, every day brings a new turn (together with a 500 up or down in the Dow), no one fully undertsands how we got here (some of the villans, subprimes, clearly not being everything), no one really knows how to get out of the hole.

But that is not the only thing lost. Although I just learned that Ed Kennedy is working on comprehensive heallth care reform (bless him, I wish him well but this may be his parting gift to Congress and the American People), I think that people like Bean, Gingrich and Kerry, who just out forward a suggestions to run medicine like baseball, should do a reality check. Here are some things they wrote that bug me:

Studies have shown that most health care is not based on clinical studies of what works best and what does not, be it a test, treatment, drug or technology. Instead, most care is based on informed opinion, personal observation or tradition (…)  We can do better if doctors have better access to concise, evidence-based medical information (…)  Evidence-based health care would not strip doctors of their decision-making authority nor replace their expertise. Instead, data and evidence should complement a lifetime of experience, so that doctors can deliver the best quality care at the lowest possible cost.

First, apart from the fact that a baseball player can hardly be compared with a doctor, it is not like Evidence Based Medicine is a new concept. It has been around for decades. And the barrier to findings new evidence is not primarlily the lack of will of doctors to accept it, it’s the lack of evidence, caused by a lack of studies, especially unbiased studies. The US government and public have sat back, NIH funding has been insufficient, and we have left it to the drug industry to go and find the evidence. Thus there is a lot of (often biased) evidence of the most lucrative conditions (although the FDA’s orphan drug program has made some difference), like the new diseases everybody seems to have (restless legs, social anxiety, ADHD). Meanwhile, it has become more and more expensive to get a medical education, there is a shortage of physcians, particularly in primary care, the doctors that do work often have no time, and sometimes no funds, for continuing education. Furthremore,  the number of un- and underinsured people is at an alltime high. Although I think it is a great idea, adequately funding the NIH, or some new institution, to run large unbiased clinical trials will have no immediate impact on clinical care: evidence will take years to accumulate and be transplated into practice and it will cost billions that Americans unfortunately are not willing  to pay (more taxes, anyone?).

Everyday I deal with the checkbox mentality of doctors: patient has condition X, so I must check Y and order Z. If I don’t, my hospital gets poor marks on the statistics used to judge their performance, and soon will determine their reimbursement. Furthermore, doctors are trained to think that if they do yet another test, they will not get sued and risk their livelihood and job as a result. Meanwhile, they have not time to talk to the patient, take a good history and review the chart. There is little, if any, evidence that increaseing the ‘batting average” of a doctor to run test Z does anything to make a patient better.  What we need NOW (notn in 5 to 10 years), is to get off the island. Not mb checking boxes, or more tax breaks, but by comprehensive health care reform. Let’s get Un-Lost!

One the first glance, the news that Medicare will not pay for the cost of hospital errors such as line infections and may seem logical, and it may achieve what it sets out to do: reduce the number of errors. But is it the best way? I guess in a way it hits hospitals where it hurts: hard cash, probably the best incentive for businesses. It will probably create an surge in cutting down on dangerous practices. But it seems to make the assumptions that we (health care providers) can be perfect. But we can’t. We can be better.

Leaving sponges or other objecs in the patients or ‘wrong patient wrong side procedures’ occur, but they are relatively rare. So are severe transfusion reactions. What is common are catheter sepsis and other hospital acquired infections.

Fact: if a patient does not need a central venous catheter, she/he should not have one.

Fact: if a patient has a central venous catheter, there will be a proportion of patients who develop complications. These events can be reduced, but not eliminated.

So instead of requiring hospitals to conduct more expensive tests (will we now need to draw a blood culture with every catheter insertion just to cover our backs?), shouldn’t we rather mandate surveillance programs and safety procedures, like they are in place in many hospitals already? If the savings are as great as they are claimed to be (and they probably are), then the system should pay for itself. Procedures in the hospitals I attend call for contact isolation of every patient that ever had an MRSA or VRE infection, on every admission. Check lists are in place to make sure that sterile procedure is followed while inserting central lines and their need has to be assessed daily. Should the hospital be punished for an infection that was not preventable? Health care is not free and they need to compensate for the money elsewhere – at another hospital I used to work, a popular cost cutting measure was to restrict indigent care…

Eventually, all this will probably achieve the same goal. It will force health care providers to practice like they should: with the best interest of the patient in mind. I would have welcomed a pilot project to test this method before widespread implementation.

Maybe others think differently – feel free to comment!!!