A new patient consult, "Typical atrial flutter, age 65" the schedule said.
With a history of renal cell and a nephrectomy,
And an bleeding ulcer while on aspirin,
And a stroke (now better),
And polycythemia vera,
And a monoclonal gammopathy,
And a "low grade" lymphoma,
And a history of "bleeding" with the tiniest of scratches while on warfarin,
And a history of a hemolytic transfusion reaction,
And an EKG of atrial fibrillation a year ago,
And an EKG of typical atrial flutter now,
On no anticoagulant or aspirin,
On dialysis,
In in a patient who doesn't feel the arrhythmia and is feeling fine.
"Management?" the consult read.
This should be easy, right? Just "Get With the Guidelines!"
More often than not, it is difficult to follow pre-defined guidelines (as the above case demonstrates).
More often than not, there are many, many independent variables that weigh on patient management decisions. Despite this reality, there has been a growing call for treatment standards, guidelines, protocols, and checklists by those tasked with paying for health care. Payers want perfect outcomes or they will not pay for care, as if people are widgets on a production line with interchangeable parts.
But how may people exist in the center of a Bell curve? How many more do not?
Current models for health care delivery attempt to make generalizations about treatment regimens for as many people as possible because payers want to receive as much value as possible for every dollar spent. On the surface, such an approach seems so logical. But for the majority of individuals who fall outside the center of normative data sets upon which standards, guidelines, protocols and checklists are based, the doctor and patient must face the reality that there are often no perfect answers for treatment.
In these cases we look into each others' eyes, weigh what we know and what we don't know together, then join hands and walk into the uncharted treatment waters of real life.
This is OUR standard, our expectation, our reality...
... and one that clashes head-on with pre-specified guarantees of outcomes.
-Wes
6 comments:
guidelines are an interesting thing. last october when i got my current pacemaker my insurance company did not want to pay for it. the pacer i had at the time was still working and was less than two years old. the reason my doctor wanted to switch it out was that a study had been done showing that a biotronik pacer with closed loop stimulation had a good chance of stopping my syncope. it has. and my new pacemaker has already paid for itself if you assume that i would have fainted the same number of times this year as each of the last five. and required the same number of tests, or nights in the hospital after hitting my head or ambulance rides after fainting at a basketball game, etc. but they had their guidelines that would not pay for it. they eventually did. and it has already saved them money and will continue to do so for the next 7 years and 3 months (the expected battery life per my last interrogation).
i am not sure what guidelines you are referring to in this post- are they cms? hrs? your hospital's?
i hear a lot about government coming between doctors and patients. that does not happen with private insurance that i am aware of (or if it does i have yet to see a documented case of it). it will not happen under obamacare. under obamacare the only people that come between a doctor and a patient are insurance companies. and it happened before obamacare and it will continue after obamacare.
at the same time i believe that there should be guidelines. like back when there was a flu shot shortage a couple years ago. it made sense to make it available first to healthcare workers, the elderly, and those with weakened immune systems. i think it makes sense to have guidelines for when to operate on an aortic aneurysm versus when to treat it medically.
the issue is not the guidelines- the issue is what hoops you have to jump through when you need to break the rules. that process is the issue.
Excellent post Wes. Despite guidelines, which have a place to play and which have generally led to improved care, experience and good clinical judgement will always be invaluable and why monkeys can never do our job!
Oh, good Lord! A patient more complicated to treat than me. Unimaginable.
First of all, they are not guidelines. Please refer to them as commandments as in "thou shall not implant before 40 days".
Federal law states that you cannot display the commandments in the entry of a public hospital.
Seriously, I just landed a gig reviewing charts for a hospital to ensure that they are adhering to the guidelines. If this goes well and I get some referrals, it could be a full time job. Why practice medicine when you can ensure that other are doing it 'correctly'?
In my world, it seems many guidelines are determined by clinical studies, i.e. "evidence." The evidence is there....based on trials that are often sponsored by drug companies to ensure approval of a drug. But to that end, the drug companies design trials to optimize the chances of drug approval, so the patients have NO co-morbidities. So, is the "evidence" valid for the general population. Probably not. Physicians use clinical experience to extrapolate, but then got caught in the trap. Sigh.
Do the guidelines for afib ablation support ablating sympathetics to the heart? Just another example of our country falling behind the rest of the world. A 50% reduction in the recurrence of afib and Dr. Wes will be unable to offer it to his patients. Medicare will modify the NCD by 2030. In the meantime, just do the inferior procedure.
http://www.cardiosource.org/Science-And-Quality/Journal-Scan/2012/09/A-Randomized-Comparison-of-Pulmonary-Vein-Isolation.aspx?w_nav=LN
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