By Dr. R.S.C., M.D.
A hundred years ago, one man could master the cumulative medical knowledge of all humanity. Today, one man could spend a lifetime reading the new findings published in a single year. We doctors learn it ‘all’ in medical school. But, of course, that is not enough. We must keep up with the continuing flow of new data. How do practicing physicians manage the torrential onslaught of new information inherent in the modern age? How do they find and learn the information? How do they integrate new findings into their daily activity? How often does this happen? What mechanisms for learning are there?
Medicine mandates education for doctors be they Chaired Professors at a University or generalists. It is the responsibility of every physician to log a required number of hours of education per year.
These Continuing Medical Education (CME) requirements supposedly define medical practice in the digital age. We mandate post-graduate education. There are over 750 CME sites on the Web. CME can be any approved meeting, symposium, tumor board, educational cruise or vacation, medical staff lectures and iCME: from the Internet. However, the subject of the lecture may be only relevant to a small percentage of the assembled doctors – yet they all qualify for CME.
The majority of physicians derive their CME credits from the Friday noon staff meeting and lecture at the hospital.
Medical Specialties, such as Medical Oncology, have their own meetings, journals and network. Oncologists also have Clinical Practice Guidelines with detailed schemes for treatment of just about every cancer at every stage.
For the average physician, standards of care conveyed through CME and educational activities are an essential mandated part of the life of a Physician.
The legal definition for standard of care is defined as “reasonable and prudent physician”. Previously the standard focused on local standards of care. Because we are so connected the standard now is national standard and describes behavior of a physician who ‘stands in the same shoes’ as another.
The standard of care changes as technology, information and values change. While standard of care is the foundation of the practicing physician’s work, we only examine it when someone complains. The rest of the time the Physician relies on the advice of cartoon character Jiminy Cricket: “Let your conscience by your guide”.
The fruits of CME are supposed to lead to a uniform standard of care. However, are the results substantially better because of it? Let us look at some examples:
The American Cancer Society equates fecal occult blood testing (FOBT), sigmoidoscopy and colonoscopy as screening methods for colon cancer: is a doctor “doing the right thing” if he uses a sigmoidoscope which looks at only the lower end of the colon rather than colonoscopy which looks at the entire organ? This is roughly equivalent to a unilateral mammogram for breast cancer screening. How can this be standard of care?
Can any traction be given to the concept that a sigmoidoscopy is a reimbursable cost and can be done by general practitioners or even nurse practitioners, while a colonoscopy is only done by a gastroenterologist?
Here is an example I mentioned earlier: The shocking fact that 10,000,000 annual Pap smears are done unnecessarily. The American Board of OB-GYN has issued a statement on this practice. The uncomfortable thought is that a proportion of the Pap takers know that it is a worthless procedure. If it is not standard of care, and even biologically indefensible, isn’t it a breach of the standard?
More money spent against recommendations: It is generally settled that PSA testing for prostate cancer should be discouraged. The USPSTF (United States Preventive Task Force) agrees. Yet, a proportion of Medicare spending is for charges for this procedure in older men. Is this “correct”? Were the procedures warranted? Were these procedures within the standard?
In 2009 Medicare paid doctors more then $100 million for ~550,000 colonoscopies, many for screening. Although the USPTF discourages this procedure in patients over age 75, around 40% of the colonoscopies were in patients in this group. [New York Times May 25, 2011 Squandering Medicare’s Money]
We have a medical dictum primum non nocere (first, do no harm). A physician who engages in acts outside of the standard defends themselves by what they say is the absence of harm. The harms turn out to be almost all economic although there is a biologic price to be paid by the patient for useless but radiation dense imaging studies. The only ‘help’ is to someone’s bottom line. Who pays for the unneeded service?
Medicare and other insurance plans pay for screening procedures that are not beneficial and not recommended. Can the fact that reimbursement will follow be some incentive for doing a procedure? Is this the standard of care?
Medical costs are so high, and rising, that there is an impact on standard of care – we cannot afford it. Medicare spends most of its money on the last few years of life of its enrollees. Horror scenarios like the Schiavone case in Florida recently, where ignorance trumped reality, are a good example of this phenomenon.
As our population ages, Medicare will assume a larger financial burden than today. As usual, taxpayers will pay for it.
Cost and effectiveness need consideration before subjecting a patient to testing or treatment. It was only a number of years ago that the cost of sequencing a genome was prohibitive. Now whole genome sequencing is approaching the $1000 level. Companies are taking advantage of genomic technology by offering “gene scans” for individuals at prices that range from a few hundred to a few thousand dollars.
We see the Standard from different viewpoints depending on where we practice. How up-to-date does a practitioner have to be? Considering that progress is made through analysis of clinical studies, the recommendations come from the results of research done and evaluated by dedicated specialists. The finding is reported in, say, the New England Journal of Medicine. However, our doctor does not subscribe to the NEJM. What is the likelihood information will reach a practitioner?
Even more vexing is the quality of incoming information; how reliable is it? Is the sample size too small, too skewed in distribution? Is the finding statistically significant? How do advances affect an individual physicians’ practice? Would a practitioner take the time to analyze an article? Publication in an “authoritative” source is not always accurate or relevant.
Over prescribing and over treatment are other wastes of money and may lead to serious toxicity. Perhaps the recent story about Levaquin, the antibiotic, may be instructive: This is an extremely powerful antibiotic. It should only be reserved for the most serious of infections. Using this antibiotic where another would be just as effective exposes the patient to side effects of a powerful drug and the added liability that treatment of minor infections with this could lead to resistance of the bacteria to its effects.
The report (on The PBS Newshour June 16, 2011) described several patients who were assumed to have had a toxic reaction to the drug. The point was that Levaquin is being over prescribed, and used for indications outside of its intended purpose. Why? Because the physician is “worried” that this may be a significant infection and Levaquin being a powerful drug works quickly and completely. So, is prescribing Levaquin for a sore throat the standard or is it a dangerous treatment?
Consider cancer treatment. How many non-oncologists are giving chemotherapy in this country? Is this a good idea? What is the risk of harm? Because many treatments happen outside hospitals, there is no regulation of these activities in private offices.
Practice differs across the country; some communities have enormous health care costs while others with a comparable population but another area are substantially different. There are published guidelines for most of the medical disciplines. However, it should be evident that compliance in certain areas is lacking. Until we can better organize ourselves to teach and learn we will continue to fall short of our practice goals.
By Dr. R.S.C., M.D.