Patients Are People
Too
Daily Observer
S.Q.
Lapius was busy reading and underlining, muttering to
himself and uttering occasional expletives.
“You
sound vexed, Simon, something must be amiss.”
“No,
Harry. Just studying the means by which
doctors will be able to go on strike, or perhaps forced to.”
“Go
on strike? Doctors? Clearly a breach of the
medical tradition. What did you
do? Join a union or some such thing?”
“Not
at all, Harry. Simply
studying the Accreditation Manual for Hospitals put out by the Joint Commission
for the Accreditation of Hospitals, the JCAH, to be brief.”
“What’s
so revolutionary about the manual?
Surely it doesn’t preach revolution.”
“Of course not. It
simply details what doctors are supposed to do to maintain a viable medical
staff. Shall I quote?”
“If
you must” I said, laying aside the evening paper. It looked like I would be in for a long
night.
“All
right, if you insist. Quote: Because the
overall responsibility for the quality of medical practice rests with the
medical staff, the individual staff member will be held accountable for the
appropriateness of care rendered to his patients. Medical care evaluation should be a fact
finding and educational function. To
accomplish such analysis effectively, criteria for evaluating medical care must
be established by the medical staff -.
Whatever the organizational pattern selected, the medical staff must
provide an appropriate peer group method by which the required basic functions
of medical, surgical and obstetrical audit are thoroughly performed at least
monthly. The tissue review should
include an evaluation of tissue removed at operation. Similar review should be performed with
respect to those situations in which no tissue was removed at the time of
surgery. Medical care evaluation shall
include periodic review of the utilization of the bed facilities and the
diagnostic, nursing, and therapeutic resources of the hospital, with respect to
both the availability of resources to all patients in accordance with their
medical needs and the recognition of the medical practitioner’s responsibility
for the costs of health care. This
review should cover, on a sample or other basis, admissions, lengths of stay,
professional services furnished and the availability and alternate use of
out-of-hospital facilities for diagnosis and therapy should be reviewed. Minutes that adequately
reflect the transactions of the medical care evaluation shall be kept etc. etc.
etc. unquote.”
“So
why are you going on strike?” I asked.
“I’m
not. I simply have found the device
whereby the physicians can appear to be on strike. All they have to do is to follow the by-laws
to the letter. To do this each would
have to spend about 20 hours from their practices performing these chores. Suddenly the doctor shortage would become
critical. Can you imagine the hubbub if
a patient tried to reach his doctor only to find that he was busy auditing the
work of other doctors, and spending his time trying to find out if the
community was properly served, and if the facilities were being properly used?”
“It
would cause a scandal,” I admitted.
“Probably. Certainly
the patients would be better served if each doctor preserved his time to
practice medicine, follow the journals, continue his
education at meetings and post-graduate courses. After all I’ve never gone to a meeting that
wasn’t crowded. Sometimes there is
standing room only. Before a physician
is admitted to the medical staff of a hospital he must be carefully screened
and his credentials validated.”
“But
you are not really against physicians policing themselves, are you Simon? As a matter of fact you have always been the
first to request the medical department to devote more time to case review.”
“But
we have always policed ourselves. What
is going on now is that the JCAH wants to institute a medical audit that will
select cases that have gone awry, and have these scrutinized for the reason the
patient didn’t do as well as he should have.”
“Are
you against that? It sounds reasonable.”
“Not
in principle. But medicine and medical
problems are immediate. It is very hard
to rehash them from the records, or to get a true picture of what was actually
happening at the moment. In my view the
best medical surveillance should occur while a patient is still in the
hospital. Problem cases should be
brought to committee to get the collective wisdom of the department. In that way the patient might be helped when
he needs it most. Lumping of cases leads
to statistical evaluation, but medicine is too much an art to be regulated
entirely by statistics. The fact is I
keep coming back to the first line I quoted you.
‘Because
the overall responsibility for the quality of medical practice rests with the
medical staff…’ The important thing is
that the quality of medical practice within a hospital is to a great extent a
function of the quality of the hospital, the discipline of the nursing staff,
the alertness and interest of the pharmacist.
To a great extent, the medical staff is powerless to affect these
matters because it is administered by
the board of trustees who hold legal power in a hospital. The board also, in most cases, maintains the
prerogative of hiring the pathologist and radiologist, two key personnel in
medical practice within a hospital. Can
the medical staff be held responsible for their proficiency in the practice of
medicine? I think what I object to is
that the effect of these audit mandates always leaves the impression with the
public that it requires policing…both
of which are base canards.
“Secondly
it leaves open the question of who policies the hospital? In reality, the doctors have little power to
police the ecology of the hospital. If
not they, who then? The real point is
that medicine is an individual problem, and if a patient in the hospital is in
trouble it is that patient at that moment who should be the focus of attention
by the doctors, nurses and administration.
Not months later from the devitalized medical records just to provide
the appearance of self policing.”
“Simon,”
I laughed, “you are an unreconstructed individualist.”
“Only because my patients are individuals, Harry.”