Doctors, quality guides, and unnecessary tests: Don’t tell me what to do!

April 28th, 2012

Wow.  We REALLY do not like being told what to do.

As a background, quality improvement is a major professional goal of mine.  I have had formal QI training, I’ve taken a lot of classes that explore the issues of quality in medicine, and a significant proportion of my time is spent thinking about how to improve and streamline our delivery of high quality care.

We should all want that, right?  Shouldn’t we all want to improve?

Yeah, you’d think.

Maybe not.  Or at least not in a way that feels like homework/grades/slaps on wrists/cookbooks/“The Man”/you can’t tell me what to do damnit!

An alarmingly large proportion of physicians in the Medscape 2012 annual physician compensation report seemed durn determined to do whatever they ~individually~ feel is best for their patient, ignoring the guidelines that their own professional societies created.  They seem to feel justified, though by stating they don’t think the guidelines are going to do any good/aren’t in their patient’s best interest.

Let’s look at a couple of slides (annotation is mine: locate source URL by clicking on the Medscape link above):


I know the challenges to implementing changes that can actually drive improvement.  These challenges plague each step of the process: What is quality of care?  How to you define it? How do you measure it?  How to you balance quality for the patient with quality for the physician and quality for our nation?  How do you pay for it?  How do you convince people less medicine is quality care?

I also know why doctors dislike guidelines: they want to make the decisions for themselves at the bedside, and they don’t want to deny interventions to patients when they think there’s a possible chance it could help.  Evidence-based medicine looks at things on a big scale, and docs want the freedom to think, “what if my patient in front of me really is the one that an Umpteenth Emergency Department CT abdomen Scan shows the as-yet-to-be-diagnosed cancer that caused the last 5 years of his/her abdominal pain?” (Yes I’m being facetious, OK, I’m trying to make a point).

I belong to several professional GI societies, and one of those societies, the American Gastroenterological Association (AGA) has recently joined many other professional societies in the Choosing Wisely campaign [see a JAMA viewpoint article here].  Together they are trying to come up with medical interventions that are IN GENERAL  unnecessary: tests or therapies that add very little to making people better.

For years the AGA, American College of Gastroenterology (ACG), and the American Society for Gastrointestinal Endoscopy (ASGE) have published guidelines that seek to provide the best possible evidence for what has been shown to help people.  DOCTORS WROTE THESE GUIDELINES, along with many other people (and sometimes laypeople).

They are also actively partnering with national non-profit organizations to create and promote better quality in healthcare.

Not that I didn’t know that a lot of doctors don’t like guidelines, or at least don’t like being forced to conform to guidelines.  No American likes being told what to do: patients, physicians alike.  I get it, but C’MON PEOPLE.  You/we are not perfect.  There are truly some things we need to do to get our butts in gear and accept we don’t always provide high quality care, and guidelines can be very helpful tools (when applied correctly) to get better at what we do.

There is still a huge amount of autonomy in the American practice of medicine.  Probably too much autonomy as physicians and patients have been allowed to willy-nilly demand pointless interventions that satisfy our guts (no pun intended) but do little to actually improve health.  We will pass the exhorbitant costs of this wasteful care onto our children who will eventually face a crisis of debt and widespread health disparities.

That is, if we don’t take the bull by the horns and do something about it.

I was recently appointed to the AGA Institute Clinical Practice & Quality Management committee, and I was thrilled to be able to help shape these issues for our field and truly help bring GI into a higher standard of care.

Well, I guess I have my work cut out for me.  I’m going to become “The Man”, so to speak, the “Bad Guidelines Guy”, or umm “Gal”.

So, I guess my challenges in quality improvement are:

  • To try to move that needle on those surveys and convince physicians that being mindful of evidence based medicine can improve population health and individual health
  • To try to understand why so many doctors dismiss the guidelines they created
  • Find out what they think really will help improve patient care
  • To fight with insurance companies, government, and local administrators who apply these guidelines inappropriately (and just fuel those doubting doctor’s fears)
  • To determine what really makes a difference in improving care and decreasing the economic burden of healthcare for my future children

Good luck to us all.

2 Responses to “Doctors, quality guides, and unnecessary tests: Don’t tell me what to do!”

  1. John Allen on April 28, 2012 11:50 AM

    Wonderful. Glad you will be part of the guideline team – now we have to figure out how to embed EBM into our core culture.

  2. Lena Palmer on April 28, 2012 11:54 AM

    Thanks! Totally on board. Hitting the ground running at DDW 2012.

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    About Me

    Professional Gastroenterology Fellow

    Amateur Martha Stewart/Bob Villa/Julia Child/Collette Peters