PSROs Eliminate Vital Rounds
S.Q. Lapius refused to
serve the pre-prandial cocktail in deference to Sandford,
his nephew, “No sense inculcating bad habits in the little tyke,” he whispered
to me. Lapius had to baby sit for Sandford from time to time and it was quite a trial,
because children to Lapius were
foreign creatures from other planets. Not all children, but Sandford in particular, who repudiated the finely scented
foods that Lapis was wont to serving from time to time in favor of corn
flakes. “Ugh,” said Lapius as he poured the
crackling cereal into Sandford’s bowl.
“Tell me a story while I
eat, Uncle Simon,” Sandford said as endearingly as he
could.
“And if I don’t?”
“I’ll vomit,” Sandford promised.
“Very well, then,” Lapius surrendered. “What story would you have me
tell you?”
“The one about the fairy
prince--,”
“I don’t know that one, Sandford. I’ll tell you instead about the
merry-go-round.”
“Oooh,
that’s exciting,” Sandford said, pouring milk and
several tablespoons of sugar on his cold cereal.
“Once upon a time, long
before you were born, Sandford,” Lapius
said, raising his eyes skyward, “before doctors earned $10,000 dollars a year
just to be interns, during the time they were happy just to get food and board
to serve in a good hospital, during the time when sleep was taken at odd
moments throughout the day because doctors were up on their feet mostly day and
night, doctors used to go on rounds.”
“Merry-go-rounds?” Sandford asked.
“Actually they were
sadly-go-rounds, when the doctors visited the sick people in the hospital,” Lapius suddenly forgot Sandford.
“They were the days,
Harry, when the departmental discipline was quite strict. You remember, I’m sure. We would gather in the ward at
eight a.m. and the chief would already be there chomping on the bit. His
assistants would flank him, and we would go from bed to bed like a flying kite
of white coats. The intern would recite the medical history. We
would take turns feeling a belly or percussing the chest, scanning the
cardiograms, checking lab reports. Then we would have an active
discussion about the condition of the patient, whether or not the patient
should have surgery.”
“But what happened to
the merry-go-round?” Sandford asked, burbling his
words through the soggy flakes.
“Be patient, Sandford, I’m getting to that. As a matter of fact,
it broke down. Insurance plans started up and suddenly there were no more
wards. You see, Sandford, in these days the
poor people who couldn’t afford a hospital went into wards, and in return, the
doctors who treated them used them as teaching cases. But when people
started to get Blue Cross and Blue Shield insurance, and finally Medicare, the
system of teaching at the bedside broke down.”
“But what happened to
the merry-go-round?” Sandford wailed.
“I’m coming to
that. As I told you,” Lapius said directing his
conversation to Sandford, but talking to me, “the
merry-go-round of teaching rounds broke down as soon as the wards
disappeared. But then a surprising thing happened. The insurance
companies and the government who were now paying most of the bills for illness
wanted to be sure they were getting their money’s worth, and that the doctors
were not making any mistakes in diagnosis. So they started the
Professional Standards Review Organizations, otherwise known as PSRO’s.”
“Pisserooos?”
asked Sandford.
“Well, yes, in a way,
Stanford, you call them that. In any case, the P.S.R.O.’s
are designed to create what is called quality control in medical care.
The only trouble is that it sets doctor against doctor, and invades
confidentiality. Why, Ralph Nader even thinks that there should be a
medical specialty composed of doctors who do nothing but inspect the work of
other doctors.”
“Oooh,
that sounds like a good idea,” Sandford squealed.
“Harry,” Lapius whispered apologetically, “the birth control pills
were invented just one year too late to prevent Sandford.”
Then turning to Sandford, “No, they
are not good. What good is it to inspect records long after the
patient is gone from the hospital? Medical rounds were a vital living
experience that taught doctors on the spot. They could see the patient
from day to day. On rounds you could tell the good doctors from those who
needed help or experience. They learned on rounds. What good will
it do to have a group of outsiders inspecting charts
long after the case is over and try to decide from the record, at their
leisure, about decisions the doctor on the case was forced to make in a matter
of minutes?”
“But
what about the merry-go-round?” Sandford persisted.
“I’m coming to
that. So the wheel has come full cycle. One of the big criticisms
about medical rounds was that it was an invasion of privacy of the poor.
Actually the poor often had better care than private cases because their
problems were constantly being conferenced during
medical rounds and there was an exchange of ideas. It is lonely to take
care of a patient all by yourself without consultation. But medical
rounds were considered to be an indignity conferred on the poor.”
“But now the government
through the ‘PSRO’ law of Senator Bennet, may he lose
his next election, has turned the entire population of sick people into
teaching cases by snooping at their medical records long after they have left
the hospital. They will not have had the benefit of medical consultation,
but their doctors will certainly be intimidated because the law states in
section 249F of Public Law 92-603, Equal Professional Standards Review
Organization shall apply professionally developed norms of care, diagnosis and
treatment based upon typical patterns of practice in its regions (including
typical lengths of stay for institutional care by age and diagnosis) as
principle points of evaluation and review-.
“This certainly will
tend to preempt the individual doctor’s judgment in favor of cookbook
medicine. So the wheel has come full circle now and the entire nation
under the auspices of Peer Review will really be subject to a type of medical
rounds. Except instead of being for the individual patient’s welfare,
like the old ward rounds, they will merely be statistical snooping parties
which will invade privacy, confidentiality, and which, instead of teaching the
doctor, will force him into a straightjacket of medical practice. It will
diffuse responsibility and break up the most important aspect of medical care,
the bond of faith that must exist between the doctor and the patient. In
the old days if a patient didn’t like his doctor he could change to another
doctor. Soon it won’t make any difference, because all doctors will have
to treat patients according to ‘medical norms’ established by the
government. That, Sandford, is the
merry-go-round. Do you hear me, Sandford?”
Sandford didn’t hear a word. He was fast asleep, his
face buried in his cornflakes.
“Don’t disturb the
little tyke, Harry. Let him sleep. Now we can have our drink,” Lapius said.