Patients Are People Too

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 polices 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.”