Doctors Must Be Involved in Development of Guidelines

By Harvey B. Lefton, M.D.

We are practicing in an age of rapidly changing treatment modalities and increasing pharmacologic options.  What is changing even more rapidly is the practice environment that insurers, government agencies and even patients use to judge us.  We are all seeing the development of practice guidelines—parameters external agencies are using to decide whether we measure up to their standards.  It is no longer enough to have patients tell their friends what a great physician we are.  We now have specialty societies and government agencies developing professional yardsticks to measure us.

While these guidelines are being used to evaluate us, they are also being used to measure our practice efficiency.  When looked at in this light, we can understand that EMR is not only useful for making records readable and portable but also easier for those auditing us!  What we must realize is that government created this as much to reduce reimbursements as they did for practice accountability.           

We are experiencing a rush to use guidelines to re-engineer the healthcare system.  Physicians are forced to adopt EMR while the burden of its cost impacts on practice income, often not positively.  Industry has used computer oversight successfully in the past.  IBM was able to re-engineer its credit request process from six days to four hours when a new management team approached the problem.  Using computers alone to analyze this process was not enough to make changes.  What finally worked was a team of individuals personally evaluating the process.  This professional approach is needed in medicine.

Electronic medical records, pay for performance, chronic disease management, and legal reform to the tort system all must be analyzed if we want to improve costs of care and efficiency.  We must also determine how we can integrate lifestyle changes to reduce costs.  As long as we have a population consuming 150 pounds of sugar per person each year and twice the recommended daily salt, we will not reduce the chronic problems of obesity, diabetes, heart disease and cancer through technology alone.

Clinicians do not have the luxury of television’s Dr. Gregory House, who performed every test available until an exotic diagnosis was reached.  We are taught to first rely on our skills in history taking and physical exam to make a diagnosis.  These skills are often overlooked when practice guidelines are developed as the emphasis is placed on management of disease and medication error.  The ABIM program, “Choosing Wisely” highlights appropriate paths of diagnosis.  Hopefully, this program will refocus the need for clinician skill and allow saving healthcare dollars.  Sir William Osler once said, “Listen to the patient.  He is trying to tell you what is wrong with him.”  Digital information skills must be integrated into the physician interview to maintain this humanism of medicine and maintain clinical skills.

Moving forward we need physician participation so accountability measures truly promote quality.  These measure need to be continually re-examined to validate their necessity.  As an example, the Joint Commission found no relationship between hospital discharge performance measures for congestive heart failure and re-admission rates.  This emphasizes the need for education but most importantly highlights developing meaningful measures for patient care.  We would not recommend someone to start exercising by running a four-minute mile.  Likewise, we cannot expect physicians to follow new guidelines they have not helped to develop.

There must be a national ongoing process to help develop meaningful accountability measures that allow us to interact with and produce a comfort level.  With a doctor shortage of 100,000 physicians by 2020, physicians must work together with CMS, insurers, and national societies to develop guidelines that are doctor and patient friendly.  Unreasonable accountability guidelines developed without physician input will only deepen this shortage and do little to lower healthcare costs.

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Harvey B. Lefton, M.D. is President of the Philadelphia County Medical Society.