The Train Is off the Track (2008)

Seventeen years ago, I sat in one of our orthopaedic staff conferences and was astonished to hear a senior member of our hospital administration inform us that-from that point onward-we should consider ourselves to be "health care providers" and our patients as "consumers." Even then I had a strange foreboding that the practice of medicine as I had known it for the preceding 18 years was to change forever! Little did any of us in the academic environment in which I was working-and remain to this day-realize that medicine would be viewed by many as a business, with those practicing it as an occupation rather than a profession. What no one could have predicted was the ever-increasing regulations, scrutiny, and documentation of all of our activities. At times, this seems to be the major interest of our institution. From my perspective, it is rapidly going out of control, akin to a runaway train. Certainly, many of the regulations regarding patient safety are needed and justified, yet how can any patient begin to have confidence as a "consumer" when they are deluged almost on a daily basis in news media, magazines, and various other sources of information regarding the problems of medical errors? Recently, one large academic institution in Boston announced with some fanfare that their documentation of hospital-acquired medical errors would be available to the public. We have come to learn that hospital-acquired infections in indwelling cathers or longlines, even in the most compromised of hosts, is to be considered an avoidable error and subject to denial of payment of care needed to resolve the situation. Will pintrac infections in external fixator pins in polytraumatized patients-or the need to redo an internal fixation-be the next reasons for denial of payment? A few months ago, I was a guest speaker at a large academic center. Prior to my lecture, the department chair announced to his staff that from that point on, all infection in arthoplasties must be reported to both the hospital administration as well as to the state board of medicine. Yet he was unable to respond to the question of what constituted the type of infection, i.e., acute, readmission, or a patient referred for treatment of an infection acquired elsewhere. He simply said the policy was enacted without his, nor colleagues, input. A reconstructive surgeon who routinely holds off preoperative antibiotics for revision arthroplasties in order to get a more accurate intraoperative culture is repeatedly notified that he has "violated" standard-of-care procedure, and this is recorded in the patient's permanent record! We now have spies watching our hand washing, monitoring and recording the accuracy of our "sign outs," and it will not be long before our hours will be controlled just as we now see with our residents. One only has to wonder how much more money is being spent on "risk management" rather than on enhancing direct patient care. Our CME providers are under ever-increasing scrutiny and are finding it hard to comply with the ever-changing requirements. Concern for conflicts of interest has driven some large medical centers to divorce themselves from any contact with industry, be it sponsorship of education programs or research activities. Medicine and surgery remain a unique and wonderful profession that I am ever grateful for having the opportunity to practice, but there is no denying that it is-by its very nature-exceedingly stressful. Perhaps some thought should be taken to temper the pace of these regulations and scrutiny with continual input by our profession; otherwise this train will continually be running off the track. Jesse B. Jupiter, MD Co-Editor-in-Chief