Outrage #1: Wasting time of skilled caregivers.Everyday skillednurses and physicians assistants waste hours of time on the telephone eithergetting approval for medications that we prescribe for our patients or tryingto fight a rejection for a medication we requested.Outrage #2: Choosing a medication for cost, noteffectiveness. Achild cannot breathe because the acid and other nasty stomach contents come upfrom the stomach and inflame the airways without the right treatment. Althoughmany of them might respond to one preferred drug, not all of them do. And,guess what? There is another non-preferred drug to which more of them willrespond, but it is not allowed as a first line treatment, even in this criticalairway situation. When there is an airway problem and the infant is choking,coughing, turning blue and not sleeping, or the airway is becomingprogressively narrower, wouldnt you want your child to have the medicationthat works more often? I know I would. The insurance companies call theirapproach best practices because most, but not more, might respond.Outrage #3: Pretending we are giving care whenwe are not. So theone preferred (i.e. less expensive) medication also tastes really nasty. Manykids wont take it at all no matter what flavor is used. So then families aretold to mix it with their formula or juice or some other food and this dilutesits effects because it wont work in that preparation.Outrage #4: Pretending that patient diversitydoesnt exist. Differentpeople respond to medication differently (? pharmaco-genetics). You know thatstrue just from the way some of us fall asleep after one dose of Benadryl andothers of us dont get knocked out even with a whopping dose of morphine. Weare in a real quandary when we have to fight (sometimes for weeks or months) totry another medication because the one we are allowed (first tier) doesntwork. And then on the second or third tier, the family cannot afford it,doesnt get the medication, and the child might go untreated. We have wastedmoney, time and have put the child in harms way.Friends, Iam not making this up. And the problem is going to get worse. Why? Becausethere are some with influence who really believe (incorrectly) that there areexperts who know the right thing to do for an individual patient, whom theyhave never met. Well, they dont. Each patient has a unique set of variablesthat requires a lot of thought before prescribing occurs. I have just named afew.Thismisguided approach to patient care is much more eloquently discussed by PamelaHartzband, MD and Jerome Groopman, MD in an editorial in the Wall StreetJournal. I was so pleased to see that these two brilliant Harvard minds (wifeand husband) have continued to chip away at the myth that there are such thingsas best practices or that expert opinion will result in the best care forall.In myalmost 10 year tenure as director of the Center for Pediatric Quality at theChildrens Hospital, I firmly resisted even using the term best practices,because I truly believed that there were only better practices. What we thinkis best today would and should be replaced by what is better tomorrow. That iswhat makes medicine challenging and what creates the forward