Demanding medical excellence: doctors and accountability in the information age

Abstract

Accountability in American health care is not just for doctors and patients but for hospitals, government agencies, insurance companies, and even the benefits coordinators for large employers. Millenson chronicles their issues and relationships in recent years. As a good journalist (a former Chicago Tribune reporter who specializes in health care issues), he carefully cites names, actions, dates, and places and deciphers euphemisms. This is a history of changing power, a history of a true “paradigm shift.” The mid-century postwar period of provider autonomy with no accountability for outcomes generated abuses that led to a major social and political backlash. Medicine practiced by tradition and personal opinion led to widespread variability in outcomes (mortality and morbidity), hidden until exposed by outcomes research. “The operation was a success, but the patient died” is no longer acceptable at the dawn of the “Age of Evidence-Based Medicine.” Practice variation is not caused by “bad” or “ignorant” doctors. Rather it is a natural consequence of a system that systematically tracks neither its processes nor its outcomes, preferring to presume that good facilities, good intentions, and good training lead automatically to good results. Providers remain more comfortable with the habits of a guild, where each craftsman trusts his fellows, than with the demands of the Information Age. Collegiality is too often mistaken for quality control. (p. 376) [T]he number one cause of medical mistakes is not incompetence but confusion. Although outright negligence and incompetence certainly exist, most treatment-related errors are caused by a poorly designed process of care that lacks safeguards to protect against anything less than human perfection. (p. 54) Millenson cites research sources for the following assertions: We have seen that only a small percentage of contemporary medical practices have been scientifically validated. At the same time, effective therapies can take years to make their way into common use. Medical textbooks are frequently outdated, and journals go unread or unheeded. Continuing medical education has proved better at providing doctors with memorable meals or vacation snapshots than at changing their behavior. The consensus conferences on “best practices” sponsored by the National Institutes of Health are no more effective at producing behavioral change than the free meals. Meanwhile, when a group of doctors is asked whether the care in a particular case meets the highest professional standards, the “physician agreement regarding quality of care is only slightly better than the level expected by chance.” Research medicine and everyday medicine often seem to exist in separate worlds. The public thrills to stories about a pill that may slow the aging process. But in everyday medicine we are just now examining the best way to perform the hip-replacement surgery that hundreds of thousands of Americans who are aging undergo annually at a cost of nearly $3 billion. … In illness after illness and disease after disease we have seen almost random variation in how different doctors treat patients with similar clinical symptoms. (p. 350) Consumer and third-party payer concern has shifted from issues of access to popular providers to measurable quality of care provided for the lowest cost. In the cost containment battles, who guards quality? Millenson traces the history of various fee for service and prepaid systems, as well as the development of the different quality-tracking efforts and quality improvement programs. Almost every sector of American society appears to be involved—individual patients and practitioners, health care professional organizations, health care corporations, accrediting organizations, government and nongovernment agencies, politicians, the courts, and the press. Albeit polemic at times, the account is so thick with documented details that, with its index and notes, it qualifies as a reference book useful in any health sciences library. Originally published in 1997, this edition includes a new afterword that continues the saga.