Practice Standards: Implications for the Internist

Abstract

Pressure for national standards of medical practice is increasing from cost control initiatives, medical malpractice liability, and the desire to simplify complex practice problems. Good standards need to be academically sound, focused enough to be clinically useful, yet flexible enough to allow for the realities of practice. Standards have already been created by several professional societies, including anesthesiology and cardiology in internal medicine. Although physician education is primary, controlling the use of expensive new technologies is an unwritten but important secondary goal. While standards have reduced malpractice liability in some professional groups, some clinicians are concerned that standards will be too academic and unrealistic. Currently, third-party payers are watching the development of practice standards but are hesitant to use them as criteria for determination of reimbursement. The federal government has a major interest in practice standards as a means of both monitoring quality of care and controlling costs. A number of agencies are studying the development of standards and their implications for use. Recent articles questioning the usefulness of common diagnostic tests and even the routine physical examination have raised concern among internists that restriction of practice and reimbursement will follow. Some evolving standards, such as screening for breast cancer, seem to ignore the realities of clinical practice and may generate more cost than they save. Internists need to provide input as standards are developed to guarantee appropriateness and feasibility.