In the late 90’s we started pushing for pain to be the next vital sign. These guidelines pressured many physicians to increase their opioid prescribing rates. Guidelines to regulate physicians and their clinical habits has become an epidemic since the evolution of EHR’s.
By the early 2000’s patients learned about online pharmacies and learned that they could raid their grandma’s stash of pain meds and the opioid epidemic started. Which was blamed on physicians.
Physicians responded by taking their chronic pain patients off of opioids which was society judged as inhumane.
It was only a matter of time before new guidelines would dictate how doctors should manage the discontinuation of opioids. That’s what we’re dealing with now, in 2019.
The only problem I see here is the creation of guidelines which do nothing more than micromanage physicians.
I am in favor of clinical guidelines when they are used as guidelines. But we’re all adults here – ain’t no guideline just a guideline. At least not when it’s created by the HHS or AHA or ADA.
It’s only a guideline when the content is shared among clinical professionals, by clinical clinical professionals.
But when you take a guideline and have a lawyer go to town on it, and use it in a court case to demonstrate physician incompetency or negligence, I would hardly call that a guideline. More like a noose.
Back in the 90’s we didn’t need a guideline to tell us that opioids would one day become a problem. Even the FDA only approved such medication for short-term use.
We weren’t the heartless bastards the patient interest groups made us out to be, after all.
The Burden on Primary Care
Guidelines don’t have a net-neutral effect on the practice of medicine. Most are written by bureaucrats or people with PhD’s and people with MD’s who have either never practiced medicine or only worked at teaching institutions.
I won’t whine as a Primary Care doctor about my workload. I don’t feel that my work is difficult or that I’m underpaid. I get to choose how much work I want to do for my patients based on how much time I have and how I’m reimbursed.
Give me 7.5 minutes for the patient who is on 4 different BP meds, 2 different types of insulin, an antidepressant, a birth control medication, and cholesterol meds, and I’ll be spending 6.5 minutes to reconcile those meds.
The other 1 minute will be spent ordering labs and reviewing labs.
So I’m not worried about me, the physician. I can move with the punches and still collect a juicy paycheck. Slurp. The burden in Primary Care with such guidelines is shouldered purely by the patient.
Patients are the ones who suffer from the guidelines meant to regulate physicians.
All of us are as much patients as we are doctors. The state medical board who is regulating my professional license supposedly also represents me as a patient.
The HHS who issued this guideline might be clueless to how Primary Care is practiced in the US. Because not only do I have to read this entire document and make sense of its clinical jargon, but I also have to completely change my workflow and patient scheduling in order to figure out a way to implement their guidelines.
These organizations who supposedly represent patients might look stellar because they “responded” to this supposed crisis but they are punishing the exact population whom they are paid to represent.
You cannot take the 8-hour workday of a doctor and add an extra workflow to it without taking away something from the patient.
Whether the HHS likes to believe it or not, they voted that pain management takes precedence over insulin titration. That me referring a patient to mental health upon off-titration is more important than counseling my teenage patient on safe sex practices.
I am sure that no drug company had any doing in pushing the legislative bodies to force such guidelines.
The Real Patient Advocate
The only group of people who don’t aim to exploit patients are doctors.
Sure, some among us will perform unnecessary surgeries and infuse chemo to half-dead patients. But we didn’t start out doing that. We’re doing that because we are anesthetized to caring about the patient.
When you see 30 patients a day as a specialist, you are dealing with quantity not quality. Even if you are able to remember your patient’s names, you are a cattle farmer, not the physician you started out to be.
Insurance companies exploit patients.
The drug companies exploit patients.
The medical boards manipulate patient sentiment.
And the health media – whoa!
I, the physician, care only that my patient suffers as little as possible using the tools available to me.
But cut my face-to-face time with the patient in half and I’ll be forced to reach for the quickest solution: the pain med, the statin, the weekly immunosuppressant infusion, or the surgery.
I drank the Kool-Aid in residency when even my most well-intentioned attendings were trying to convince me that our healthcare system works. That something in it made sense. And that as long as I am a diligent doctor, my patients will enjoy better health.
Bullshit. Don’t put that shit on me and don’t place the blame on me when I see my patients get fatter, sicker, and use more and more medication. That wasn’t my doing, that was my training. That was me trusting the policy makers, the guideline creators, and the post-doc PhD nerds who know nothing else to do but torture animals in a lab.
My training has been all about making the patient dependent on healthcare. Empowerment my ass. “Shared decision making” – come on, how did we fall for that?
How many years of reprogramming would I have to go through to teach myself how to empower patients? And who will support me in that process? Guidelines which micromanage physicians help our clients, they create more patients, not something we set out to do as doctors.
Patient empowerment is synonymous with patient education. It’s about telling the patient that their health has nothing to do with healthcare. That coming to the doctor doesn’t make you healthy.
That patients have the ability to make their own health decisions without having to suffer the crippling fear which our health media feeds them.
To Avoid Complaining …
I know that my writing sometimes comes across as though I’m bitter about my profession or that I’m complaining. Lemme check you on that.
I love medicine. The practice of medicine, being a physician, still in love with it. I love learning relevant shit which I can actually apply to my patients to help them enjoy their ideal definition of health.
This is exactly why I refuse to sell out and just take the highest paying job and pocket the dough, pushing insulin on insulin resistant patients. It’s why I want to talk about this stuff even if half of the stuff I say might be wrong – I’m sure I’ll learn.
So, let me not just mention the problem, let me discuss the potential solutions.
First, I think that as a rather small community of physicians, which we are, we can self-regulate each other. If anything, the lack of external regulations would bring us closer together.
We also have technology at our fingertips. If we didn’t have so many regulations preventing us from using it. Companies like openxmed allow us to create internal algorithms and workflows to better help our patients.
As a physician I have enough faith in my ability to keep learning. I don’t believe that I need micromanagement by a medical board or a board certification body in order to improve my skills as a doctor.
But, I need time to learn. That’s on me. Let Big Medicine do whatever it wants – I’ll cut back my hours as needed to maintain my independent time for learning and self-improvement as a physician.
2 replies on “Guidelines to Regulate Physicians”
Great post! What most people miss is the multitude of different agencies that sit over medicine. Each of them puts forward requirements that seem reasonably innocuous to them because they should “only take a minute”. Such decisions are made in a vacuum without considering the other agencies that are doing the exact same thing. As it all adds up, they are decimating the doctor-patient visit. Thanks for speaking clearly to the heart of the insanity pervasive in health care. There are a lot of physicians like you that love to practice medicine, but feel so beat up by the system.
Apparently, as the rumor goes, cash medicine gets rid of a lot of these oversight agencies. And I believe it but have a hard time digesting it. In theory it sounds amazing to see a patient, get the cash for the visit and order whatever they need and have them shop for the best cash prices for those occasional services.
We’ll see if that’s the case. It has been so when I do my own telemedicine with my own patients. But I hope that’s the case too if I ever decide to open my own private practice.