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Omnia pro aegroto

Clinical Pathways

by Lawrence R. Huntoon, M.D., Ph.D.

from an address to the medical staff of WCA Hospital in Jamestown, NY

March 24, 1999

It might surprise some of you to know that I am not opposed to clinical pathways per se. I am, however, strongly opposed to their misapplication and misuse. If individual physicians want to follow their own clinical pathways that they personally have established, they are free to do so now. But the Clinical Pathways crowd, of course, isn't satisfied with physicians making their own voluntary choices with respect to patient care: They want to force their rigid cookbook pathways on others. And that's where we have a problem. Clinical pathways may be a good teaching tool in medical school and residency. They may even be useful for post-operative patients in situations in which their needs may not be all that different-after hip or knee replacements, for example. What I-with many other physicians-am opposed to is making Clinical Pathways mandatory in the hospital. Clinical Pathways are totally inappropriate for medical patients, many of whom are elderly and have multiple and complex problems. Trying to fit these fragile and complex patients into a Clinical Pathway is like trying to force a square peg into a round hole-no matter how much you try, it simply doesn't fit. Clinical Pathways are not patient-oriented. They are disease-oriented and more specifically, they are DRG- and LOS-oriented. The DRGs and LOSs, of course, are things that are determined in large part by bureaucrats with or without M.D. degrees.

Now in order to get its foot in the door, so to speak, the hospital administration wants to convince us that Clinical Pathways are voluntary. But make no mistake, once the door is slightly open, it won't take long for the rest of the beast to wiggle its way in. You will note that the Clinical Pathways outline the plan to do what's called "variance tracking." Variance tracking means that those who do not follow the Clinical Pathway will be tracked. And pressure WILL be exerted one way or another to "encourage" us to follow those pathways. It doesn't take a mental giant to figure out that once Clinical Pathways are in place and bureaucrats start doing their variance tracking, cases that deviate will be referred to care evaluation committees for care that is not in compliance with the "standard of care." What the bureaucrats don't want us to recognize is that once implemented, Clinical Pathways will become mandatory by virtue of their acceptance as the standard of care in the hospital. It will never require a vote by the medical staff, it will just happen. . . . by design.

There are those who argue that this is just for the bad doctors. The good doctors who are practicing good medicine are doing most of the things in these pathways anyway and have nothing to worry about. We have, of course, heard the same argument applied to unreasonable searches and seizures conducted by government authorities. If you are not doing anything wrong and have nothing to hide, you have nothing to worry about when the authorities kick down your door without a warrant and turn your house upside down searching for whatever they can find. Thankfully, we have the Constitution to protect us from such unreasonable searches and seizures when we are not doing anything wrong. The point is that we need to limit the power of those who would rule us, instead of submitting to intrusive and unreasonable things like rigid Clinical Pathways. And, the truth be known, such Clinical Pathways will have an adverse impact on the good doctors along with the bad. Once a rigid written standard of care, such as Clinical Pathways, is accepted in a hospital, it will make it infinitely easier for attorneys to sue physicians for malpractice, based upon some minor deviation from the written pathway. If we agree to adopt formalized, inflexible Clinical Pathways, we will be providing the means for our own demise.

I don't want to waste a lot of time citing every little item that is wrong with a particular Clinical Pathway because trying to fix something that is inherently wrong is an exercise in futility. Suffice it to say that the hospital is looking at purchasing the Milliman and Robertson medical cookbook. I don't know if that is better or worse than the Betty Crocker or the Fanny Farmer cookbook. But, I have heard the pediatricians voice their concern that the Milliman and Robertson cookbook allows only three days to treat bacterial meningitis in pediatric patients. I suppose that's a little like baking a cake in 5 minutes. You have to wonder, when you hear such things, whether you're dealing with a baker or a bureaucrat who has never actually baked anything in his entire life. Therein lies the problem, of course, with Clinical Pathways that are centered around DRGs and length of stay.

The administration would also like to convince us that there is no framework or mechanism to deal with this "quality" of care crisis, and that is why they want to sell us on Clinical Pathways. But the truth of the matter is that there is a framework and there is a mechanism to deal with care that is not acceptable. We have care evaluation committees, and they are working quite well. The administration argues that this is all retroactive review, however, and that they need concurrent review for outliers in order to be effective. But that mechanism already exists also and is available to physician-run care evaluation committees. In the medical department's care evaluation committee, for example, we have, when necessary, done concurrent, real-time review of cases in the hospital from the day of admission to the day of discharge. This mechanism is available to any care evaluation committee in the hospital when a problem has been identified. We don't need intrusive and burdensome Clinical Pathways and case managers and utilization review coordinators to deal with quality-of-care problems-we already have a fair, reasonable and effective means of doing it. In addition, we have a proactive way of addressing length-of-stay problems. The length of stay in this hospital was shortened from an average of 9 days to an average of 6 or 7 days recently, and I would point out to you that this was accomplished without having to implement Clinical Pathways. What we don't need is to create a whole new cumbersome bureaucracy, which would do more harm than good and which would waste an ever-expanding amount of limited physician time and energy. I'm told that for all the talk of dire need for these pathways, there is on average only a single admission per month that is denied.

I have listened to the doom-and-gloom argument that "Clinical Pathways are a reality." And, "it might not be right, but that's the world we live in." We note that this very same argument was advanced more than 50 years ago in Europe when it seemed inevitable that the Nazis would take over all of Europe and, if they followed their strategic plan, the entire world. And to be certain there were physician collaborators who said, "Well, that's just the world we live in ... We'll just have to join the Nazi party and the Reich's Chamber of Physicians because that's reality." And, you might be interested to know that the Nazis also developed their own clinical guidelines or pathways that they expected their physicians to follow. Those clinical pathways included futility-of-care guidelines that were effectively carried out-resulting in the active killing of sick, mentally ill, and chronically ill patients by compliant physicians. Moreover, it was all done with the idea that they were improving the health of society. Fortunately, there were physicians who courageously resisted and who refused to adopt the Nazi's clinical pathways. Many of the Dutch physicians, for example, gave up their licenses, took down their shingles, and risked practicing medicine without the Nazi's permission rather than submit to the Nazi's clinical pathways. The lesson to be learned from this is that the course of events is often changed by a courageous few who stand up and say "I'm not going to do that because it's bad medicine, it's harmful to patients, and it's wrong!" It is never too late to do the right thing and it is always too early to do the wrong thing. As the Dutch physicians proved more than 50 years ago, reality is what we make it. To a large degree, we are responsible for our own reality.

If we choose to turn the practice of medicine in a hospital over to case managers and utilization review coordinators and box ourselves into these ill-advised Clinical Pathways, then we will only have ourselves to blame. The expansion of Clinical Pathways and the unprecedented concentration of power in the hands of a few utilization people is not a done deal. Despite the hospital administration's persistence in trying to force these length-of-stay driven protocols upon us, we have the ability to stop them. As physicians, we can vote them out. I would urge you not to give up what you have worked so hard and so long to achieve. These mandatory Clinical Pathways are an insult to our integrity, our training, our experience, and our individual practice of the art of medicine. If medicine were simply a matter of following a cookbook, a monkey could do it. Let's not let them make monkeys of us by forcing us to follow rigid Clinical Pathways.

The choice is ours. We must act now or live with the consequences.

Pamphlet No. 1067, May, 1999