So apparently Don Berwick is the nominee for CMS head.  I know and like Don Berwick.  No one can argue that he has done much to advance the fields of quality and safety.  But …

Don Berwick has the strengths and weaknesses of a zealot and proselytizer.  He believes a bit too strongly, and is unwilling to await data on his beliefs.  Bob Wachter wrote a brilliant piece about this in 2008 – The Great Quality Debate: Berwick’s Plea for Action vs. Evidence-Based Medicine

We must change how we deliver health care, but we must test our hypotheses.  We know too well that Robert Burns was right –

The best-laid plans o’ mice an’ men
Gang aft a-gley,
An’ lea’e us nought but grief an’ pain
For promised joy.

We see the traps of good intentions throughout medicine.  Swan-Ganz catheters should have improved critical care outcomes.  Estrogens should have decreased cardiac events in post-menopausal women.  Erythropoietin should have improved mortality in ESRD.  Rapid response teams should have improved safety. P4P should have improved overall quality.

But all those sentences are should haves, not dids.

So I must exercise some caution in this appointment.  Has Don learned from his enthusiasm.  Will he look at the data before mandating massive change.

If confirmed, he will have a most important position.  Can an innovator, rabble-rouser, quality and safety pundit make the transformation to bureaucratic leaders?  Will he proceed with appropriate swiftness yet appropriate caution?  Will he make his decisions based upon analyzing pilot data or as Bob Wachter brilliantly wrote 2 years ago:

On the other hand, in our zeal to “do something,” vigorously promoting or mandating practices with weak evidence risks squandering scarce resources, diverts us from better strategies, and subjects the safety field to the whims of opinions and biases. Berwick worries that our EBM pushback gives intellectual ammo to the dark forces of status quo. This is a reasonable concern. But given the public interest in quality and patient safety, I worry more that the distance between “this seems like a good idea” to “let’s include it as part of a campaign” to “let’s make it a new Joint Commission standard” to “let’s make it a state law” is perilously short. Accordingly, we should require awfully strong evidence that we’re doing the correct thing as we traverse that path, particularly when practices are complex and expensive.