As we look back at 2018 we see a worsening atmosphere for practicing physicians. We have an epidemic of burnout. Many physicians are retiring somewhat prematurely. Some performance measures negatively impact patient care. Patients complain (appropriately) that too many physicians spend their time looking at the computer screen rather than the patient. Increasing patients commit suicide when their opiates are arbitrarily stopped.
All of these observations come about secondary to unintended consequences.
The road to hell is paved with good intentions is a proverb or aphorism. An alternative form is “Hell is full of good meanings, but heaven is full of good works“
Wikipedia
Health care is complex. Being a physician is complex. We must balance evidence and patient preferences. We treat diseases and patients and sometimes the best treatment for a disease is not the best treatment for the patient.
Everytime we see a new law or regulation, we should wonder what unintended consequences could result. Mandating electronic medical records without understanding how they would impact patient care, physician and nurse satisfaction and medical care costs is a prototypical example. EMRs seem wonderful in theory. They certainly have advantages when seeing patients whose exist in the EMR. But entering the data has become a horrible curse for many health care professionals. EMRs were not developed with enough practicing physicians. Dr. Bob Wachter wrote about this wonderfully in his book The Digital Doctor.
CMS looked at their data and decided that we have too many readmissions within 30 days. So they decided to penalize hospitals that have excessive readmission rates. This article points out the unintended consequence of this regulations – LOWER READMISSIONS LINKED TO HIGHER RISK OF DEATH
Regulators and insurance companies are impacting patient care through their well-intended rules. They do not seem think deeply about their rules. If they would use premortem examinations, perhaps we would have less of these problems. I wrote about this 2 years ago – Incentives without forethought
The continued problem of unintended consequences is one that many medical societies have addressed. I am most familiar with ACP. Their current Patients before Paperwork initiative makes many of these points consistently. Their Performance Measurement Committee (of which I am a member) consistently critiques proposed measures. Unfortunately, we continue to have difficulty influencing the decision makers.
We must all fight this battle every day. The lack of progress is frustrating, but we must not accept bad rules meekly. When the Emperor has no clothes, we should not pretend otherwise. Unfortunately, this is the overwhelming story in health care for 2018.
