Do protocols and guidelines really offer safer and better medicine?

The instruments were indicating to the two co-pilots at the controls of the Airbus that they needed to pull back on the stick.

They held back on the stick for 54 seconds.

This is the position they were in when the Air France jet plunged into the cold water of the Atlantic killing everyone on board.

The fix?

Recognizing that a protocol or guideline might be giving them wrong instructions, seeing that there might be a stall occurring and the airplane was falling out of the sky -- by applying basic airmanship learned during the early hours of learning to fly -- push forward on the stick, gain airspeed, and fly the airplane out of the stall.

So does this happen in medicine? Are we putting patients in the ground by following protocols and not practicing medicine?

Certainly, protocols have revolutionized patient safety in hospital settings. From central line infections, ICU ventilator management, antibiotic use in surgery, suicide prevention with ER counseling -- there are too many to list.

And these successes have lead to a plethora of committee created guidelines for care and protocols. A physician recently spoke at the American Medical Association meeting that one of the largest and most well respected hospitals in the country now has a protocol and guideline for a Whipple procedure!

This is a complex surgical procedure relating to bowel and pancreas resection and the protocol covers the entire hospital stay. Can a committee really dictate all of the ins and outs of a hospital stay of 10 to 14 days duration?

The protocol discussion has also become a huge issue in the mid-level provider debate. When individuals are attempting to practice medicine without the complete training of a physician, nothing is better than a set of rules to follow. And for visits like well child visits and hypertension management -- these work very well.

But can you really develop protocols and guidelines for complex medical procedures or illnesses?

Or more importantly, what parts of your own healthcare would you want managed with a protocol?

I know that if I'm really sick I want a pilot at the controls that can recognize that this time the protocol doesn't apply.

Because at some point in my life my body will be in the situation of flying out of La Guardia, hitting a flock of geese, and having to be hand flown without power into the Hudson River.

They don't make protocols for patients like me.


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Location:At the AMA Interim Meeting in New Orleans

Patients feel "Medicare is my benefit!"

TMA President Dr. Bruce Malone tells a patient story describing that "Medicare is my benefit!" His testimony was before a reference committee at the interim meeting of the American Medical Association in New Orleans, Louisiana. Dr. Malone was speaking in favor of direct contracting -- allowing patients a choice to see any physician they want regardless if that physician participates in the Medicare plan or not.

Stark Contrast: How the Democrats are missing again on healthcare

Recently Pete Stark told a group that the Republicans were trying to shove a massive bill to repeal the Obamacare Bill down the throats of the Democrats.

The Republicans two-page bill stands in sharp contrast to the 2000-plus page bill pushed through by the Democrats last spring. So Mr. Stark, what's different now?

I had the pleasure of spending an hour with Congressman Stark last March right before the historic vote that changed the way healthcare is financed and delivered in this country. He was adamant at that time that he would never "support" the Senate version of the healthcare bill.

Well he did.

Now this isn't the first time or probably the last that a member of Congress has changed their mind.

But fundamentally the reason he voted for the bill as did most of the Democrats was political: legislation had to be passed regardless if it was good or not. Nancy Pelosi's health care chief told me in a meeting the same day that "we know its not a good bill but we can always fix it later."

The Republicans have taken the position that repeal is the best choice, followed by not funding key elements of the legislation, and probably hoping that the Supreme Court will rule that the Democrats overstepped their interpretation of the commerce clause. The latter is the ruse that allowed them to pass the bill in the first place.

So now the Democrats believe they have to defend the bill they created. And reforming the legislation would be tantamount to failure.

The American Medical Association adopted a recent slogan from their Texan brethren when they started preaching the "Keep what's good. Fix what's broken" mantra. But this lobby tactic would assume that either side would want to fix anything in the first place.

Neither the Democrats nor the Republicans are really motivated to reform the legislation. These polar opposite positions place American patients right in the middle of a stand off -- most likely to be killed by "friendly" fire.

Democrats are missing the boat here by not learning from prior mistakes and following the advice that we talked with Pete Stark about a year ago. Give patients some protections from preexisting illness and right of recision rules from the insurance companies and allow them to keep their doctor.

That's really what patients and taxpayers want.

And, tank the rest of the 2000 pages of the bill.

The 18 thousand new IRS agents, the Independent Medicare Advisory Panel, the criminalization of billing issues, the mandate on individual coverage, the expansion of a broken Medicaid system -- all of this needs to go away. None of it will improve the health of America.

But sadly it is doubtful that anything good will happen in Congress this term related to healthcare.

Yes, the House can refuse to fund key elements of the legislation...they can vote to repeal the bill. But the Democratically controlled Senate and the sitting President will not allow the bill go away.

In the meantime Washington bureaucrats will be turning out millions of pages of rules and regulations that will immortalize Obamacare for millions of patients.




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Conversation with a Health Care Leader: the past and future of health reform with Dr. Susan Rudd Bailey

Today we talked with Susan Rudd Bailey, MD who is the President of the nation's largest state medical society about the genesis of federal health reform and what she expects for the future.  This nationally known leader of the Texas Medical Association is candid in her discussion of the role that physicians and patients play in determining the ultimate outcome of the recent federal health regulation.  She also discusses the implications of the flawed funding mechanism for Medicare -- the so called "SGR".

Dear Santa: I want a Medicare fix

Well it's that time of year again.

No, not Thanksgiving or Christmas, or even the venerable Interim Meeting of the AMA. It's the time that physicians nationwide anticipate another mandatory cut in Medicare reimbursement rates.

This time the recurrent temporary fix will result in a cut of 23.6 percent on December 1st. Assuming political gridlock the rate will fall another fraction of 6.5 percent on January 1.

History dictates that there will be lobbying, bluffing, puffing and even some "take my toys and go to my room" childish attitude but in the end Congress will create another "fix". In the past this has been to stabilize payment rates to a Victorian-era fee schedule (ok, 1997 or so) and set up an expiration schedule that again is measured in months.

But this year might be different. Or, at least it threatens to be.

American voters stampeded to the polls to vote out the status quo in favor of a new Republican House and a "lack of cloture" Democratically impotent Senate. Many of these new Republicans campaigned on the promise of fiscal responsibility (read: make the Bush tax cuts permanent and curb spending, including entitlement programs).

The Republicans have as a group pledged to cut $100 billion in January.

Now enter the AMA.

This association is again lobbying for a fix -- though now it is not the "permanent fix" but rather a tempered 13-month patch to give physicians at least a year to worry until the next SGR induced armageddon.

But will this new Congress support the AMA proposal? I don't think so.

Rumors abound to the cost of the AMA idea but it ranges between $17 billion to upwards of $20 billion. I'm certainly not an insider, but a new Republican congressman might find it challenging to explain to those tea party goers about why one of his first actions was to vote to support a double digit entitlement extension.

The other options are also mind stretching.

The lame duck Democratic controlled body could pass a 1 month extension and leave it up to the Republicans to spend the money in 2011. Or, they could use the pout strategy and just grind out the final month with the cut in place with Medicare physicians having to deal with a very arduous Christmas present.

So what will happen? It's anybody's guess but a likely outcome will be a compromise of sorts.

It would be fairly easy to disguise a three or four month fix as part of a January revenue bill to add some permanence to the Bush era tax cuts. This would of course create another type of March Madness, but it also would only cost a minuscule five or six billion. Chump change.

There is the issue of raising the debt ceiling that will have to survive a potential Senate filibuster by one of our new freshman Kentucky senators who will be calling for a balanced federal budget. This ophthalmologist turned tea drinker may not see eye to eye with adding more money to a spending bill -- even if it would be good for patients.

But no one said it would be easy.

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Location:37,000 feet over Arizona