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THE
NEW GALENIC ERA
IN HEALTH CARE |
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For over two thousand years all medical
thinking was based on Galen of Pergamon’s
textbook. Not only was it "the mainstream
of all medical thought" it was generally acknowledged, until
the Renaissance in the 13th century, that there existed nothing
else worth knowing. It now appears that we are entering
the new Galenic era in health care. |
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With little public notice a Seattle insurance
consulting firm, Milliman and Robertson (M&R) has, since the
1950s provided the insurance industry with advice on
premiums. The focus of national attention on this relatively
small firm (1,300 employees in 28 offices) was occasioned by their decision to publish medical "guidebooks" recommending
specific treatments for medical conditions, advising appropriate
length of hospital stays and other approaches for the health care
industry. These "guidebooks" have generated millions of dollars of sales
for M&R. The "guidebooks" have,
however, been less successful in convincing the medical
profession that any deviation from these guidelines is a legitimate
reason for their being censured at the same time that their
patients are being denied treatment.
Despite the protests of M&R that their "guidelines"
reflect only information gathering and are intended only as references
intended to promote efficiency and consistency they have, in
fact, been often applied in a Galenic fashion by the health care
industry and hospitals to physicians who are being stringently held to
the M&R criteria.
Now, for the first time, M&R is being taken to task, in legal suits,
for being engaged in the "practice of medicine" at
more-than "arm's length" from patients and responsible
for having caused alleged harm in the process. Jim Turner, a M&R
vice-president has been quoted as providing the disclaimer:
"We don't know how to treat patients, and we don't know about
the organizational structure of hospitals and health care
organizations. We look at the numbers."
James Schibanoff, Editor-in-Chief of M&R wrote to the Wall Street
Journal (October 3, 2000)
"The guidelines are evidence-based clinical tools designed to
assist health-care professionals in providing the best quality
health care while maximizing the medical community's efficiency in
the use of finite resources."
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| Evidence-Based
Medical Practice |
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The United States Government under it Agency for
Healthcare Research and Quality (AHRQ) has been developing what
they refer to as "scientific" information intended for
the use of agencies and organizations. The expressed
purpose of this effort is to "base clinical guidelines,
performance measures, and other quality improvement
tools." The "buzz word" being used to
describe the product is the "Evidence-Based Practice
Program" (EBPP). In this program the
"evidence" is collected by contractor institutions who
are charged with reviewing all "relevant" scientific
literature on assigned clinical care topics and produce
"evidence reports and technology assessments", and also
conduct research on methodologies and the
"effectiveness" of their implementation, as well as
participating in "technical assistance
activities."
As the evidence-based program has begun to issue reports it is
evident that semantics and glossaries need to be improved so as to
clarify their frames of reference. In addition the criteria
of clinical success are unclear. A significant concern
relates to the fast-tract medical therapy is on and the failure of
"evidence" to keep track of this. The very best
therapy may have been introduced last week. There are
different types of evidence and in some areas anecdotal
information constitutes the best present evidence. The
government admits that controlled clinical studies are rare.
Once again we have "guidelines." At what point
will "evidence-based" become a dictum?
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If you believe the statements from
AHRQ you would probably be someone
who would also have taken the United States government at their word
when the Social Security system was introduced. |
It can
be clearly seen from the image on the left that these
numbers were not to be used for the
purposes of identification.
What is the status of that assurance today? |
| State
Standards for Medical Practice |
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At this point in the discussion it should
not come as a surprise that a new Minnesota project is underway to
set "standards"
of medical care. With the cooperation of some physicians
a "Minnesota Model" of standard treatment and prevention
procedures has been created "which doctors are not required
to follow." While "models" for care have been
a Minnesota tradition (i.e. the Elizabeth Kenny treatment program
for polio) the introduction of "standards" of care comes
with Galenic overtones. Once again it appears that
organizations are poised to insinuate their own interests above
those of the patient.
"Programs" characteristically represent innovative
and creative approaches which, if successful, establish new guidelines
for medical practice. Medical "standards" are,
only too often, an excuse to deny care or a means of
censuring those attempting to innovate or create advancements in
the system. It took the medical profession almost 4 decades
to finally admit, in print, that the Sister Kenny treatment
program was a significant improvement over the then
"standard" therapy which was immobilization with
body casts and long periods of enforced bed rest.
The second guessing of physicians who
deal with the reality of treating disease on a continuing face-to-face basis in a
real world is understandably attractive to the cost-conscious managed health care
industry. Their justification for this behavior is the statement:
"We don't want to waste the patient's money."
Nowhere in this equation is there consideration given to the
patient's wishes. The bottom line is the answer to the
question "if the patient were spending their own money would
they pay for this therapy or program?" What's more, in
the case of M&R and Evidence-Based Programs, information
is not
provided on treatment options or document the potential
pitfalls of the therapies being touted. It is clear that Galen's
rebirth might just be accompanied by some Orwellian twists*.
Ref: Beason T: Decisions, Decisions
The Seattle Times, Business Section, August 13, 2000.
* George Orwell, 1903-1950 (b. Eric Arthur Blair), author of
"Nineteen Eighty-Four" (1949). |
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