Stewart v. McCaughey
I really enjoyed the last Daily Show before their 3 week break. Not because of Jon Stewart - he's usually good but I actually think he was wrong about a lot of stuff and didn't do well even when he was right. I liked his guest Betsy McCaughey. I ended up watching the entire interview twice all the way through, not counting extensive rewinds and
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I have no doubt that this is true in all cases, including the one where no performance metric exists. If there are government-imposed performance metrics you're going to do certain things to game the numbers which end up getting reported. If there are private, free market performance metrics like Yelp or RateMDs.com you're going to do certain things to the numbers that they're reporting. And in the absence of any reporting at all you're going to do things that you wouldn't do if there was a system that gave reports for what you were doing.
I completely accept that no system of regulation or reporting is perfect and that all rules will end up producing unintended consequences, including no rules at all. Historically, the consequences of there being no rules at all are the main reason why we've got rules now, and I'm not prepared to let some impossible perfect un-gameable hypothetical system become the enemy of a reasonably good or improved system. The fact that I can 'game' speed limits by finding clever ways to exceed them in certain cases does not mean that I'd rather live in a world without speed limits.
Like you I don't believe it's possible to set up uniform clinical practice guidelines that can improve in all cases on what a modern, well-educated, successful doc can do. I *do* believe it's possible to set up uniform clinical practice guidelines that can either avoid interfering with or improve in more cases than not on what modern, well-educated, successful docs actually do.
The immediate and ubiquitous result? People with 3 vessel severe disease who used to benefit from the operation suddenly couldn't find a surgeon willing to risk wrecking his rating by touching them. Instead, they went on to die of their untreated disease.
I recognize that there are bad solutions that cause more problems than they solve. And I recognize that the cardiac ratings situation might be one of those situations.
What I *don't* recognize is what this has to do with the creation of or adherence to end-of-life orders. I don't see what the parallels are. Are you saying that a patient with meddlesome relatives who used to benefit from doctor's counsel will suddenly be unable to find doctors willing to help them write a living will or DNR order?
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Nothing; two comments, two totally separate issues, which was why I left them as two separate comments.
Although I think if it takes me an hour to sit down and counsel a patient and their relatives about end-of-life directives, why should that be free, when I get paid to sit down and counsel them about, say, tingling feet? These are useful things that docs do. We've already gone a long, long way down the road of "if it ain't a procedure, it don't get paid." The result: brainless, scalpel-happy O.R. drones dominate the medical landscape to the tune of billions per year; thoughtful, cognitively active docs who are thinking hard about how to benefit their patients go right out of business. If you are in favor of single payer, you have to think about these issues because the single payer will be the decider of what is paid for.
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