by Del Meyer, MD

This month we pay homage to academia, the ivory tower of medicine. We've invited Dean Lazarus of UCD for an annual message to the practicing physicians in our community.

We've all passed through academia to obtain our medical diplomas. Most of us have been through one of the hundred twenty six medical schools and then possibly through one of the 155 academic centers with the 4287 postdoctoral training programs. This cross breeding has produced a half million physicians and surgeons each with a unique learning experience dealing with patients' illnesses in a very personalized way. This wide variation in care is frequently confused with inappropriate care and even unnecessary care. To bring order to this disparity, the various specialties have designed some guidelines of care as an educational tool. This is much like going to a medical conference and coming home with a line of reasoning on the disease discussed. However, the guidelines have now backfired.

As we have previously discussed in these columns, physicians at specialty meetings have expressed concern that practice guidelines may be used by attorneys for ulterior purposes. Not following a guideline would almost be like res ipsa loquitur, the action speaks for itself. In other words, you are guilty, no further proof of negligence is required.

Edward Felsenthal (WSJ) reports that doctors are finding that they can get burned by cookbook medicine. Recent court cases, as well as a Harvard University study of 259 malpractice claims over 13 years, suggest that written guidelines on how to treat particular medical conditions have become powerful weapons for plaintiffs in malpractice cases. Where plaintiffs once had to rely on hired experts to argue that a procedure was botched, they can now point to official treatment recipes issued by physician groups themselves. New York Plaintiffs' lawyer Stephen Mackauf states, "Lawyers like me are using them in court all the time to say, `Gee, your own organization says this is a minimum standard of care, and you didn't follow it.'" They cite a dental case that didn't follow the AHA guideline for antibiotics in heart murmurs. The case was settled out of court even though the standard should not have been applied inasmuch as the woman's infection was caused by a non oral pathogen and probably would not have been altered by following the guidelines.

Troyen Brennan, a health-law expert and an author of the Harvard study states that ironically, doctors have embraced and developed guidelines in recent years, believing they could be used to fight malpractice suits. The Harvard study, however, revealed that such guidelines are about three times more likely to be used against doctors than in their defense. Richard Turbin, a Honolulu plaintiffs' lawyer, says that without the breast-cancer guidelines, he could not have won a $1.5 million arbitration award on behalf of a woman who died of the disease last year. The study warns that the rising use of guidelines in malpractice litigation could chill physician interest in writing new ones.

Practice guidelines, written by local practicing physicians, have recently surfaced in hospitals in this community. It has been stated that if the guideline doesn't apply to your patient, just don't use it. On the other hand, Dr. David F. Lobach at the American Medical Informatics Association states that there are too many guidelines for a primary care physician to keep up with, much less implement without computer technology. Even with his computer program in diabetes, the compliance increased from 15% to only 40%.

Guidelines do make it easier for non licensed allied health persons to practice medicine. A number of years ago there was a person in Michigan with no medical education who was able to practice cookbook medicine for a good amount of time before he got caught. Even in retrospect after he was arrested, his patients praised him for his kind and sensitive manner stating they got good care.

Attorney David Galie, of FREEMAN & GALIE in San Francisco, whose practice is in large part defending doctors in administrative actions, informed me that most doctors don't have a clue as to what is coming down the pike at them from the California Medical Board, MediCal, MediCare, National Data Bank, hospitals, and various fiscal intermediaries.

A great national tragedy is in the making that most of us don't yet comprehend. The world's most noble profession, which attracts the most brilliant minds and the most talented students of our nation, spending more years in training than any other profession, is under attack. We continue to participate in hundreds of hours of continuing medical education by attending post graduate courses at academia and journal reading every year totaling an additional medical school education every twenty years. No individual stays in medical school or in medicine without a concern, commitment, and responsibility to our patients extending beyond any normal work schedule, with excellence and continuous quality improvement as our middle names. And our critics state our quality of care is less than optimal. We have achieved the most advanced level of medical care found any where in the world, and if more funds were available could even achieve a higher standard of care, and we are told to obtain less diagnostic tests, fewer consults, and procedures. We are the worlds best physicians, clinicians, researchers, teachers and professors garnering more Nobel prizes in medicine and physiology than the rest of the world combined. Rather than hang our head in shame, let's look at the problems as perceived by society, deal with them, and get on with our mission of the best possible care for those impaired, sick, and dying, at a price we can all afford.

While our specialty societies rethink the guideline strategy which has been subverted to cookbook medicine, our modus operandi should continue to be our high level diligent practice, a few hours of journals reading a week, and spending a week each year at some academic center to continue our striving for the best and develop our own personal practice patterns and guidelines. We can then defend them in any court of law or court of public opinion.