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CURRENT CONTROVERSIES IN CRITICAL CARE |
It is naive to view technology as a mere means or tool to accomplish well-specified and established goals. This view of technology is naive because it ignores the institutional and human tendencies to "routinize" technology.1 The danger is that once one has a tool, such as a Swan-Gang catheter or a fetal monitoring machine, the world turns into a place where these interventions must be used. The analogy is that when the only tool one has is a hammer, then the whole world can become resplendent with nails. At the heart of the problem is not technology itself. Technology has made lifesaving critical care possible and accessible to most people. The potential for misusing technology is heightened when clinicians develop a technological understanding of self and world. A technological view of self and the world is that the world, situation, and environment are meaningless, chaotic places consisting of resources to be ordered, tamed, and controlled by technology. An alternative view is more holistic, that is, that our bodies, the world, situation, and environment come to us already with order and meanings. Technology can facilitate or disrupt effective order and functioning, or it can shore up disorder and breakdown. It takes good clinical judgment to decide when it is doing what. Our methods and tools influence our actions as much and sometimes more than our theories and scientific evidence influence our actions. Part of the problem is the ease with which technical interventions become routine, a well-oiled path that is no longer subjected to critical thinking in relation to each particular patient.
Compounding the problem are economic incentives to use existing or newly purchased technologies when the flow of money is available to pay for their use. The current legal investigations of the questionable practices by Tenet Health Care System and 2 cardiovascular surgeons in Redding, Calif, point up the dangers of financial incentives tipping the scale of prudence and judicious intervention over to the market equivalent of a "cash crop." Research has shown that the likelihood that someone will undergo cardiac bypass surgery can vary significantly among communities, depending on the way local doctors practice (see Table
).
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Snapshot reasoning or tunnel vision may also lead to the overuse of technology. Clinical reasoning by its nature is reasoning across time about the changes in the particular patient and changes in the clinician’s understanding of the patient’s condition.4 A quick snapshot appraisal of results of laboratory studies or diagnostic tests can dangerously overlook the particular trends and history of the patient. The clinician is obliged to ask what happened in the past that accounts for this patient’s laboratory values and test results. The test results may point to underlying pathophysiology or they may point to sequelae from drug therapies or other technical interventions. Clinicians are familiar with technological cascades that develop when one intervention causes new problems, and multiple corrections of failed therapies are required. The immediate history of the patient must be taken into account when drawing conclusions about the current effectiveness of interventions. Appropriate use of technology is most difficult in patients newly admitted from the emergency department when little immediate history is known. Social and physical stereotypes of patients may color the clinician’s evaluation of the present moment. Such stereotypes can be challenged by knowing the patient’s specific history and becoming acquainted with the patient’s/family’s understanding of the illness.
Clinicians can become dependent on clinical data that is costly to patients in terms of inconvenience, risk, and cost. Imprudent use of technology also leads to higher societal healthcare costs. Good intentions to be thorough with an eye to covering every possible problem can lead to overly aggressive testing and intervention. To counteract this, clinicians must carefully evaluate the utility of discovering the "possible" diagnosis, with the potential benefits to the patient, and the expense and risk to the patient for the diagnostic tests themselves. Will the test become unnecessary if one merely waits until a potential drug reaction has cleared or a clinical condition has predictably resolved on its own? Is there a good clinical intervention for the potential diagnosis? Will harm be created by not knowing the diagnosis immediately? What are the variations in diagnostic tests and interventions for the potential clinical abnormality? Benchmarks or variations in treatment patterns help here, but they cannot supplant the good clinical judgment of healthcare providers in relation to the specific patient. The Dartmouth Atlas of Health Care5 is a data base that analyzes treatment variations and healthcare consumption across the country and within each state.
When More Is Not Necessarily BetterFor the last 10 years, the Dartmouth Atlas Project has focused on accurately describing the distribution and consumption of medical resources in the United States. Funded by the Robert Wood Johnson Foundation, research from the project has been presented in the Journal of the American Medical Association, the New England Journal of Medicine, the New York Times, and to the U.S. Congress. Policymakers, journalists and the general public can access the study’s findings in book or CD format, or online, where browsers can view state-by-state charts or download data for further analyses.
If information is power, the Dartmouth Atlas Project’s research may empower healthcare consumers to become better informed about the care they receive. With this in mind, project researchers have high hopes for the future of healthcare in the United States. They envision a system that reduces unwanted and excessive medical procedures and encourages patient participation in healthcare decisions.
Above all, the project has revealed that the kind of healthcare Americans receive can depend very much on where they happen to live. "We typically find up to 10-fold variation in rates of common surgical procedures," says McAndrew-Cooper [Co-investigator and Editor]. "And we find similar differences in the per capita supply of resources such as hospital beds, medical specialists, surgeons and other hospital employees."
Perhaps surprisingly, however, project results reveal higher treatment levels in regions with more doctors and hospital beds but no marked differences in medical results. In other words, says McAndrew-Cooper, "More is not necessarily better." The example of Miami and Minneapolis illustrates this point: in 1996, per capita Medicare expenditures were $8414 in Miami, compared with $3431 in Minneapolis. But researchers found no measurable difference in the health or longevity between the 2 populations.2
Cost containment may clash with quality of care so that technology may be underutilized or overutilized as a result of commercial and cost-containment interests. The California Medical Association (CMA) and The California Health Care Association (CHA) issued a joint statement warning of the threats to quality of care posed by "economic credentialing," which they defined as "the use of economic criteria which do not apply to quality to determine a physician’s qualification for the granting or renewal of medical staff membership or privileges." In underdetermined practices such as healthcare, where complex and ambiguous judgments must be made on the basis of the best evidence possible, there is no way to bypass quality assurance by ongoing peer review of practice and the notions of good internal to healthcare practice. System design can be useful for setting limiting boundaries and guidelines, but it is unreasonable to imagine legislating and bureaucratically controlling all possible conduct. The fiduciary responsibility of the healthcare provider to the patient and the patient’s family cannot be avoided or bypassed safely. To this end, the CMA and CHA issued the following opinions on the dangers of commercialism and cost containment to quality of care:
The need to prevent profit motives from determining how and whether patients receive needed care has been addressed on both state and federal levels. Congress, via Medicare, has recognized that cost containment must be offset by quality assurance mechanisms to prevent interest in conserving fiscal resources from overwhelming the obligation for providing necessary, albeit costly, health care.*
In another situation, when a for-profit chain of hospitals established an incentive program to attempt to influence physicians to change their practices to maximize the hospitals’ profit from diagnosis-related groups, Congress moved to prohibit such schemes. There are many circumstances in which the most cost-effective way to treat a patient is also the best quality care. Excessive treatment may result in poor quality of care, as in the case of unnecessary surgery. . . .
Quality patient care must not be harmed by economic motivations. This only can be achieved by ensuring that the medical staff quality assurance mechanisms are supported, not circumvented, so that physicians can continue to work in the patients’ interests.6
Often, overtreatment or undertreatment are within the realm of reasonable clinical misjudgments. It is the professional duty of clinicians to reflect on and learn from such unavoidable errors in judgment. A self-improving healthcare practice requires ongoing improvement in clinical reasoning across time about changes in the patient’s condition and changes in the clinician’s understanding, as well as reviewing the best and most relevant evidence for each patient. External legal and procedural monitoring and corrections to the practice are necessary, but they cannot by themselves achieve the quality of patient care required by continuously improving clinical judgment that places the particular patient’s interests first. To achieve good clinical judgment, clinicians must be vigilant against subtle and not-so-subtle economic pressures and taken-for-granted technological imperatives.
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REFERENCES
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