Attempts to reform medicine and use standardized quality markers to pay physicians are driving up costs and endangering patients. Should medicine be about developing and respecting standards of care? Just that catch phrase \"Standards of Care,\" can mean something different to a physician who is acting according to her training and a business person who is doing cost benefit accounting. Both have a valuable perspective. But, medicine is not one of those professions where compromise is beneficial or desirable. The main reason is that diseases present themselves differently in each patient. Community acquired pneumonia in a robust college athlete is a nuisance and causes fever and sweats, makes you feel shitty. When the same pathogen takes up residence in an elderly man with poor circulation and COPD, the result is often fatal regardless of the treatment. So why not have quality markers for each situation? Simply put, you can\'t go there - there are endless variations on the same theme and only a person who is trained to observe the dynamics of an illness episode can fashion the best treatment on the fly. We spend billions training physicians to think on their feet - to marshal incredible amounts of data in real time and make adjustments that can vary from increasing a drug dose in a recovering patient, who may have experienced serum dilution from improved hydration to cutting the dose in half if renal failure develops. Basically there are two dominant approaches to diagnosis that are roughly congruent with the way that we predict the weather in the USA and the way that the British have been predicting the weather for centuries. Here in the USA we choose some pertinent parameters - like air temperature, barometric pressure, humidity and we come up with the most likely weather condition that would have those indices. When it works, it works well,but in places where prevailing winds change rapidly - like Boston - by the time our predictions are made public, the parameters have changed. For those unstable conditions, we need to go British. The Greenwich Observatory has kept records of the prevailing weather conditions according to latitude and longitude throughout the world - at least covering the navigable trade routes - these are indexed by chronometer time, so that a British weatherman can look up the place and time, and then search for a previous date with the same prevailing conditions. To find out what came next, the British weatherperson can then follow the text to find out what happened next on prior occasions. Even the most exhaustive list of parameters that are commonly measured to predict the weather has relatively few components - compared to the nearly infinite list of laboratory tests, radiology and cardiology studies, many of which require several hours or even days to become available. So the prudent physician is trained to begin with gross observations like the sounds of air passing (or not) through the lungs, chest x-ray and EKG to rule out common problems. Most of those studies will not matter eventually - after the fact. So, our cost benefit accountant asks the busy physician \"why did you order that chest x-ray, when you know that statistically it was likely to be of questionable value?\" To which the physician replies, well.. since you seem to know a lot about chest x-rays I guess maybe you are suggesting that I shouldn\'t order a \"routine\" chest x-ray when ever someone comes in squeaks and wheezes coming from her chest. The tragic failure in this encounter is that the cost benefit accountant isn\'t the one with the funny air sounds, which if he had them, he would expect his physician to be completely 100% correct making a perfect diagnosis. All we are doing is cancelling the other guy\'s work up and not taking responsibility for the same precision that we would expect if we were the patient with the same symptoms. Repeat this with every mammogram, Pap smear, hematocrit, white blood count, urinalysis, erhythrocyte sedimentation rate, blood culture, and immune globulin electrophoresis. There you have a dandy way to reduce the costs in at lease one column of your ledger. This is cool as long as you don\'t look at the last column where the final expense is tallied up. We have broad spectrum antibiotics that can wipe out most common germs in a few hours. We have drugs to goose a failing heart into improved activity, but what we do not have is any means to determine which tests to order that will have near 100% utility at a given time in a given patient with a certain set of symptoms - and who has not responded to the \"statistically most likely\" diagnosis and treatment gleaned from relying on a set of high yield tests that are highly correlated with diagnosing a statistically common illness. A glance at the standard curve is instructive. IF we consider the first standard deviation, which indicates that 66% of the time those high yield tests will result in a correct diagnosis that leads to a successful treatment and an uneventful recovery. The next less likely standard deviation from 66% to 91% would represent conditions that may have hidden complications that probably won\'t interfere with the most likely treatment - but there can be surprises since none of those conditions has been detected using high yield testing. OK, so there are a few booboos - no biggie - most of the time. It\'s when we get to the third standard deviation from 92% to 99% that we start to mistake the hoof beats of our most likely diagnosis as if they were coming from horses - when in fact we are hearing zebras sigh unseen and undetected. Here there is a high likelihood, 8% of the time, that our lucky treatment will fail completely - usually with no time to go back and make corrections. Nature is like that. Our carefully enlightened cost accounting has cost us poor results 26% of the time (between the first and second stardard deviations), and disasterously wrong diagnosis and treatment 8% of the time. Who are the bean counters working for? Surely not for risk management..... Maybe we could program a computer to start indexing human beings, but that is not even a remote possibility - we are stuck with relying on the expertise of a physician who has been trained by watching a senior colleague make judgments, attempt treatments and make corrections - in real time. Even fairly sophisticated diagnostic software is only useful to check on a diagnostic approach - to make sure that some vital test has been left out - and not to find out which tests not to do when the patient is new or failing. Instead of that, we have concluded that our physicians, having been lured inito making faulty diagnoses over 30% of the time, really don\'t know what they are doing - since we should all be in perfect health if we weren\'t abusing our bodies. We can learn how to stay healthy, so we won\'t need any of those nasty machines that people get put on right before they die. Of course, here again that mean old standard distribution trips up even the most dedicated dietitian: only 66% of the population are doing to have hips and knees and lungs that are fully adequate to sustain vigorous exercise over lengthy periods of time. We wear out not in. A fair picture of today\'s medical model has a patient at the center and a host of physicians at the periphery - with dozens or even hundreds of intermediaries in between doctor and patient. Each of those intermediaries got there by assuming or usurping a small (or not so small) piece of the doctor - patient relationship. First cam the administrators \"hey doc we can save us all a lot of money if you allow us to tell you what not to do and when not to do it -- at the cost of a very tiny portion of your inflated greedy income.\" The poor doc who agreed with the first cost accountant who suggested that chest x-rays were not routinely necessary was the index proband who spread the word that all you need to do to earn a pretty good living is to find a way to take over just a tiny bit of the physician\'s income - without having to take on any of the physician\'s liability. You just have to preach a good sermon on healthy living. Finally, what do patients really want from their physicians? The obvious answer is......nothing. People don\'t want to see doctors, or if they do need a doctor they want the least distressful and fastest treatment so that they can return to not wanting anything from a doctor - hopefully for a good long time. The doctors job is to provide fixer-upper services so that people can get on with their healthy living plans and make enough income to invest in patent remedies, or any of the other long list of vices to which human beings tend to fall err. The risk we are facing today is that the line of helping others between the doctor and her patient has become way too long. Each of those non-professional intermediaries has become very adept at proclaiming their right to and need to exist - to make up for the loss of the physician\'s executive capacity. Like many fault lines, this one has only recently become evident - the incremental loss of income (which, sadly, equates with the loss of prestige and respect) has begun to dumb down the profession - leaving whole geographical areas and socio-economic brackets derelict of any coverage. There are simply not enough mediocre doctors, para-professionals, and alternative healthcare workers to make up for that 34% of untreated or misdiagnosed patients - ultimately all of those people will have to get to a physician who can\'t or won\'t stint on performing a thorough workup to go back and find what was overlooked by the inevitable failings of statistics driven quality outcome driven theory of practice. Only if we can edcuate the germs and cancer cells to heed our new way of thinking wil any of this make a real difference.

The concept is so simple: find a confluence of power and money and find a way claim just a tiny bit of the profits - in the guise of working for the public good. The problem with this scam is that no one told the disease germs or the cancer cells to behave like silent conspirators. They never have and they never will. So eventually the doctors have become cash cows for all of those intermediaries who just wanted to take one little bit of the doctor\'s compensation to \"make the system work better.\"The overall cost of this efficiency reform: 40% of every health care dollar goes to the administrators and the only way to make the system cost effective is to screw the doctor over and over and over. So the insurance companies and the government regulators are actually working for the germs and the cancer cells.Hope that helps you understand the bottom line in medicine. Pay the doctors and accommodate that reality or let the germs and the cancer cells take over for every bit you take from the doctors. in nature, fair is fair as long as you realize that nature always wins when you upset the balance of power. good luck suckers......