Friday, May 30, 2008

Irreconcilable Differences

Verapamil SR 240mg/day. Protonix 40mg/day. Aspirin 81mg/day. Xanax 0.5mg PRN. Zocor 20mg/day.

Not an uncommon list of medications for one of my patients. All important, some needed daily and some can be missed for a little while. But, this is just a list, not a set of instructions for building a nuclear power plant. This type of list is a good indication, a set of road signs if you will, of what other issues a patient I am asked to see faces other than their surgical problem. How I need to deal with each of them varies, depending upon the medication, the patient, their anticipated surgery, and the length of time they will be hospitalized.

That's a funny little game we like to play, called "being a doctor."

However, the bureaucratic bastards otherwise known as The Borg JCAHO don't want us to use our brains. They view the patient's list of medications as the Word of God, not to be tampered with, to be accepted as Gospel from the patient. Of course, this view is not to be tainted with the suggestion that, well, some patients really don't know which medications they take, or how often, or what dose is involved. It is THE LIST!!! It is to be FOLLOWED!!! And, most importantly in this bureaucratic sinkhole our hospitals are collapsing into, it must be RECONCILED!!!!

Yes, comrades, in its infinite wisdom and compassion, the Politburo JCAHO decided to mandate that every patient who is cared for at a hospital must have a Medication Reconciliation Form filled out. In theory, this is a pretty good idea --- the folks caring for a patient should know what meds, at what doses, a patient is taking. The "reconciliation" part comes in deciding which meds to continue, which ones to stop, which ones to change, etc when a patient comes in the hospital. For the majority of my patients, nothing changes; they continue on as before surgery with no alteration in their medications other than the addition of some pain medication. For others, I may need to find an IV form of one drug or another while they are NPO.

Once again, this is where that little thing called "medical school" comes in handy. We then must "reconcile" the patient's medications when they are sent home.

Of course, bureaucrats being what they are, this whole reconciliation process simply cannot be accomplished without that most sacred instrument, The Form.

And, of course, since bureaucratic policies expand inexorably to smother all sentient beings (particularly aggressively when there is no evidence for their usefulness), The Form must now be completed for every patient having a purely outpatient procedure. That means if you come in for a hernia repair, some poor nurse has to spend an inordinate amount of time listing each medication you take, at what dose, at what time, and when you last took it --- including nonprescription items such as vitamins an ibuprofen --- and in the case at our hospital then enter this into ENIAC the 1970's era computer system. I am then required to check off each and every medication, vitamin, and herbal supplement ingested by this person after I complete a 30 minute operation. I am surprised that I am not required to review their dinner menu and martini recipe as well.

Now, as we all know comrades, The Form is not and can never be inaccurate in any way, because it has been handed down from on high by the Central Committee our new JCAHO overlords. Even if I know that the medication reconciliation form contains errors, attempts at correcting them (i.e., truly reconciling the form with what the patient is supposed to be taking) are akin to climbing the north face of the Eiger. And woe to the physician who doesn't complete, sign, date, and thumbprint with blood The Form in exactly the mandated manner. He is met with a response reminiscent of the way a Communist party apparatchik in the USSR viewed any form placed in front of his imperious nostrils --- to be sneered at unless it is filled out "correctly," with the definition of "correct" to be determined by the wind direction and how many fecal molecules made up his most recent fart.

Well, perhaps apparatchik is not the best term. Too much of a cliché. This whole process really carries the mark of Vogons. What, exactly, are Vogons? From The Hitckhiker's Guide to the Galaxy,

Vogons are one of the most unpleasant races in the galaxy. Not evil, but bad tempered, bureaucratic, officious and callous. They wouldn't even lift a finger to save their own grandmothers from the Ravenous Bugblatter Beast of Traal without orders signed in triplicate, sent in, sent back, queried, lost, found, subjected to public enquiry, lost again, and finally buried in soft peat for three months and recycled as firelighters.
Yeah. That nails it. JCAHO headquarters = the Vogsphere.

Sometimes I feel like I'm in some dystopian alternate universe a la Brazil, where there is really no thinking allowed. I am nothing if not a cynic (surprised?), so please take my rant here with a square cubit of salt, but I truly believe we have crossed the point of no return, and are now in a realm where process trumps everything. Process outweighs progress, patient results, or even common sense in the modern hyper-regulated hospital. And that will prevent us in the next decade or so from actually making real improvements in patient care.

I'll have more to say about process über alles in another post, but for now, here is a simple visual clue as to how I feel every time I have to fill out the sacred Medication Reconciliation Form.