Saturday, October 31, 2015


The current zeitgeist in medicine encompasses a wide range of “DO NOTs.” The kind that limits a physician’s input in the care of the patient. Without the shade of a thought that medical evaluation is being reduced to a set of guidelines; the “DO’s.” It all stems from the mantra that was proffered some time ago, “Hospital Stupidity Costs 85,000 Lives and $35 Billion Per Year.” After the much ballyhooed report there were fixes attached to the follies that created the problem of these “premature deaths” Everyone in the bureaucratic industry ran amuck with the paper in hand and started pointing fingers and laying blame across the threshold of sanity. The bureaucratic jungle is a flourishing canopy of protective veil that hides its own flaws to the detriment of all. The medical world was stunned, actually stunned by the reporting and not having any numerical values of their own, starting nodding their heads in unison when the media poured out their venom by using simple arithmetic to get higher ratings with the likes of “Medical errors kill enough people to fill four jumbo jets a week.” 

The foothold had been granted and the bureaucratic “dogs of war” had been unleashed. The entire medical care industry was soon tied up in knots with regulatory fiat. Many well-wishing physicians started to move in lock-step with the mandates and guidelines and other entrepreneurial spirited ones devised their own schemes to rip a page off the book of the incipient collective thought and created the terminology of the “public good.” One such entity; The American Board of Internal Medicine ABIM organization added to their once a lifetime certification examination the process of a 10-year recertification process and as the bureaucratic voices within grew their penchant for luxurious items and high salaries grew as well and they added the Maintenance of Certification process; a biannual process that reaped more than $130 million in 7 years.

While these spectacular shenanigans were going on the bureaucrats, policy wonks and legislators wanted to quantify every communication between patient and physician in a “meaningful” way through coding for billing. The CMS or Centers for Medicare and Medicaid Services gave the dog and pony show to the American Medical Association to come up with more lipstick on the pig with the ICD coding system. The ICD-9 codes numbered in the 17,000 for all medical diseases and each coded was fitted with an “appropriate payment.” Seeing a potential for a follow up revenue to the tune of $200+ million the AMA upped the ante by creating the 70,000+ coded-ways to describe medical illnesses with the ICD-10 coding system. This was a bonanza for the AMA, whose survival no longer seemed to depend on membership of physicians but on its alliance with the industry, governmental affairs cash cow and the data mining wonks. This coding system, they surmised would help the medical insurance industry to actually see how and when and where the illnesses occurred, maybe in the hopes that further legislations would help create more checklists and legislations for the common folk with the “DO NOTs” and give the insurance legitimacy in payment denials to the physicians and other care givers. A win-win for all they said.

Meanwhile the patient and physicians started to see barriers erected in the empty space that existed between them. Once the physician would sit and listen to the patient, eyes locked, hands touching to determine the malady, a soothing voice to comfort against the pathos of the cellular machinery now suddenly the space had thick walls of checklists, guidance, warnings, etc. erected between them.
Communication, once a simple process of speaking and listening, soon became a legal verbose jungle that had to be done for the perfect patient understanding of the expressed information. The voice that once said, “Hello Mrs. Smith” now was broken down into the nuance of implied meanings in the word “Hello!” Was there any implied empathy expressed in that word or was their implied coercion or threat? What was the meaning of the word "is" soon took reins. Empathy leaders sprung up all over the medical education landscape to fill that chasm. Linguistic experts were hired to determine the shades of the meaning within the meaning of the word itself. Meanwhile as the sentence was being analyzed by the billion-line codes of the software algorithm, the payment for services rendered by the physician was being held in abeyance till resolution was reached. Ah! no claim...denied! Each step of the communication with its many turns and twists had to be carefully scrutinized. Any deviation from the norm coded into the algorithm was rejected and the physician reprimanded for his behavior. At that point payment was not even on the physician’s mind because a much higher fine could be imposed for such a misdeed. This is where we find ourselves today. Ignorance is no bliss.

The universality of error-making, the inevitability of it and the humanness of it are now a forgotten knowledge. What remains is the “DO NOTs” and the “DO’s.” We have ceased to learn from errors. We only need the errors to find fault and point fingers of blame, because it soothes the bureaucratic mind to do so. The bureaucrats and other wonks seem to think that the current knowledge is the last drop from the fountain of wisdom and there are no more springs or pools of knowledge left to behold. That, what is, is IT! What they don’t understand that today’s knowledge will be supplanted by tomorrow’s discoveries and become laughable if not outright disdained. As they print out their mandates and grind to a halt the very machinery of human excellence, a hefty price will have to be paid, someday soon. Economics teaches us the same thing. Forever tinkering with fiscal policy will have its day of reckoning. Sometime the illogic of the rampant bureaucracy blunts even the Occam’s razor with its layers of Matryoshka Russian nesting dolls approach.

The rabbit hole has gotten deeper and deeper as more blinding rain water flows through it. The deluge from the bureaucratic mindset has flooded the lands and only an Arc will save us now.

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