walkitout (walkitout) wrote,
walkitout
walkitout

Charles Kenney, _The Best Practice_

Posted with infant on lap, so expect interruptions.

Kenney is writing the kind of non-fiction I usually like. I liked this a little better than Halpern's _Can't Remember What I Forgot_, but not by much. The challenge, again, was why.

First, the topic. I'm always fascinated by medical policy with a muckraking element and a book about the New Quality Movement in Medicine should have satisfied that. Yet it did not.

Second, the research and presentation stance: following the experts around and asking them questions. Like Halpern, Kenney is a little too wide-eyed and accepting of what he is being told.

Third, the attitude towards the topic. I like a little snarking, but with compassion. I like an author who wants to believe, but discovers problems. Kenney doesn't see any real problems -- it's all blue skies ahead.

I already posted about how he presented as "good work" a new decision not to charge patients for being goat fucked. Yes, it is better to not charge people who have been goat-fucked. The hospitality industry has understood this for a Long, Long Time. I'm a little shocked health care is just now getting that good old time religion. But I think what bugs me the most about this book is the screwed up priorities of the people the author is describing. And he had an opportunity to know better, because he knew about Wennberg's variations work, and the followup being down out of Dartmouth.

Think of it this way. Let's say you've got 20 people about to have a medical procedure, about half of whom will die on the table, and then about half of the rest will die because the procedure couldn't successfully fix whatever was wrong, leaving you with 5 people alive at the end.

You might think, let's fix the medical error; that will save half the people. Probably not, but it would then leave that other half for us to discover whether the procedure would have saved them at different rates than the ones who didn't die of medical error (probably not, but you never know).

But what if it turned out that the procedure really shouldn't have been done on 19 of those people anyway? It was sort of a recreational, we thought it might help, theory said it might work episiotomy kind of thing. Or like an unholy amount of cardiac surgery. Then, medical errors disappear into insignificance. Maybe if you hadn't touched any of them, you'd have 9-10 people alive. Maybe if you could figure out the one person who would benefit, you could operate on those two people. If you didn't eliminate medical error, at that point, you'd probably just be swapping deaths; if you could eliminate medical error, then maybe you'd have 11 people alive. But absolutely, not doing surgery on people it won't help anyway is a Really Great Thing. [ETA: I feel suspicious of my math here. Feel free to correct.]

And this book barely touched it.

Parallel examples can be created for a lot of medication, particularly in folk in skilled nursing facilities where polypharmacy runs rampant. Sure, eliminating conflicting prescriptions is good. But not prescribing stuff that won't help on its own is even better.

Besides, people who think that hospitals should be put in charge of the health of populations are just flat out crazy. And if Berwick thinks it's a good idea to put individual doctors in charge of Learning to Improve, I don't see how he hasn't just returned to the Bad Old Days of Make Up Your Own Practice Rules.

All that aside, there's some interesting information in here about some movers and shakers in health care over the last decade-ish, pushing hard for things like Bundles (detailed procedures for things like managing central lines, surgical sites, vents, etc.), electronic medical records, rapid response teams that can be scrambled within hospitals whenever a patient starts to decline, etc. The work being done by these people is important. It should be publicized. It needs to continue.

But for all the rah rah rah'ing, I came away from this one really profoundly depressed.

ETA: I think my problem was best captured with the whole attack on the status quo (I support attacks on the status quo) based on "Don't Just Stand There". See, I agree, action must be taken to stop the madness. But a lot of the madness is action. The correct stance is, don't just do something, stand there! Look and learn. First do no harm doesn't mean, don't change from the way you were taught because the way you were taught is perfect and the new way might be bad. That's, "Change Is Bad", basic toddlerese. First do no harm is, don't do questionable procedures. Don't prescribe crap. Don't do invasive testing on asymptomatic people. Don't do so much stuff.
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