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    Friday, May 8, 2009



    The WSJ ran several letters received in response to Groopman and Hatzband alarming data- most from “quality professionals” pointing to 30 years of data in the Dartmouth Atlas showing widespread variation in the quality of care in many common chronic conditions. The Rand Corp statements that patients receive only about 56% of recommended care is also quoted. This widespread U.S. variation in healthcare is equated with low quality, injurious and costly medical care by these quality professionals instead of Groopman’s “what is best sometimes deviates from the norms.”

    One letter writer from San Diego pathetically wrote that “Drs. Groopman and Hartzband state very well the dangers of general mandates in the practice of medicine. At our institution we are very concerned about the emergence of multi-drug resistant microbes, and we designed a treatment regimen for community acquired pneumonia to avoid certain antibiotics notorious for causing antibiotic resistance and Clostridium difficile infection. We were informed, however, that if we varied from the prescribed medication directive we would be out of compliance and suffer the consequences. Naturally, we caved to the pressure. Long-term consequences are not involved in the ‘metric.’"

    But not answered adequately by these letter responses are the lack of outcome studies showing proof that the use of process quality measurements or metrics will improve morbidity or mortality in the real world. This unfortunately if addressed by the letter writers was not printed in the responses.

    The devil in the details of “quality care” outlined by the letter-writing physicians is what the medical expert can use in his defense of the defendant physician “straying from the guidelines as we’ll see in a later chapter.

    These devil in the quality details are:
    • First, the federal incentive program entitled "pay-for-performance" is really "pay-for-process."
    • Rather than measuring and rewarding improved outcomes, the program which is also being adopted by state and private insurers rewards adherence to practice guidelines.
    • Second, there is little or no evidence the quality measures that comprise the guidelines correlate with improved outcomes, and
    • If government and private insurers want to penalize and reward physicians for their practices they should measure those physicians' outcomes.
    • This is dramatically demonstrated by the UCLA study mentioned above of over 5,000 patients at 91 hospitals published in 2007 in the Journal of the American Medical Association found that the application of most federal quality process measures did not change mortality from heart failure.
    One must agree that using quality guidelines seems like good thinking superficially, but these rigid rules cannot fit the complexity of the human condition.

    I spoke about this matter with my good friend Dr. Bernie Rosof, a pioneer in the Quality movement about this controversy on P4P guidelines. He replied that
    • These guidelines must be nimble, i.e. they must quickly change as the profession believes in a new guideline prompted by an appropriate study.
    • In addition he believes that more recent guidelines should based on both process and outcome studies.
    • And finally the new money on the health care scene will drive us to do more comparative studies to make sure the guidelines are appropriate and to drive down the high variability that is now the current scene in medical care.
    What we need most are evidence based outcome studies showing the benefits of quality metrics on mortality/morbidity in concert with the application of such studies rather than experts getting together to hammer out compromised clinical practice guidelines as exists today.

    Until such time my opinion as a medical expert based on a reasonable degree of medical probability is that a good defense can be offered to a physician defendant on an individualized basis.


    Book I - “Medical Malpractice Expert Witnessing: Introductory Guide for Physicians and Medical Professionals” (Hardcover) by Perry Hookman, MD (Author) : 592 pages.27 chapters. Publisher: CRC; Potomac Press; Language: English ISBN-10: 1420058959 ISBN-13: 978-1420058956; Dimensions: 10.1 x 7.1 x 1.4 inches; Shipping Weight: 2.6 pounds; price $239.95.
    For author information visit; for book purchase visit

    Book II –“Medical Expert Testimony: Advanced Syllabus for Physicians and Medical Professionals”
    (Hardcover) by Perry Hookman MD (Author) 32 chapters; 936 pages. Proj.Pub date Spring 2009. Publisher: Potomac Press-CRC; ; Language: English ISBN: 978-0-9817570-0-1; ISBN:10:0-9817570-0-6 - Barcode (9780981757001.eps) Dimensions: 10.1 x 7.1 x 2.1 inches; Shipping Weight: 3.0 pounds; Price $289.95; includes CD-ROM. For author information visit; for book purchase visit

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