A new patient consult, "Typical atrial flutter, age 65" the schedule said.
With a history of renal cell and a nephrectomy,
And an bleeding ulcer while on aspirin,
And a stroke (now better),
And polycythemia vera,
And a monoclonal gammopathy,
And a "low grade" lymphoma,
And a history of "bleeding" with the tiniest of scratches while on warfarin,
And a history of a hemolytic transfusion reaction,
And an EKG of atrial fibrillation a year ago,
And an EKG of typical atrial flutter now,
On no anticoagulant or aspirin,
On dialysis,
In in a patient who doesn’t feel the arrhythmia and is feeling fine.
"Management?" the consult read.
This should be easy, right? Just "Get With the Guidelines!"
More often than not, it is difficult to follow pre-defined guidelines (as the above case demonstrates).
More often than not, there are many, many independent variables that weigh on patient management decisions. Despite this reality, there has been a growing call for treatment standards, guidelines, protocols, and checklists by those tasked with paying for health care. Payers want perfect outcomes or they will not pay for care, as if people are widgets on a production line with interchangeable parts.
But how may people exist in the center of a Bell curve? How many more do not?
Current models for health care delivery attempt to make generalizations about treatment regimens for as many people as possible because payers want to receive as much value as possible for every dollar spent. On the surface, such an approach seems so logical. But for the majority of individuals who fall outside the center of normative data sets upon which standards, guidelines, protocols and checklists are based, the doctor and patient must face the reality that there are often no perfect answers for treatment.
In these cases we look into each others’ eyes, weigh what we know and what we don’t know together, then join hands and walk into the uncharted treatment waters of real life.
This is OUR standard, our expectation, our reality…
… and one that clashes head-on with pre-specified guarantees of outcomes.
-Wes
