Saturday, January 15, 2011

Form Police

I’ve been thinking of giving up my life as a surgeon and joining the opposition as a member of the Form Police. Now, you’ve probably never heard of them, but the recently passed healthcare legislation has a provision for the establishment of a review panel that will ensure that certain standards of care are maintained. In order to monitor these standards a cadre of healthcare professionals is to be recruited: the Form Police.

First a bit of background for the uninitiated. In the course of providing medical care for the sick and injured it is necessary that certain items be properly documented. When I started in medical school, thirty years ago, such documentation consisted of a complete, thorough history and physical, appropriate orders and daily progress notes. Upon completion of a hospital stay the patient was given discharge instructions, prescriptions and a discharge summary was generated, documenting the pertinent information relative to the just completed hospital admission. All these items carried a single purpose; to create a clear and concise record of an individual’s hospital stay so that other healthcare providers, (I believe they were called physicians and nurses in those days), at future dates, could review the events, which facilitated future care.

If surgery was performed, the surgeon would sit down with the patient and explain the procedure and document, in the progress notes, that the procedure had been explained to the patient, including all risks, benefits and alternatives. The nurse would then obtain the proper consent, based upon the doctor’s order and the surgery would proceed.

During surgery the circulating nurse kept a record of events, who was present, the procedure and any other pertinent information. The anesthesiologist generated his record of time the surgery started, medications administered, patient’s condition at fifteen minute intervals and any unexpected events. The surgeon dictated an operative report immediately following the procedure; the patient spent an hour in the Recovery Room (now the Post Anesthesia Care Unit of PACU), where another record was generated and then the patient returned to his hospital room or was discharged home.

But, times have changed. Our benevolent government, as part of its self proclaimed mandate to eliminate medical errors, has instituted a variety of protocols designed to optimize, standardize, epitomize, quantify, enhance and beautify many aspects of patient care. We have been given SCIP, the Surgical Care Improvement Program. This is a program that was instituted to ensure that appropriate prophylactic antibiotic protocols are followed as well as proper prophylaxis against deep venous thrombosis. There are other aspects to the program, but these are the two that are most pertinent to surgery.

Prophylactic antibiotics are given prior to elective surgeries to help minimize the risk of infection. They are most appropriate for procedures that involve placement of foreign material in the patient, such as a total knee replacement, or in cases where some contamination is unavoidable, such as colon surgery. The antibiotics are given preoperatively and for a brief period after surgery, usually stopped within twenty four hours after the surgery has finished. Instruction in proper prophylactic antibiotic regimens is part of every surgical clerkship in medical school and is repeatedly drilled into the heads of surgical residents.

Similarly, prevention of deep venous thrombosis (DVT) is an important part of the care of the surgical patient. Practices such as early ambulation, utilization of anti-embolic stockings or pneumatic compression stockings and administration of various blood thinners are all in the armamentarium of weapons for the fight against DVT. Such prevention is important because DVT’s can be life threatening if they lead to pulmonary embolus, which is a blood clot breaking off from a major vein and traveling to the lungs, which can cause sudden death. Once again, instruction in DVT prophylaxis is part of medical training at every level.

But, now we are being monitored; which is OK. The hospitals, however, have been given significant financial incentives to be sure that the SCIP protocols are properly addressed. I would have no problem with this if the personnel that have been delegated the task of monitoring SCIP were properly educated, so that they would be able to understand that patients that are on preoperative therapeutic antibiotics do not fall under SCIP. Such patients are being treated for active or presumed infections and are on scheduled antibiotics. Also, patients that are found at surgery to have an active infection, such as a perforated appendicitis will remain on antibiotics for a longer period of time than the SCIP prescribed twenty four hours and also fall outside SCIP’s purview.

Likewise, patients that have undergone surgery and have the potential for bleeding in the immediate post operative period may not be appropriate candidates for some of the powerful anticoagulants utilized for DVT prophylaxis. Intermediate measures, such as stockings, which carry fewer risks of bleeding and may be nearly as effective can usually be instituted, particularly if they are applied before surgery, which is, of course the hallmark of true prophylaxis.

But, I digress. All this bureaucratic insanity generates an enormous amount of paper. Endless forms that are designed to document compliance with the rapidly reproducing protocols, require constant monitoring to maximize physician compliance and hospital profits. The amount of paper is becoming so enormous that last week, after signing a stack of forms that made Mt. Everest look like a gentle hill outside Austin, I found my poor patient at the bottom of the pile, crushed to death. Of course such an event required even more forms be filled out and signed.

And so, we will have the “Form Police”. This elite squad of enforcers will be directly under the auspices of the Dept. of Health and Human Services. The team, composed of physicians, nurses, lawyers and health care administrators will be charged with the task of disciplining wayward healthcare professionals who are noncompliant with the current form requirements. Neatly outfitted in light brown uniforms, with a blue “FP” on the sleeve and shiny black boots, the Form Police will have the authority to make immediate judgment and mete out appropriate punishment to noncompliant individuals.

It is expected that first offenders will be let off with a simple warning, an admonishment to refrain from such dereliction of duty in the future. Repeat offenders will receive “Form Detention” which will put them in a room by themselves where they will be required to read the entire “form” manual, write “I will fill out all forms properly and in a timely manner” 1000 times on the blackboard and pass an exit exam before being allowed to return to their healthcare position.

The rare person that persists in “form” negligence will undergo a thirty day period of rehabilitation, during which the finer points of “form” etiquette will be driven home via twenty four hour, nonstop “form” video and audio. Completion of this “Form Boot Camp” will be mandatory for all multiple offenders and may be repeated as often as necessary until the healthcare provider achieves adequate levels of compliance.

Finally, incorrigible, unrepentant, hardcore “form” violators will be sentenced to three months of solitary “form” confinement. During this time the latest methods of persuasion, developed jointly by the CIA, Israeli Secret Police and Pre-school Monitors, will be utilized to give the offender one last opportunity to comply with proper “form” protocol. Those deemed incapable of rehabilitation will expelled from healthcare permanently.

And so it’s good-bye surgery, hello Form Police. I figure that the income from extortion alone will far exceed the meager reimbursement I now receive for saving lives and stamping out disease. And I will be performing a great service for all humanity.