DONALD J. MURPHY
Money, and Malpractice
Expectations for outcomes data and resulting practice guidelines are high for many health care professionals. I, too, share enthusiasm for the critical analysis (i.e., outcomes research and guideline development) that has emerged over the last two decades, but I also have doubts about the promises of this movement.
From a clinician's perspective, I will focus on the practical obstacles to guidelines' reaching their potential. I choose guidelines because their recommendations for action are unequivocal. If guidelines are to enhance health care yet control costs, professionals and outcomes researchers must overcome most of these obstacles. Obstacles can be eliminated, but it won't be easy.
Many factors influence physicians' compliance with guidelines. These include their attitudes about utilization review, 1 government regulation, 2 physician profiling, 3 uncertainty, 4 private industry, 5 clinical autonomy, 6 sponsors of the guidelines, 7 necessity and appropriateness of care, 8 opinion leaders, 9 conflict in guidelines, 10 and the value of guidelines in general. 11 Patients' expectations 12 and the sociocultural milieu are other important factors. 13 No doubt many more factors exist that have not been studied.
This chapter focuses on three other factors that are frequently operative from a clinician's perspective. Investigators and clinicians are well aware of two of these factors, money and malpractice. 14 At some level, many physicians think about money and malpractice every day. The third factor, measurements, is not so obvious. A case study helps illustrate these three factors.
Mrs. Hart is an eighty-five-year-old with diabetes, a history of breast cancer, and advanced coronary artery disease. She had an angioplasty in 1990. Her angina and shortness of breath were stable until September 1994, when these symptoms accelerated despite near maximal medical therapy. The attending physician referred Mrs. Hart to a cardiologist to see if she needed another angioplasty. The cardiologist interviewed and examined Mrs. Hart, did an