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OB/GYN Editorial January 2005
Four Resolutions
Ronald T. Burkman, MD
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The start of each new year is often a time of reflection and the setting of goals, aka resolutions, for the next 12 months. Whether or not one elects to adhere to goals or resolutions—or to quickly go another route—may be a matter of personal preference, but is more likely related to how painful or difficult achieving a given goal is in the context of the demands of our daily life. Relative to the practice of medicine and, in particular, to the practice of obstetrics and gynecology, I feel the setting of goals for 2005 is an important exercise. Further, many of the goals I suggest are worthy of achieving. The order in which the goals are listed does not necessarily rank them by importance; from my perspective, each one of them is important for us to consider.
Continue the Fight for Tort Reform.—In many states, such as Maryland and Florida, the situation clearly is getting worse. In other states, it has been suggested that there may be some leveling off relative to the magnitude of awards such that the days of double-digit premium increases may be a thing of the past. However, slow growth of premiums, particularly if reimbursement does not keep pace, only stabilizes an already bad situation and does not represent real improvement. Although many may not like the result of the national election, the party currently in power lists tort reform as one of its priorities. Thus, the topic will remain in front of the public, giving us a rare opportunity to continue the fight both nationally and locally with a reasonable amount of public attention and hopefully support. One may question whether any national bill can clear the roadblocks in the Senate. The currently constructed bills, which mimic the legislation that has been in existence in California, appear to have no chance of clearing the Senate. It may be necessary to drop our insistence on controversial provisions such as caps for pain and suffering, and substitute another approach that may be more palatable such as alternative methods for dispute resolution (eg, special courts or tribunals). What must not happen is for us to throw in the towel and pessimistically adopt an air of defeatism. Remember, the fight for tort reform is a marathon, not a sprint. Finally, it is also important to keep the rationale for tort reform in proper perspective. The reason for tort reform is not primarily to reward physicians with monetary legislative relief that might not be available to others. Rather, it is to address the real concern that the availability of appropriate medical services for women will decline as physicians either give up or reduce their scope of practice—or elect not to enter the specialty in the first place.
Continue to Focus on Error Reduction.—It is the view of the vast majority of those who have closely examined errors in medicine that many are avoidable and are related to systems problems rather than the competency of individuals. In a previous editorial, I listed some of the approaches being used nationally as well as locally at my own institution. What I failed to point out, however, is that there will be the need to achieve a real cultural change to make meaningful improvements. Hierarchal structures will need to be drastically modified, leadership will have to be absolutely committed to change, and institutions will need to think outside of the usual "medical/surgical box." However, if we enjoy success, our patients will benefit and we will gain support for other initiatives such as tort reform.
Adopt an Evidence-based Approach to Practice.—As a given, only a minority of what we do has published, high level evidence to support a particular practice pattern. However, that does not mean that we should not insist on utilizing high quality evidence to guide us when it is available. In particular, when new and often expensive drugs or technical innovations are introduced, we should insist on being able to evaluate them against our current standards relative to efficacy, safety, and overall cost-effectiveness. We should not succumb to the sales pitch of pharmaceutical or equipment company representatives without first carefully examining the evidence and determining if it is of suitable benefit to lead to a change in practice.
Focus on Quality as Well as Cost-effectiveness.—This goal or resolution is a corollary of the previous goal. It requires a careful analysis of what and why we do what we do in practice, whether or not it truly benefits patients, and whether the cost is worthwhile. For example, should routine 18-week screening ultrasounds performed on mothers without risk factors be repeated when the images cannot adequately see the heart or part of an extremity? I would suggest that the return on such repeat scans is quite low. There has been a recent proliferation of devices to carry out endometrial ablation or to construct a sling for the midurethra in the management of stress urinary incontinence. Do we need all of these innovations, and have they all been proven to be more effective or safer than the technology they are replacing, particularly over the long haul? I would suggest that, in many instances, this question has not been adequately answered.
The four goals listed above represent areas of particular interest to me. Although goal setting might be viewed as just an academic exercise, I do feel it helps one focus on what is important at the time. I am sure that you may have other considerations and suggestions. Let us know. And, best wishes for the New Year!
Ronald T. Burkman, MD
Associate Advisory Board Member
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