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Luang Prabang, Laos - photo by JoAnn Sturman
My partner Mary, a real person but an invented name, is confronted with a dilemma. While administering general anesthesia, she avoids giving multiple antiemetic drugs preemptively unless there is a sound reason. She goes on to add, “As a rule, I don’t use N20 on adult patients, and I’m judicious with the amount of narcotics I give to them.” About 5% of her patients experience PONV in PACU, most of whom are successfully treated using a standardized protocol.
Mark, on the other hand, is very aggressive when it comes to prophylacticly treating PONV. He sums up his point of view, “After the operation is concluded, I prefer not to deal with annoying problems in PACU. Any patient issue, however minor, could potentially give hospital administrators the idea I’m not doing my job well.” He typically gives all his patients four or five anti emetics in the operating room. Only 2% of his patients experience PONV compared to Mary’s 5%.
Hospitals use data in an attempt to establish objective measures for clinical comparison. By grading performance, outliers can be identified and behaviors altered. From an administrator’s point of view Mark’s technique is clearly superior to Mary’s. Although her complication rate is relatively low, there is a statistical significant difference when compared to Mark.
When narrowly defining a problem and ignoring other variables, distortions are bound to occur. If a number is attached to an outcome, one is left with the impression the analysis is somehow more scientific and less contestable, even though the objectivity is incomplete. Although Mary’s practice preferences are more traditional, it is not unreasonable to avoid exposing patients to medications which could potentially cause harm, particularly if there is a fall back strategy in place for treating symptomatic patients in the PACU. Anyone who has been in the medical profession long enough knows even the safest drugs occasionally cause adverse effects. Then there is the financial cost of giving thousands of doses of medications to reduce the incidence of PONV in PACU by 3%.
Mary will have to decide if this a battle worth fighting. Is it worth being a purist and leaving oneself open to criticism, while Mark loads up the syringes and floats quietly under the radar?
Cathedral of Santo Domingo, Cuzco - photo by JoAnn Sturman
Editor's note: This past week Dr. Benjamin Carson, Director of Pediatric Neurosurgery at Johns Hopkins University, spoke at the National Prayer Breakfast about the importance of HSAs in health care reform, political correctness, and national unity.
