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Yeah I spent a couple of years in the US Army, albeit a long time ago. There were many rules and directives, a lot it was incredibly picky with minuscule impact

Yeah I spent a couple of years in the US Army, albeit a long time ago. There were many rules and directives, a lot it was incredibly picky with minuscule impact and soon forgotten. There was an art to divining what was really important and what wasn't. In medicine today it's sort of similar, a lot of rules are propagated by bureaucratic minds. Sometimes it's just annoying, other times a big headache. On rare occasions such rules actually makes sense. The problem with rules like the one I cited is the risk that it will be enforced. This can happen in institutional settings like large clinics, a health care system or government agency. No set of rules or guidelines will be airtight and completely defensible. Yes, we're duty bound to act on the basis of reason and good judgement. However when rules are generated that are out of touch with reality there's a risk that regulatory entities, insurers, etc., will pick up that ball and run with it. Impediments to practicing according to one's best medical judgement are ubiquitous. One is insurance company rules requiring preauthorization for medications, even many generics. Can't tell you how many hours me and staff have spent knocking this around. Of course delayed treatment affects patient well-being. Ironically 95% of the time the meds I intended to prescribe were eventually approved anyway. Having to play the game accomplished nothing of value for anyone. You ask "What central authority...?" Of course, central authorities don't know the best solutions, often enough not even passable solutions to problems. Too many rules are as dangerous as not enough rules. I believe developing rules via "bottom-up" methodologies would produce rule sets with minimum necessary restriction and conceivably could even be productivity enhancing. I'll be quiet very soon, but I'm reminded of a patient encounter. A man was in my office talking about conflicts at work re: a micromanaging supervisor. It was a group of PhD-level software engineers. I was thinking, do these people even need "supervision"? Shouldn't they be trusted? Trustworthy professionals can be relied on to do their jobs. Sure, keep an eye on work quality, allow the track records to speak for themselves.

wolverine876 5y ago
The problem is our politics - clearly our health care system needs fixing. But nobody chooses to act on politics, and the obvious obstructions to progress. > I'm reminded of a patient encounter. A man was in my office talking about conflicts at work re: a micromanaging supervisor. It was a group of PhD-level software engineers. I was thinking, do these people even need "supervision"? Shouldn't they be trusted? Trustworthy professionals can be relied on to do their jobs. Sure, keep an eye on work quality, allow the track records to speak for themselves. Generally, yes, good management is knowing who to trust, and putting them in a position to succeed. But the original bias, of course, is toward ourselves. They/we are still human, we still put our pants on one leg at a time. Just because we are highly skilled in something, doesn't mean we have good judgment in other ways, we are motivated, not distracted, biased in other ways, etc. Plenty of very successful people do god-awful stupid things.
- jrapdx3 5y ago
  No question about it, no one is immune, "to err is human". Also true that assessing performance of tasks requiring complex judgement is itself error prone. Credentials alone are an insufficient baseline. So for all kinds of roles auditing mechanisms are necessary to monitor performance. And truly responsible professionals don't object to quality assurance measures, in fact they want to know if their performance declines in some respect. In my observation it's problematic when rules become intrusive, overly restrictive, or needlessly punitive. At that point monitoring no longer serves its nominal purpose. There's a proper balance that's minimally adversarial, making it work requires mutual respect and constrained interaction between professionals and reviewers. I think that's the source of a significant share of the problems in our health care systems. Way too much energy is wasted on battling phantoms. Not sure how the trends can be reversed. Best advice to patients is to make sure to strongly advocate for themselves. I know both sides as doctor and patient, I know how big a challenge it can be getting what we need despite layers of roadblocks and potholes on the path.
Dylan16807 5y ago
> The problem with rules like the one I cited is the risk that it will be enforced. This can happen in institutional settings like large clinics, a health care system or government agency. Ha! I thought you were saying the exact opposite! That urologists, following their "evidence", will do too many tests and cause many people to suffer from false positives. But you were actually calling the guidelines "evidence" and saying they were the problem? Maybe! But in that case why are the guidelines so wrong?

wolverine876 5y ago

The problem is our politics - clearly our health care system needs fixing. But nobody chooses to act on politics, and the obvious obstructions to progress. > I'm reminded of a patient encounter. A man was in my office talking about conflicts at work re: a micromanaging supervisor. It was a group of PhD-level software engineers. I was thinking, do these people even need "supervision"? Shouldn't they be trusted? Trustworthy professionals can be relied on to do their jobs. Sure, keep an eye on work quality, allow the track records to speak for themselves. Generally, yes, good management is knowing who to trust, and putting them in a position to succeed. But the original bias, of course, is toward ourselves. They/we are still human, we still put our pants on one leg at a time. Just because we are highly skilled in something, doesn't mean we have good judgment in other ways, we are motivated, not distracted, biased in other ways, etc. Plenty of very successful people do god-awful stupid things.

jrapdx3 5y ago
No question about it, no one is immune, "to err is human". Also true that assessing performance of tasks requiring complex judgement is itself error prone. Credentials alone are an insufficient baseline. So for all kinds of roles auditing mechanisms are necessary to monitor performance. And truly responsible professionals don't object to quality assurance measures, in fact they want to know if their performance declines in some respect. In my observation it's problematic when rules become intrusive, overly restrictive, or needlessly punitive. At that point monitoring no longer serves its nominal purpose. There's a proper balance that's minimally adversarial, making it work requires mutual respect and constrained interaction between professionals and reviewers. I think that's the source of a significant share of the problems in our health care systems. Way too much energy is wasted on battling phantoms. Not sure how the trends can be reversed. Best advice to patients is to make sure to strongly advocate for themselves. I know both sides as doctor and patient, I know how big a challenge it can be getting what we need despite layers of roadblocks and potholes on the path.

Dylan16807 5y ago

> The problem with rules like the one I cited is the risk that it will be enforced. This can happen in institutional settings like large clinics, a health care system or government agency. Ha! I thought you were saying the exact opposite! That urologists, following their "evidence", will do too many tests and cause many people to suffer from false positives. But you were actually calling the guidelines "evidence" and saying they were the problem? Maybe! But in that case why are the guidelines so wrong?