PSRO’s Remove
Vital Rounds
Daily Observer
S.Q.
Lapius refused to serve the pre-prandial cocktail in
deference to Sandford, his nephew, “No sense
inculcating bad habits in the little tyke,” he whispered to me. Lapius had to baby
sit for Sandford from time to time and it was quite a
trial, because children to Lapius were foreign
creatures from other planets. Not all
children, but Sandford in particular, who repudiated
the finely scented foods that Lapis was wont to serving from time to time in
favor of corn flakes. “Ugh,” said Lapius as he poured the crackling cereal into Sandford’s bowl.
“Tell
me a story while I eat, Uncle Simon,” Sandford said
as endearingly as he could.
“And
if I don’t?”
“I’ll
vomit,” Sandford promised.
“Very
well, then,” Lapius surrendered. “What story would you have me tell you?”
“The
one about the fairy prince--,”
“I
don’t know that one, Sandford. I’ll tell you instead about the
merry-go-round.”
“Oooh, that’s exciting,” Sandford
said, pouring milk and several tablespoons of sugar on his cold cereal.
“Once
upon a time, long before you were born, Sandford,” Lapius said, raising his eyes skyward, “before doctors
earned $10,000 dollars a year just to be interns, during the time they were
happy just to get food and board to serve in a good hospital, during the time
when sleep was taken at odd moments throughout the day because doctors were up
on their feet mostly day and night, doctors used to go on rounds.”
“Merry-go-rounds?” Sandford asked.
“Actually
they were sadly-go-rounds, when the doctors visited the sick people in the
hospital,” Lapius suddenly forgot Sandford.
“They
were the days, Harry, when the departmental discipline was quite strict. You remember, I’m sure. We would gather in the ward at
“But
what happened to the merry-go-round?” Sandford asked,
burbling his words through the soggy flakes.
“Be
patient, Sandford, I’m getting to that. As a matter of fact, it broke down. Insurance plans started up and suddenly there
were no more wards. You see, Sandford, in these days the poor people who couldn’t afford
a hospital went into wards, and in return, the doctors who treated them used
them as teaching cases. But when people
started to get Blue Cross and Blue Shield insurance, and finally Medicare, the
system of teaching at the bedside broke down.”
“But
what happened to the merry-go-round?” Sandford
wailed.
“I’m
coming to that. As I told you,” Lapius said directing his conversation to Sandford, but talking to me, “the merry-go-round of
teaching rounds broke down as soon as the wards disappeared. But then a surprising thing happened. The insurance companies and the government
who were now paying most of the bills for illness wanted to be sure they were
getting their money’s worth, and that the doctors were not making any mistakes
in diagnosis. So they started the
Professional Standards Review Organizations, otherwise known as PSRO’s.”
“Pisserooos?” asked Sandford.
“Well,
yes, in a way, Stanford, you call them that.
In any case, the P.S.R.O.’s are designed to
create what is called quality control in medical care. The only trouble is that it sets doctor
against doctor, and invades confidentiality.
Why, Ralph Nader even thinks that there should be a medical specialty
composed of doctors who do nothing but inspect the work of other doctors.”
“Oooh, that sounds like a good idea,” Sandford
squealed.
“Harry,”
Lapius whispered apologetically, “the birth control
pills were invented just one year too late to prevent Sandford.” Then turning to Sandford, “No, they are not good. What good is it to inspect records long after
the patient is gone from the hospital?
Medical rounds were a vital living experience that taught doctors on the
spot. They could see the patient from
day to day. On rounds you could tell the
good doctors from those who needed help or experience. They learned on rounds. What good will it do
to have a group of outsiders inspecting charts long after the case is over and
try to decide from the record, at their leisure, about decisions the doctor on
the case was forced to make in a matter of minutes?”
“But what about the merry-go-round?” Sandford
persisted.
“I’m
coming to that. So the wheel has come
full cycle. One of the big criticisms
about medical rounds was that it was an invasion of privacy of the poor. Actually the poor often had better care than
private cases because their problems were constantly being conferenced
during medical rounds and there was an exchange of ideas. It is lonely to take care of a patient all by
yourself without consultation. But
medical rounds were considered to be an indignity conferred on the poor.”
“But
now the government through the ‘PSRO’ law of Senator Bennet,
may he lose his next election, has turned the entire population of sick people
into teaching cases by snooping at their medical records long after they have
left the hospital. They will not have
had the benefit of medical consultation, but their doctors will certainly be
intimidated because the law states in section 249F of Public Law 92-603, Equal
Professional Standards Review Organization shall apply professionally developed
norms of care, diagnosis and treatment based upon typical patterns of practice
in its regions (including typical lengths of stay for institutional care by age
and diagnosis) as principle points of evaluation and review-.
“This
certainly will tend to preempt the individual doctor’s judgment in favor of
cookbook medicine. So the wheel has come
full circle now and the entire nation under the auspices of Peer Review will
really be subject to a type of medical rounds.
Except instead of being for the individual patient’s welfare, like the
old ward rounds, they will merely be statistical snooping parties which will
invade privacy, confidentiality, and which, instead of teaching the doctor,
will force him into a straightjacket of medical practice. It will diffuse responsibility and break up
the most important aspect of medical care, the bond of faith that must exist
between the doctor and the patient. In
the old days if a patient didn’t like his doctor he could change to another doctor. Soon it won’t make any difference, because
all doctors will have to treat patients according to ‘medical norms’
established by the government. That, Sandford, is the merry-go-round. Do you hear me, Sandford?”
Sandford didn’t hear a word. He was fast asleep, his face buried in his
cornflakes.
“Don’t
disturb the little tyke, Harry. Let him
sleep. Now we can have our drink,” Lapius said.