PSROs Eliminate Vital Rounds

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 eight a.m. and the chief would already be there chomping on the bit.  His assistants would flank him, and we would go from bed to bed like a flying kite of white coats.  The intern would recite the medical history.  We would take turns feeling a belly or percussing the chest, scanning the cardiograms, checking lab reports.  Then we would have an active discussion about the condition of the patient, whether or not the patient should have surgery.”

“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.