Well-Intentioned Physician Mandates Lack Success

December 22, 2014

Look no further than the recent issue of JAMA for evidence that physician mandates are not beneficial, but paternalistic and coercive.

A great deal of what afflicts physicians today has been instigated by legislators and government regulators goaded into action by national committees populated by self-anointed experts. The same kind of activity that brought you the EHR mandate is also responsible for time-limited board certification, maintenance of certification (MOC), resident work hour restrictions, and requirements that ER residents have constant faculty supervision. This is not to question the merits of continuing medical education, the responsibility of each physician to maintain their skills, the importance of sleep, or the value of mentoring trainees in real-time. It is to question the idea that, at a national level, a group of arbitrary rules can be concocted and imposed on everyone because there is an "obvious" problem and it is "obvious" the new scheme is the cure.

The same issue has confronted parents and local school boards across the country. Scattered instances of abuse provide the "foot in the door" for officials eager to ignore the merits of local control and impose standard curricula and testing, under federal control. Just as with EHR, you can opt out of their game but it will cost you big time. No matter how well-intentioned, it's paternalistic and coercive.

What could possibly excuse this kind of intrusion into our daily activities? Evidence that the proposed scheme is safe and effective. We don't allow the distribution of pharmaceuticals for which there is no evidence of this kind. We do attempt to intrude into people's lives by requiring school children to be immunized against a variety of infectious diseases despite there being strong evidence that the benefit, both to the individual and to the population, dramatically outweighs the risk. The current re-emergence of measles and the pertussis outbreak in California attest to the merit of the mandate and the consequences of allowing (which we do) individuals to ignore it without penalty.

So what evidence supports the mandates mentioned above? In fact, there has been precious little. The decisions to undertake the nationwide schemes is based mostly on "expert opinion" and the "obvious ability" of the scheme to solve the problem, forgetting that "ability" is an after-the-fact characterization of something for which there is confirmatory evidence.

A recent issue of The Journal of the American Medical Association is chock full of evidence and it is bad news for those who were so confident in their schemes. Here are the results in a nutshell (conclusions of each paper are excerpts):

• "Association Between Imposition of a Maintenance of Certification Requirement and Ambulatory Care–Sensitive Hospitalizations and Health Care Costs"

Imposition of the MOC requirement was not associated with a difference in the increase in ambulatory care–sensitive hospitalizations but was associated with a small reduction in the growth rate of costs for some Medicare beneficiaries.

"Association Between Physician Time-Unlimited vs. Time-Limited Internal Medicine Board Certification and Ambulatory Patient Care Quality"

Among internists providing primary care at 4 VA medical centers, there were no significant differences between those with time-limited ABIM certification and those with time-unlimited ABIM certification on 10 primary-care performance measures.

"Association of the 2011 ACGME Resident Duty Hour Reforms With Mortality and Readmissions Among Hospitalized Medicare Patients"

Among Medicare beneficiaries, there were no significant differences in the change in 30-day mortality rates or 30-day all-cause readmission rates for those hospitalized in more intensive relative to less intensive teaching hospitals.

"Association of the 2011 ACGME Resident Duty Hour Reform With General Surgery Patient Outcomes and With Resident Examination Performance"

Implementation of the 2011 ACGME duty hour reform was not associated with a change in general surgery patient outcomes or differences in resident examination performance.

"Emergency Department Resource Use by Supervised Residents vs. Attending Physicians Alone"

In a sample of U.S. EDs, supervised visits were associated with a greater likelihood of hospital admission and use of advanced imaging and with longer ED stays.

The available evidence about the purported benefits of EHR, as reported by Arthur L. Kellermann of RAND, is similarly negative, yet the insanity continues and it is driving physicians crazy.  I've avoided including ICD-10 and HIPAA in this discussion, but the same questions are applicable.

Of course, single studies are not conclusive proof, but if the beneficial potential was supposed to be so great and so obvious, you would think that the benefit would be easy to demonstrate, or at least, that the results would be inconclusive. If the Republicans want to discredit President Obama's healthcare scheme without hurting patients, they should take aim at these regulatory mandates. They are great candidates for the chopping block.