David Slawson, MD, one of the founders of InfoPOEMs®, gave a provocative talk during the concurrent sessions on Sunday, October 19, 2008 at the 2008 Midwest Chapter/MLA and MHSLA joint meeting. He pointed out that according to WHO rankings, the U.S. is 12th out of 13 countries in regard to quality, but first in regard to health care costs. Because of inequities in access to health care in the U.S., and our reluctance to ration care, he stated, “We don’t ration services, we ration people.” He discussed fallacies regarding rationing.
In the U.S., overuse and misuse of treatments and screening tools has led to large increases in costs while decreasing value. Value (value is equal to quality divided by cost) will not increase until doctors use evidence to make rational treatment decisions, thus decreasing costs. Because doctors are the ones who decide what treatments to use, they are the key to the control of costs and value. They must use the evidence when providing care and deciding on what treatments to use. He stated that we can “safely eliminate at least 20% of what we currently do” in the U.S. He added, “We must limit unnecessary services (or deny care to more people).”
For example, he believes that based on the evidence, women who have had hysterectomies for benign reasons and women who have had consecutively normal Pap smears do not need to have yearly Pap smears. In another example, he points out that doctors frequently ignore recommendations about treatment for hypertension, using the newest drug or samples that they have on hand, rather than prescribing the cheaper beta blockers and diuretics that are recommended as the first step in treatment. He quoted David Eddy (Clinical Decision Making: From Theory to Practice, Jones and Bartlett, 1996) who said, “In a field filled with uncertainty and doubt, the difference between ‘when in doubt, do it’ and ‘When in doubt, stop’ could easily swing $100 billion a year.”
Dr. Slawson and his co-author, Allen F. Shaughnessy, have several prescriptions:
- "Analyze practices at the level of specific indications, e.g. mammography, other cancer screening, BMD, others."
- "Accept that resources are limited."
- "Change our way of thinking from qualitative to quantitative reasoning."
- "Focus on populations rather than on individuals."
- "Help patients understand consequences."
- "Ensure that measures used to judge value of services lead to an increase in quality while decreasing costs."
- "For the individual practitioner: ‘When in doubt, don’t.’”
The slides for Dr. Slawson’s presentation (titled "The True Mission of Information Mastery: Using “Medical Poetry” to Remove the Inequities in Health Care Delivery”) are available at http://snipurl.com/4ts8y or from the University of Virginia Health System’s Information Master Practicum and Course page at
http://snipurl.com/4tscd.
Mary K. Taylor, Natural Sciences Librarian
Morris Library, Southern Illinois University Carbondale
mtaylor AT lib.siu.edu