Diabetes Registry Not a Solution

Dr. Lynn Silver and others have decided that collecting patients' data on diabetes and then sending them letters will help control diabetes, and they maintain that “the potential benefit in light of the epidemic condition outweighs any risk to privacy.” They also argue that doctors can't take care of patients without an electronic medical record (“NY Diabetes Monitoring Program Raises Privacy Concerns,” February 2006, p. 6). Wrong on all counts.

Sending patients letters is not going to make a difference in management. As for dietician counseling and diabetes education, physicians are already doing that. Why pay for a duplicative system?

Also, nothing in an electronic database is confidential, and it will lead to discrimination and data brokering. Others don't have the right to decide for the patient that the benefits outweigh the risks.

Finally, medical management takes cognition, conscientiousness, knowledge, and experience. Recording it on paper or in a computer doesn't indicate quality of care.

It's time for doctors, patients, and taxpayers to nip this one in the bud.

Frances Parisi, M.D.

Lancaster, N.Y.

'Cookbook' vs. Real-World Medicine

As commonly occurs, an academic physician discussing the medical system as it exists comes forth with a simplistic response to an infinitely complicated environment (“Crossing the Quality Chasm in Health Care,” February 2006, p. 36.).

In his Guest Editorial, Dr. Harvey V. Fineberg described multiple methods whereby improvement in the medical health care system could produce a decrease in errors.

As a pulmonary critical care physician, I see innumerable uncommon presentations for common diseases that do not lend themselves to diagnoses with a “cookbook” or “practice guideline” method. Proper diagnosis and subsequent therapeutic planning require a thoughtful and appropriate evaluation in an individually designed logical and stepwise fashion.

This is not something that will be supplanted by guidelines which ignore the input of highly trained physicians.

The concept that you can create guidelines that allow hospital-based physicians or outpatient physicians to avoid errors simply by following a stepwise/cookbook model is facetious, and, again, one that is commonly promoted by academic physicians who do not live in the real world of medicine.

I agree that the model that Dr. Fineberg recommends to address some of these issues, such as giving physicians time to evaluate their patients appropriately, is good.

However, the current financial environment, with its increasing demands on physicians, does not help promote that model.

My recommendation is that Dr. Fineberg advocate for physicians to be “adequately protected” in terms of time constraints, legal constraints, and third-party payer constraints.

This may be a more effective mechanism to reduce hospital or office errors.

Gary R. Schafer, M.D.

Forest City, N.C.

Dr. Fineberg replies:

Dr. Schafer seems to regard my call for greater reliance on standards and guidelines in medical practice as a replacement for expert clinical judgment.

To the contrary, well-framed guidelines do not supplant expert medical judgment, nor are they a cookbook that treats every patient the same. Rather, guidelines informed by the best medical expertise can aid clinical decision making, match diagnostic and treatment strategies to the individual circumstances of each patient, avoid errors, and save lives.

In Dr. Schafer's field of pulmonary medicine, the American College of Chest Physicians has issued evidence-based guidelines on managing patients with problems ranging from cough to lung cancer (see

Dividing the House of Medicine

I am outraged that the American Medical Association has conducted secret negotiations with members of Congress, which end up being “on behalf” of all U.S. physicians (“AMA Pay-for-Performance Agreement Stirs Debate,” April 2006, p. 39).

I am very troubled by the concept of performance measures. The mere fact that Congress wishes to develop performance measures implies that Medicare is not getting its money's worth from American physicians. What a joke!

All of us are working harder, documenting more, and providing better care for our patients due to the advances in medical science. We have been rewarded by declining reimbursements compared with the cost of living and malpractice expenses.

Performance goals will be a tool to divide the house of medicine, separate the “good” physicians from the “bad” physicians, and further decrease reimbursement to the profession as a whole. And there will be even more documentation requirements.

I wish the AMA and the American College of Physicians were taking these messages to Congress, instead of selling us out.

Eric Frankenfeld, M.D.

Bellingham, Wash.

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