“HELTER-SKELTER” MEDICINE

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Our pathology group's Dr. John Carter coined the term "Helter-Skelter" medicine in the early 1990s to describe practicing of all aspects of medicine too fast with too little time for staff to think and interact with focused thoroughness and attention to details of a case or an issue.

A USA NATIONAL PROBLEM: INCENTIVIZATION TO PRODUCTIVITY

This is a NATIONAL problem which we recently (2007-2008) identified as the basic cause in two sentinel event reports of cancer misdiagnoses made in outside “business labs” and subsequently followed by unneeded radical surgery in our hospital. From 11/2007-6/2008, our pathology group discerned  FIVE (5) melanoma misdiagnoses from midlands area dermatopathologists. This state of USA medicine has come about gradually (the frog in the pot with the heat very gradually turned up) since the early 1970s due to relatively or absolutely reduced compensation per unit of value to all providers by insurers & governments. Such reductions lead to physicians & entities being tempted into unethical and/or ethical activities to bring in money to keep practices profitable. It has accelerated in the last 15 years and is driven by third party payers and governments who believe that the practitioners of a "classical, learned profession" can continue to be competitively evolved by a continually tweaked business model that rewards “work horses” based on an increased rate of production of "widgets" per unit time, leading to greater efficiency but increased & undetected errors of all sorts.

ACCURACY & TOP-QUALITY JUDGMENT REQUIRE TIME

Accurate and thorough diagnostic & management assessment of the pathology of tumors is of bedrock foundational importance to a top quality oncology program. Pathologist diagnosis steps warning: (1) top priority is the eyes & brain of the pathologist [the thing that insufficient staffing & helter-skelter affects most negatively]; followed by (2) excellent fixation & good H&E; followed by (3) well done ancillary studies of all types judiciously used to test/confirm the pathologist's DDX formulated in the context of as much known clinical info as he/she can get his/her hands on (anatomic path DX without clinical info becomes dangerous on small specimens). All of this takes time, and this means that a talented pathology group with significant component of seasoned judgement & experience, must be able to afford to compete for adequate pathologist & support staffing by talented, likeminded pathologists & personnel. The same is true for Radiology and other LCHSD services.

Many path reports in the US now omit gross & microscopic descriptions.  Is this practice a reflection of “Helter-Skelter” medicine? At its most basic, an Anatomic Pathology Report must be (1) helpful and (2) an accurate reflection of the patient's disease reality in that specimen. And, our group puts top priority on having the report speak PRIMARILY toward the immediate benefit of that patient (researchers and others can benefit secondarily…we are the top contributor to the statewide “tissue bank” for researchers, for instance). Though not expressly stated in our departmental documents, our approach visualizes a hugely different & more comprehensive goal from that of the brief, synoptic-report approach and is based on the Golden Rule, "Do unto others as you would have them do unto you." Our reporting pathologist...never a world-class expert on even one topic...exerts his/her best efforts in thoroughness to discern the truth of the diagnosis to be rendered in that report and express it in a way that maximally helps the doctors treating that patient select the best treatment or management plan. Attempts to optimize the written report and any associated supplemental oral or electronic communications are highly desirable. Through careful attention to detail, the pathologist must ascertain whether all facets of the case are concordant so that mistakes of various types, now abundant in the US medical field, can be detected before the report is signed.

Helter-Skelter leads to a tired and distracted brain which works less well with its eyes, does not have time to be conscientious & thorough, does not have time to be an alert evaluator of case concordance vs. discordance, and does not (therefore) have time to detect or deal with “mistakes”. The show must go on and move forward before we drown!

QUALITY OPPORTUNITY IN OUR LOCAL LCHSD

The leadership of our Lexington County Health Services District (LCHSD) is one of the few situations nationally that is in a position to stand steadily and unobtrusively against income and/or expeditiousness schemes...whether ethical or not...associated with “Helter-Skelter”. Our Board & top administration can easily take a leadership stand for top quality by a policy that testing (especially lab, pathology, imaging), for the sake of efficient & accurate treatment, should be performed within the elements of the LCHSD whether insurance favors that or not…unless a LCHSD MSO practitioner claims (with at least some legitimate anecdotal support) that LCHSD “in-house” is inferior. LMC is essentially the LCHSD.

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