Protocol Medicine – It Is Time For Doctors To Recognize Their Value

We hear that doctors do not like “protocol medicine” – they do not want to follow a “cookbook” when every patient is different. It is not a good understanding of the issues. Some years ago when I worked in a branch of he National Cancer Institute and then the University of Maryland Cancer Center, we admitted many patients with acute leukemia. The treatment approach including the necessary special tests to obtain, chemotherapy drugs, steps to prevent infection, prevent kidney problems, etc was complicated. So I wrote out a set of admission orders, had them typed up, xeroxed and kept at the nurses’ station. When a new patient was admitted, the physician took one of those order sheets and either accepted each individual order or made changes. But the doctor now would not forget something important such as a drug, its dose or the number of times per day. This worked much better than depending on memory yet any specific order could be eliminated or modified as needed for the individual patient. This was not a “cookbook” but rather an improvement in both safety and quality. Peter Pronovost and colleagues from the Johns Hopkins Bloomberg School of Public Health have worked on designing similar protocols for ICU patients for those needing the insertion of a central intravenous catheter to reduce the frequency of hospital acquired infections. This is basic stuff like gown and glove, use a disinfectant on the skin, use sterile materials, etc. It works; the infection rate falls by 60% if the guidelines are followed. Indeed in the Michigan hospitals where the technique was evaluated, the rate dropped to zero. Remarkably, many doctors at hospitals across the country rebel at having those steps to follow using the same argument of “protocol medicine.” And equally remarkably, most hospital executives are hesitant to insist. They will need to become more assertive and physicians must accept the new standards. It is a matter of rights and responsibilities. If physicians want the public (and elected representatives) to be supportive of malpractice tort reform, they will first have to accept “protocol or “cookbook” or “checklist” approaches that are tried and proven to improve quality and safety.