Now that I have discovered compadres out there who like to think about gout, I promise that soon you will have another case to chew on. I think that the next one will be harder and, frankly, I need advice.
The third reason I had a “wow” feeling concerns the ongoing discussion about quality that bears on the pay-for-performance initiative. From what I have been reading about the looming disaster on healthcare financing, however, we should also have a “pray-for-performance” initiative.
I would like to ask you some questions. Do any of the different approaches to the management of gout I described represent more quality than the others? Is there one approach that would be demonstrably better or more solidly grounded in data? Are they all equal?
My argument is that, within limits, every approach described in fact represents quality and is based on experience, informed judgment, and a serious and sober assessment of the risks and benefits.
Some physicians may worry more about creating a hemarthrosis than others, but the extent of that worry likely relates to the number of joint taps performed previously with a patient on anticoagulation. If a physician has never had a bad outcome, he or she is likely to feel confident about sticking a needle in a joint when the INR (international normalization ratio) is 3.
On the other hand, if the physician had once caused a bleed, heard a colleague tell of a mishap, or been asked to serve as an expert witness in a lawsuit about such a circumstance, the needle would stay in its protective sheath, safely away from the red, throbbing joint.
In the same way, someone who has seen the blood count plunge after a slug of colchicine would likely never go that route again.
Side Effects Aside
The issue is not just side effects.
If, on too many outings, prednisone tapers or doses of ACTH failed to calm the gout, trust me, it would soon be needle time. For both the specialty and the individual practitioner, therapy evolves. It is not set in stone. Physicians are not idiots. They do what works and they stay away from what harms.
While I am for quality improvement as much as anyone, I worry that we may be going in the wrong direction. Because the world has computers, there is an illusion that these machines—as slick and as fast as they are—can simplify, quantify, and render judgments on the decision-making in some of the knottiest and most vexing clinical situations that can be imagined. Even with the best algorithms in Googledom, medicine is a tough nut to crack.
