More Guidelines: What Are They Smoking?

Posted on April 4, 2008
Filed Under General Rationing Issues, Primary Care in America |

This is a heads-up for all you primary care doctors out there, who struggle during each and every patient visit to get through your Pay for Performance Checklist of Vital Healthcare Services (different checklists for different patients, of course, depending on their insurer), during the 7.5 minutes that the feds and the insurance companies have graciously allotted to you, in order to document for the appropriate accountants your fine performance as a modern American physician.

No doubt one item that appears on your checklist has to do with counseling your patient on smoking cessation. It’s likely you may have thought this to be one of the less objectionable mandates. You can get through your well-rehearsed pitch on smoking cessation in 20 seconds or less (unless this is one of those rare patients who is actually serious about trying to quit), and thereby make up some of the precious time, from your 7.5 minutes, that you have already spent earning some more challenging check mark (trying, perhaps, to talk the patient into taking the extraordinary steps necessary to get his hemoglobin A1c down that last 0.5% to target).

So: 20 seconds spent on smoking cessation. Check.

But whoa. Not so fast there, Dr. Welby.

Did you know there are guidelines for physicians on smoking cessation? Did you know that these guidelines were devised under the auspices of the federal government, by a committee of anti-smoking zealots (not that there’s anything wrong with that)?

From this latter fact, of course, there are certain things we already know about these guidelines before we ever have a look at them. We know that they will be very long and detailed and tedious, because a) they are federal guidelines, and b) they are devised by people whose one and only mission in life - a mission that they clearly believe is far more important than healthcare reform, terrorism, or global warming (or global cooling, as it turns out the case may be*) - is to relieve the world from the scourge of smoking, and who have been given the authority (i.e., the guideline-generating authority) to make it your primary mission in life, too.

Now have a peek at the actual guidelines; here they are. Notice, first, that the federal guidelines for physicians on smoking cessation are 196 pages long. Notice how they step you through the process of counseling, and then step you through each of the measures you must take in order to assure that your patient achieves success. And notice that an early branch point in the process of counseling is where the patient informs you of whether he/she is willing to go any further with efforts at smoking cessation; and notice further that when the patient informs you that he/she is indeed NOT willing to go any further, the guidelines do not relieve you of your obligations, no, but instead provide for interventions you must now conduct on this unwilling patient “designed to increase their motivation to quit.”

This, of course, is all to say: Your 20-second spiel on the evils of smoking just doesn’t cut the mustard, doctor. To really earn that smoking-cessation credit on your P4P checklist, you need to do a lot more than that. The 196 pages of deadly serious federal guidelines detail what that is.

Lest you are tempted to dismiss as an absurdity the expectation that you’re supposed to cram 2 hours of anti-smoking counseling into a 7.5 minute patient visit, there’s one more thing you ought to know.

One John Banzhaf, Executive Director and Chief Counsel for Action on Smoking and Health (ASH), who bills himself as the “law professor who masterminded litigation against the tobacco industry,” is not taking lightly, doctor, your obvious laxity on following federal guidelines on smoking cessation. Accordingly he has sent a letter to each of the 50 state health commissioners warning them that he will soon begin instigating medical malpractice suits, on behalf of smokers who continue to smoke as the result of their doctor’s refusal to follow federal guidelines.

Mr. Banzhaf informs the commissioners that “physicians are killing more than 40,000 American smokers each year by failing to follow federal guidelines.” That’s right, doctor, you’re killing them.(Cigarettes don’t kill people; people kill people.) Specifically he invokes the doctor’s obligation to “warn the smoking patient about the many dangers of smoking and provide effective medical treatment for the majority who wish to quit.” (Emphasis DrRich’s.) That is, it’s your job not just to counsel them and treat them, but also to see that they actually quit smoking. If you don’t follow this mandate, you’re killing them. And you must pay.

When the federal government takes the pains necessary to draft detailed management guidelines for physicians, guidelines that, if followed as written, will save tens of thousands of lives each year, society has every right to expect you to follow those guidelines to the letter - and save those lives. (This is such a brilliant scheme for ending smoking-related death and disability, one must wonder why it hasn’t yet been applied to other intractable medical problems. Just think of the good that could be accomplished, for instance, by federal guidelines that require physicians to cure cancer.)

In any case, consider these guidelines next time you’re putting that little check mark next to “Smoking cessation counseling” on your P4P checklist, and ask yourself: “Have I really done all that I am obligated to?”

Just one last thing, doctor. DrRich may be overstepping his bounds here, and if so just ignore him. But come on. If this is what “traditional” primary care medicine has come to at last, why would you continue to do it? Let WalMart and the doctor-nurses take it if they want it so badly. Extricate yourself from this muddle and practice real medicine, and let the devil take the hindmost.

*If it’s really global cooling after all, shouldn’t we be lobbying our congresspersons to change the CAFE standards to require American cars to get no more than 5 miles per gallon? Let’s get that temp back up!

Comments

8 Responses to “More Guidelines: What Are They Smoking?”

  1. anon on April 4th, 2008 7:03 am

    Looks to me like the problem is not the guideline (it actually is quite a decent review, and similar in nature to an extensive Cochrane assessment), but the attorney gone bad. He could easily have picked something from ACP, IDSA, etc., and held that up as a standard. It is probably easier because this one is from the Feds, but nonetheless, where there is a will there is way…as we all know.

    As an aside, we as docs do a crummy job with tobacco counseling and need a kick in the pants. However, still no excuse for this potential action, just plain dumb.

  2. DrRich on April 4th, 2008 8:58 am

    Anon,

    Smoking cessation is important, and doctors should have a big role in helping their patients to understand both the importance of it, and their treatment options. And (putting aside my exaggerations) the AG’s document, as you suggest, could actually be quite helpful in this regard.

    It’s when you take what in effect is a potentially useful state-of-the-art review, then declare it to be a federal guideline that must be adhered to, despite the impossible constraints already imposed on PCPs, and imply that non-adherence will be met with whatever punishments for this crime the various P4P plans have in store, not to mention tacking on malpractice suits, that I think things have gone over the line.

  3. Alan Mead DDS on April 5th, 2008 6:35 am

    How do the feds think we should treat drug seekers? It’s probably our fault if they keep using unless we convene a 12 step meeting right there in the office.

  4. DrBobC on April 5th, 2008 10:18 am

    This is one more straw on the camel’s back for the primary care doctor. Unfortunately the camel is already flat and this straw won’t really make a difference. Those I know who are getting close to 60 are clawing to get out as soon as we can afford to. This is the real tragedy. I really enjoy the interaction with the patients. It’s all the hoops I have to jump through to comply with the mandates like this one that makes it unbearable. With fewer and fewer graduates opting for primary care it’ll be hard to find one taking new patients before long. If you do happen to find one, I’ll bet they won’t be in a good mood.

  5. DensityDuck on April 8th, 2008 2:43 pm

    Hey, here’s a new income source for the ADA leeches. Step 1: Start smoking. Step 2: Go to a doctor. Step 3: Keep smoking. Step 4: Sue the doctor because you went to see him but didn’t quit smoking immediately afterwards…

    ****

    This whole thing reminds me of that bit in Stephenson’s Snow Crash, where the Federal Government publishes a book of regulations on toilet-paper usage, and declares that henceforth they will be conducting random surveys to ensure that the regulations are being obeyed…also, they estimate that the book of regulations will take 15 minutes to read, and if you don’t spend 15 minutes reading it you’re fired.

  6. Dr. Carty on April 13th, 2008 10:03 pm

    Maybe this is old news for most of you, but the American Trial Lawyers’ Association has changed its name to the “American Association for Justice.”

    Does that come with a big shovel?

  7. MHA on April 27th, 2008 6:18 pm

    The solution is obvious: create a new specialty - Smoking Cessologist. Have a transitional year as an internal medicine resident, followed by a three-year Smoking Cessology residency, with an optional one-year Smoking Cessology fellowship. Then, any PCP can dump - I mean, refer - their smoking patients to a Smoking Cessologist who is Board Certified by the American Association of Smoking Cessologists (J. Q. Doctor, M.D. FAASC) who, after a six-month languishing period necessitated by the busy 30-hour specialist work-week, can intervene appropriately. PCP is cleared of any malpractice, relieved of the burden of complying with smoking-cessation regs (enforced by the same federal government that continues to subsidize the tobacco industry) and a new (and this is the important part) high-paying specialty is created. The only problem is how to figure out a set of procedure-based interventions for the Smoking Cessologists to perform in order to maximize their compensations. Plus, med-school applicants can proclaim in their admissions interviews their altruistic passion for serving the uninsured smoking population. It’s a win-win (win)!

  8. DrRich on April 27th, 2008 8:02 pm

    MHA,

    If there were an emoticon indicating “slapping my forehead and wondering why I didn’t think of that,” I would insert it here.

    Rich

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