“We are told we live in the era of evidence-based medicine, but we know we don’t collect the best evidence. We are instructed to use published guidelines for processes of care as benchmarks against which to measure our practice, but we know that adherence to these guidelines often does not improve our patients’ outcomes. We are told when to start antibiotics, when to stop antibiotics, which patient does not need an MRI scan, who needs to be referred to physical therapy, how often we must wash our hands, how to prepare a patient for a craniotomy, etc., etc., etc. We know that too often it is compliance, not quality, that we measure and reward. We listen to harangues by airline pilots and the disciples of Japanese auto manufacturers on how to improve the safety and quality of neurosurgical care. We are compared, unfavorably, to line cooks at the Cheesecake Factory. We have been told we must transition from a medical care system that rewards volume of care to one that rewards quality of care — but we are paid based on the number of relative value units (RVUs) we generate. In short, our health-care system is chaotic, bordering on schizophrenic and getting worse instead of better. What should we do? Should we slavishly follow the present evidence-based medicine algorithm? Should we rage against the dying of the light? I believe there is a better way. Neurosurgeons need to avoid being either lemmings or Luddites.” Robert E. Harbaugh, MD, FAANS
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