Genetics: Receptors Discovered that Direct Rod Cell Development Special Report: Visa Woes Threaten Conduct of Science Neurology: Mutation Suggests Novel Signaling Mechanism in Brain Development Metabolism Kinase Pathway Seen to Regulate Urge to Eat Medical Education Fourth-years Make Matches, Favor Internal Medicine, Pediatrics Doctors Struggle with Complex Issues When a Patient is Dying HMOs May Improve Diabetes Care by Providing Home Monitors   Proceedings of the HMS Faculty Council Projects in Epidemiology, Nutrition Take Prizes at HSPH Poster Day Rabkin Fellows Announced HMS Dean's Community Service Awards Deadline Extended In Memoriam: Wayne Streilein   Practice Principles Have to Stand on Actual Data   Medical Records Hit Slow Going from Paper Trail to Digital Highway   Front Page

INCIDENT REPORT Practice Principles Have to Stand on Actual Data The response below was written by Gordon Harper, director of Patient-Doctor III, an HMS associate professor of psychiatry at the Massachusetts Mental Health Center, and an HMS Academy scholar. Incident as reported by a student: I was filling out discharge papers when the discharge coordinator asked me to change the date of a positive blood culture. It seemed that a different date would qualify for reimbursement at a higher DRG rate. I said I wouldn't do that. Was I right? Response: Students often are on the front lines of the conflict between prescribed ethics (normative behavior) and actual conduct (modal behavior). This student was asked to falsify a part of the medical record, apparently to make the patient's story justify greater reimbursement to the hospital. The student said no, but needed reassurance. All students' sense of professionalism may suffer when principles announced in the amphitheater or stated in the School's code of professional conduct encounter the actual behavior of the colleagues and superiors from whom students learn the informal curriculum of medicine. To prepare students for this encounter, our assertions of medical principles need to include an acknowledgement that we are aware of what actually happens in daily practice. Absent such an acknowledgement, we appear cynical or naive. One way to achieve these twin goals is to couple prescriptive statements with descriptive data about how far short practice often falls. A relevant example comes from work that Avorn and colleagues call "pharmacoepidemiology." While enunciating a principle of professionalism--that physicians should acquire information about new treatments from unbiased scientific sources--they have also documented the distance between this ideal and actual practice. Specifically, about 90,000 drug company "detail people" continue to lead doctors to prescribe newer, more expensive medications, despite data to the contrary. In response, the National Institutes of Health is preparing to send out 600 "government detail people" to educate physicians about more effective, less expensive alternatives. This is the kind of factual framework that students need to have. Principles and actual practice data are a powerful combination.