An intellectual agenda for hospitalists

The practice of bloodletting, performed using sticks, thorns, bones, or anything sharp, probably began in Egypt about 3,000 years ago. The practice continued in Greece, where Hippocrates recommended bloodletting to balance the body’s four humors—blood, phlegm, yellow bile, and black bile—and continued during Roman times under the influence of Galen. In the United States, perhaps the most infamous use of bloodletting was when doctors reportedly bled as much as 5 U of blood from George Washington before he died from what was probably either acute epiglottitis or streptococcal pharyngitis. Although many infectious organisms, especially malaria parasites, require iron to proliferate—and therefore may be less virulent in iron-deficient people—acute near-exsanguination undoubtedly did more harm than good in the elderly ex-president. But the practice of bloodletting continued and even flourished. In 1833 alone, France reportedly imported more than 40 million leeches to assist in bloodletting, which oftentimes was thought to be sufficiently aggressive only when the patient actually fainted. Enthusiasm for bloodletting declined in the second half of the 19th century, influenced in part by a nonrandomized study that compared mortality rates among patients who were bled early in their illness with those who were bled later. Nevertheless, Sir William Osler still recommended small amounts of bloodletting for pneumonia in his last edition of his famous textbook, The Principles and Practice of Medicine, published in 1920. By 1927, however, the first edition of the Cecil’s A Textbook of Medicine thankfully no longer recommended venesection except to treat conditions such as pulmonary edema. Why would I start this essay with a history of bloodletting? Surely, one might argue, nothing could be less relevant to a modern discussion of the quality of in-hospital medical care. The substantial literature on quality improvement emphasizes the practical implementation of strategies to increase the appropriate adherence to processes that are known to improve outcomes. A number of common quality measures quickly come to mind: the use of aspirin, b-blockers, angiotensin-converting enzyme inhibitors, and statins in post-myocardial infarction patients without contraindications, the rapid initiation of appropriate antibiotics to patients with community-acquired pneumonia, and early endoscopy for patients with acute upper gastrointestinal hemorrhage. I could go on and on, listing in-hospital interventions supported by class 1 evidence from more than one definitive randomized trial. In essentially all of these situations, the creation of quality metrics, often accompanied by measurement and feedback, have improved adherence and undoubtedly saved lives. But although adherence has improved, the explosion in evidence-based medicine means that even the best hospitals may be in perpetual catch-up mode as they try to ensure adherence with the next wave of improvement interventions. Unfortunately, every now and then a lot of attention is paid to meeting a quality metric that turns out to be misguided. Perhaps the best recent in-hospital example was the metric of prophylactic b-blocker use before major noncardiac surgery. Although this recommendation initially appeared to be based on reasonable data, the large Perioperative Ischemic Evaluation Study (POISE) trial showed that reductions in rates of myocardial infarction were more than offset by an increased risk of stroke and other complications; therefore, average-risk patients actually did worse, not better, with the b-blocker regimen used in the trial. Although some have questioned whether these results were a function of the precise b-blocker regimen that was used, the results of POISE are actually remarkably consistent with prior data on the risk of myocardial infarction and stroke. What was really different was the relative importance of these and other end points in patients whose risk of cardiac death was lower than those of higher risk patients in prior studies. But more recently, an even more disturbing reality has emerged: a number of key reports on which the guidelines were based came from an investigator whose publications included data that could not be confirmed when his studies were reviewed by his home institution. Regardless of the precise reasons, we no longer routinely recommend an intervention that at one time was a key quality indicator. *Address for correspondence and reprint requests: Lee Goldman, MD, Dean of the Faculties of Health Sciences and Medicine, Columbia University Medical Center, 630 West 168th Street, P&S 2-401, New York, NY 10032; Telephone: 212-305-2752; Fax: 212-305-3617; E-mail: lgoldman@columbia.edu