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Department of Anesthesiology; University of Rochester; Rochester, NY; peter_bailey{at}urmc.rochester.edu (Bailey, Eaton) Department of Community and Preventive Medicine; University of Rochester; Rochester, NY (McIntosh)
In Response:
We too remain frustrated and agree with Bjerke and Urdaneta and Gravenstein (1,2) that the use of ultrasound for central venous catheterization is still infrequent. What is particularly perplexing is that both the supportive evidence, as well as the logic, are rather compelling: the use of ultrasound for central venous catheterization increases success rate while simultaneously decreasing procedural time and complication rate. Why is it that, although it makes sense to use ultrasound for central venous catheterization, its use, as reported in our survey (3), is not common?
The explanations for the failure of ultrasound to be widely adopted for central venous catheterization are the same as those that explain why proven therapies and approaches are all too frequently slow to penetrate clinical practice in medicine. The underlying reasons can be reduced to two inadequacies: resources and incentives. The first is now the bane of our existence in medicine and a sorry excuse for many of our failures. The second, as with so many "problems" in and out of health care in the United States, could be viewed as a failure of the "free market." Although many of us in the medical profession like to believe that ethics more than anything else drives us to do the right thing, the facts all too often do not support this contention. The legal profession has been feasting on this for years.
The practice of medicine and the delivery of health care can be advanced in several ways. It is supposedly a duty of our government to protect its people from the consequences of free market failures. Although we may loath such approaches in health care, "pay for performance" is one bit of evidence that this approach is beginning to take hold. Professional societies have been attempting to guide clinicians toward improved practices for years. For example, the American Society of Anesthesiologists has promulgated numerous well-developed practice standards, guidelines and advisories (www.asahq.org). Locally, hospital leaders and service directors, as Dr. Bjerke suggests, can "mandate" certain practices. The use of ultrasound for central venous catheterization is required by the director of our cardiac anesthesia service. All clinicians also have a responsibility both ethically, and as practitioners wishing to maintain sound "business" practices, to update their skills and the services they provide. Finally, for better or worse, the legal profession views itself as a guarantor of our obligations to patients. These are our choices. We ask, as do Drs. Bjerke, Urdaneta, and Gravenstein in their letters, what shall we do?
REFERENCES
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