Coming to Terms with Large Databases

TO THE EDITOR:

I read with interest the recent editorial by Dr. Laine [1]. Although I applaud Dr. Laine's efforts, as well as those of Drs. Weinberger and IIui in editing the supplement “Measuring Quality and Cost of Care Using Large Databases” [2], I must express my dismay and extreme concern that this information will be used to hurt patients and their physicians. These editors are unwittingly providing yet another way in which managed care organizations, the federal government, and administrators can justify the withholding of funding for patient care, thus driving even more physicians crazy. I do not exaggerate when I write this. I am a rheumatologist in solo private practice in a small city. I have witnessed several physician colleagues suffer physical and mental illnesses that were in large part due to the inestimable stress of trying to serve their patients but also support their families. It is naive for Dr. Laine to write, “Whether large databases will ultimately prove to be as useful or as dangerous as various parties believe remains to be seen.” They are already being used to justify the withholding of necessary patient care. Databases, contrary to what the editors say, have almost no usefulness in clinical practice. By that I mean that in the day-to-day business of helping a patient, the physician is in a one-on-one relationship with this patient. He or she is ethically bound to do what he or she truly believes is in the patient's best interest, regardless of published outcomes obtained by using databases, albeit large or small. Perhaps Stephen Jay Gould, in his latest book, Full House, put it best when he wrote “I am not a measure of central tendency … . I am one single human being … and I want a best assessment of my own changes-for I have personal decisions to make, and my business cannot be dictated by abstract averages” [3]. I agree with Dr. Gould. When I become a patient, I will want my physician to treat me on the basis of my own unique set of signs and symptoms and not on the basis of previously published outcomes that may have biased my clinician's beliefs.

In short, as a practicing physician, I find that using large databases to measure quality outcomes and cost of care is interesting in an academic sense but has no practical benefit in the treatment of the patient in front of me. Whenever another such study is published, it puts more ammunition in the hands of corporate and government forces that seek to destroy compassion and individualized health care in the United States. This is not a prediction of what might happen. It is happening now in physician offices on a daily basis and is both frightening and counterproductive. I realize that databases will continue to be amassed and their contents described. Therefore, they should also come with the following admonition: Warning: These data are to be used for academic purposes only!

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