I wish I could feel guilty about this...

Early in my career I volunteered to be a Reviewer of my Peers, one of those citizens who reviews medical records to determine if appropriate medical care was delivered to Medicare beneficiaries. As an upper echelon reviewer I would get cases that had attracted the attention of a screener, then a nurse practitioner, then perhaps a physician generalist. After careful review, I would venture an opinion as to the quality of the care delivered. This feedback would reach the physician or hospital, and could have led to a variety of sanctions and punishments.

My motivation for participation was simple. I wanted to improve the delivery of healthcare in my region. I wanted to do my part. I wanted world peace.

The review organization changed hands and I received no more cases to review, which was fine. They took a lot of time to do well, and the pay was shabby. Then in the past year the medical charts began to reappear on my desk.

Before I left on vacation I had a little pile of charts for review on my desk. These charts sat untouched by human hands until earlier in the week when I received an urgent letter: "Doctor, we really need those charts back. Will you get off your duff and review them?"

In my fatigue I sat down and opened the first. A physician had hospitalized a patient who had been puking his guts out. The patient was a diabetic and a bit frail. The doctor kept him in the hospital for three days, giving him IV fluids and anti-nausea medication. He left the hospital in a greatly improved condition.

The review organization asked me to review the case to see if he merited a "good citizenship award". The doctor's writing was legible, his orders appropriate, and his intervention prevented, say, the patient from going into renal shutdown which would require very expensive dialysis.

In a parallel universe. What the screener was bringing to my attention was this:

• Did this intervention justify admission?
• The patient was in the hospital for three days. Could he have been discharged in two?
• The patient in his history reported fever and chills leading up to his hospitalization. Why were there no fever and chills documented while he was in the hospital?
• The patient's history listed "frequent urinary tract infections". Why was this used as one of the discharge diagnoses?
• Are there any other violations that we did not spot?

I've always been a person who does his best to honor his commitments, but this was the wrong case at the wrong time. I'm not going to be party to institutionalized harassment of physicians who are out there trying to do a good job.

So I sent the charts back. "I'm sorry but the time demands of my practice prevent me from giving the attention that these charts deserve. Please take me off your list of reviewers".

And I brace for the onslaught.