To the Editor. —
The Department of Defense undertook an extensive, undoubtedly expensive, review designed to assess the quality of care given by their physicians.1 While the concern for quality is praiseworthy, this program points up several of the limitations of current quality assurance methods.
When it is difficult to list objective standards with which all physicians can agree, the standards are likely to be fairly broad. Thus, in this study, hysterectomy passes review if the uterus is more than 9 weeks' size, and cholecystectomy if there are gallstones and flatulence. This tends to trivialize quality assurance.
The very topics that are selected for review are likely to be those that lend themselves most easily to this sort of standardization and not the more complicated cases for which standards are more difficult to generate. But these complex cases, often involving chronically ill patients with multiple diagnoses, are increasingly common
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