OP-ED

flying cadeuciiIt’s really quite easy to kill a doctor. Here’s a step-by-step process guaranteed to succeed at least 400 times a year:

Start early.

Be sure to denigrate medical students whenever possible. Even if they’ve come to the profession later in life and have accomplished all kinds of amazing things personally and professionally (which don’t count, of course, since those are other professions) they don’t know squat about medicine and you do. Make sure to emphasize their ignorance and inexperience at every turn, because it’s the only way to prove that you know more than they do, which of course means that you’re a better person than they are. The fact that as a group they’re all at the very top of their peer group in motivation and intelligence is irrelevant. Continue reading “How To Kill a Doctor”

Pharos Cover Art

In 1994, I recorded a fictitious interview with the person whom I imagined to be the last well person on earth. (1)  I mistakenly thought well people were disappearing and I wanted to call attention to their disappearance. I missed the big picture and now want to correct my misconceptions. Well people are not disappearing; instead, a new species of man is emerging:  homo clinicus.

An evolution of the symbiotic relationship between man and medicine has been going on for some time. Lewis Thomas deserves the credit for an early spotting of the new species, first observed in America. He called our attention to this phenomenon in the 1970s.

Nothing has changed so much in the health-care system over the past 25 years as the public’s perception of its own health. The change amounts to a loss of confidence in the human form. The general belief these days seems to be that the body is fundamentally flawed, subject to disintegration at any moment, always on the verge of mortal disease, always in need of continual monitoring and support by health-care professionals. This is a new phenomenon in our society.

Continue reading “Clinical Man *”

flying cadeuciiLast week, the Supreme Court heard arguments in the most recent and pernicious attack on the Affordable Care Act – aka Obamacare.  In the absence of a dysfunctional Congress, the case would be beneath the dignity of Court:  it addresses no complicated legal issues that might guide future decisions of lower courts.   Instead, the Supreme Court has been asked to decide whether a drafting error resulting in one unfortunate phrase in the much maligned 2000 page law –“Exchange established by the States” — means that more than 6.3 million citizens would not be eligible for federalsubsidies allowing them to afford commercial (i.e. – non-governmental) health insurance.

Ordinarily, Congress is expected to fix such drafting problems itself.  Each year Congress pass dozens of “Technical Corrections” bills to fix such errors in prior legislation.  These bills are akin to software patches that are regularly released by companies to fix unanticipated “bugs” previously release programs.  But this is no ordinary legislation.  Having spent six years vilifying for President Obama and has supporters for passing legislation that improves American lives it is far too late in the day for the Republican Congress to replace demagoguery with common sense.

So this issue is now in the lap of the Supreme Court, with its well-known partisan divide of four liberals, four arch-conservatives, and Justice Kennedy, who as the “swing vote” effectively decides many of the most divisive cases himself.  The Court can decide to gloss over this drafting error, as proposed by the Obama Administration, or apply its language to devastating effect.   Prior Supreme Court cases—i.e. “precedent” in the jargon of the law—can be found to support either position.   In the end, there have been few cases in which the Court has more judicial freedom – assuming precedent ever really binds the Court – to do whatever it wants in keeping with the Justices own political biases. Continue reading “King v. Burwell: Will the Supreme Court Save the Republican Party from Itself?”

Cochran THCBThe U.S. Department of Health and Human Services’ recent announcement to move the Medicare program toward value-based payments is among the most promising recent developments in health care.

While changing the way we pay for care will not be easy, we believe that shifting away from fee-for-service to value-based payments could be a catalyst to a better, more affordable health care system in our country.

Three Benefits of Paying for Quality
There are numerous potential benefits to paying for quality rather than quantity, including the three we want to focus on today.

  1. We believe this payment shift has the potential to accelerate progress toward achieving the Triple Aim – defined as better individual care, better population care, and lower cost.
  2. We believe the payment shift by Medicare will accelerate the transition to value-based payments among commercial insurers – a major benefit to employers in terms of improved health for employees and greater affordability.
  3. We believe value-based payments have the potential to help slow – and possibly reverse – the epidemic of physician burnout in the United States, particularly among primary care doctors. Continue reading “Value-Based Reform”

flying cadeuciiRight now there are two patients in every room. One is made with flesh, bones, and blood. One is made with a monitor, a mouse, and a keyboard.

Both demand my time.

Both demand my concentration.

A little over two weeks ago I wrote the short story Please Choose One. I posted it online. The response it generated exceeded anything I could have ever imagined. It struck a nerve. People contacted me from all over the world, from all walks of life, about the story. Everyone, it seems, can relate to the challenge of having to choose between a person and a screen.

People sent me all kinds of suggestions and ideas. A few sent words of encouragement. Yet, what struck me the most about the people who contacted me was what they did not say. Not a single IT person argued the computer was more important than the patient. Not a single healthcare provider stated they wanted more time with the screen and less time with the patient. And finally, most importantly, not a single patient wrote me and said they wished their doctor or nurse spent more time typing and less time listening.

Medicine is the art of the subtle- the resentful glance from the mother of the newborn presenting with the suspicious bruise, the solitary bead of sweat running down the temple of the fifty three year old truck driver complaining of reflux, the slight flush on the face of the teenage girl when asked if she is having thoughts of hurting herself. These things matter. And these same things are missed when our eyes are on the screen instead of the patient.

Continue reading “Feedback Loop”

Screen Shot 2015-02-26 at 5.06.17 PMAs government involvement in U.S. health care deepens—through the Affordable Care Act, Meaningful Use, and the continued revisions and expansions of Medicaid and Medicare—the politically electric watchword is “socialism.”

Online, of course, social media is not a latent communist threat, but rather the most popular destination for internet users around the world.

People, whether out of fear for being left behind, or simply tickled by the ease with which they can publicize their lives, have been sharing every element of their public (and very often, their private) lives with ever-increasing zeal. Pictures, videos, by-the-minute commentary and updates, idle musings, blogs—the means by which people broadcast themselves are as numerous and diverse as sites on the web itself.

Even as the public decries government spying programs and panics at the news of the latest massive data-breach, the daily traffic to sites like Facebook and Twitter—especially through mobile devices—not only stays high, but continues to grow. These sites are designed around users volunteering personal information, from work and education information, to preferences in music, movies, politics, and even romantic partners.

So why not health data?

Continue reading “The Facebook Model for Socialized Health Care”

Susan DentzerFor the second year running, more women than men have signed up for coverage in health insurance marketplaces during open enrollment under the Affordable Care Act. According to the Department of Health and Human Services, enrollment ran 56 percent female, 44 percent male, during last year’s open enrollment season; preliminary data from this year shows enrollment at 55 percent female, 45 percent male – a 10 percentage point difference.

What gives? An HHS spokeswoman says the department can’t explain most of the differential. Females make up about 51 percent of the U.S. population, but there is no real evidence that, prior to ACA implementation, they were disproportionately more likely to be uninsured than men – and in fact, some evidence indicates that they were less likely to be uninsured than males .

What is clear that many women were highly motivated to obtain coverage under the health reform law – most likely because they want it, and need it.

It’s widely accepted that women tend to be highly concerned about health and health care; they use more of it than men, in part due to reproductive services, and make 80 percent of health care decisions for their families . The early evidence also suggests that women who obtained coverage during open enrollment season last year actively used it.   Continue reading “What Do Women Know About Obamacare That Men Don’t?”

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It is reassuring that in a country which produced HL Mencken, Homer Simpson and Mark Twain, reports of death of satire have been grossly exaggerated.

Recently, the faculty at Harvard were up in arms because their new health plan involves copayments and deductibles. With ninety cents to the dollar covered, the plan is generous by national standards, and would be rated “platinum” in Obamacare’s exchanges. It’s not as if the professors were placed on Medicaid to show solidarity with the poor.

Increased out-of-pocket contribution is the trend post health care reform. That same reform which many Harvard professors supported and some designed. This is why their revolt, an Orwellian political satire, has spread schadenfreude amongst conservatives who are enjoying Gore Vidal’s favorite words in the English Language: “I told you so.” Continue reading “Healthcare’s Reform Pareto Trap”

flying cadeuciiAlthough you may not realize it, your doctor is a monopoly. Yes, you can see someone else, but not without difficulty. And if you wanted a second opinion, how far would you go? In part, through insurance coverage, in part based on a desire for convenience, healthcare is generally a local monopoly. However, that may be about to change.

I’m a radiologist, an expert in medical imaging. When I started my career in 1997, I’d show up for work and it was just me and my films. The exams presented to me were a mix of imaging- CT, MRI, ultrasound, plain X-Rays- all captured, presented and stored on film. By 2000, the film was gone. Just about everything I did was done on a computer.

I was an early proponent for this technology (also know as PACS for Picture Archiving and Communications Systems). It allowed my group to work faster and smarter. However through a series of steps (consolidation, specialization and finally commoditization/globalization) technology broke up the local monopoly many radiology groups enjoyed. Similar to Instagram, PACS allowed medical images to be seen instantly by anyone anywhere. And now, based on improvements in technology, I’m expecting similar changes for the rest of healthcare.

Consolidation

Tele-radiology first emerged in hospitals when computers began to be used to optimize the daily workload. At the beginning of my career, several doctors divided work for the day into piles. Each person did his or her allotment with no real help from peers. With the transition to digital, work became a common pile that was shared among physicians in the same hospital. Faster doctors filled downtime gaps reading more cases, resulting in improved overall efficiency.

Continue reading “How Technology Will Disrupt Your Doctor’s Monopoly”

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Atul Gawande is the preeminent physician-writer of this generation. His new book, Being Mortal, is a runaway bestseller, as have been his three prior books, Complications, Better, and The Checklist Manifesto.

One of the joys of my recent sabbatical in Boston was the opportunity to spend some time with Atul, getting to see what an inspirational leader and superb mentor he is, along with being a warm and menschy human being. In my continued series of interviews I conducted for The Digital Doctor, my forthcoming book on health IT, here are excerpts from my conversation with Atul Gawande on July 28, 2014 in Boston.

I began by asking him about his innovation incubator, Ariadne Labs, and how he decides which issues to focus on.

Gawande: Yeah, I’m in the innovation space, but in a funny way. Our goal is to create the most basic systems required for people to get marked improvements in the results of care. We’re working in surgery, childbirth, and end-of-life care.

The very first place we’ve gone is to non-technology innovations. Such as, what are the 19 critical things that have to happen when the patient comes in an operating room and goes under anesthesia? When the incision is made? Before the incision is made? Before the patient leaves the room? It’s like that early phase of the aviation world, when it was just a basic set of checklists.

In all of the cases, the most fundamental, most valuable, most critical innovations have nothing to do with technology. They have to do with asking some very simple, very basic questions that we never ask. Asking people who are near the end of life what their goals are. Or making sure that clinicians wash their hands. Continue reading “Computers Replacing Doctors, Innovation and the Quantified Self: An Interview with Atul Gawande”

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