The doctor is in ...


Screen Shot 2015-10-01 at 9.46.12 AMIn a recent Harvard Business Review article, authors Erin Sullivan and Andy Ellner take a stand against the “outcomes theory of value,” advanced by such economists as Michael Porter and Robert Kaplan who believe that in order to “properly manage value, both outcomes and cost must be measured at the patient level.”

In contrast, Sullivan and Ellner point out that medical care is first of all a matter of relationships:

With over 50% of primary care providers believing that efforts to measure quality-related outcomes actually make quality worse, it seems there may be something missing from the equation. Relationships may be the key…Kurt Stange, an expert in family medicine and health systems, calls relationships “the antidote to an increasingly fragmented and depersonalized health care system.”

In their article, Sullivan and Ellner describe three success stories of practice models where an emphasis on relationships led to better care.

But in describing these successes, do the authors undermine their own argument?  For in order to identify the quality of the care provided, they point to improvements in patient satisfaction surveys in one case, decreased rates of readmission in another, and fewer ER visits and hospitalizations in the third.  In other words…outcomes


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Early in my career in the 1960s, I developed an interest in patients who had physical symptoms but no definable medical disease. I began to see a number of these patients referred from my colleagues. I asked myself, “If these patients do not have a medical disease, then what do they have?”

I defined “symptoms of unknown origin” as occurring when a patient had two or more symptoms for over a month, and whose symptoms remained unexplained after a thorough medical workup. I intended to study and follow these patients, hoping to uncover the underlying cause for their symptoms whatever they might be. I was surprised to discover that many such patients carried diagnoses of non-existent diseases – that is false diagnoses. I soon found that the presence of a false diagnosis created a barrier to uncovering the real cause for the symptoms.


Michael MillensonPerhaps the most well-known part of the 1965 Medicare creation tale is the opposition by the American Medical Association (AMA) to “socialized medicine.” Yet with financial incentives assuming a new prominence for provider and patient alike, we shouldn’t overlook the AMA’s equally unsuccessful battle against the excesses of capitalistic medicine. The forgotten story of the professionalism’s failure to contain physician greed provides an important policy perspective.

The Myth Of Medicine’s ‘Golden Age’

Medical practice pre-1965 is often portrayed as a mythical “Golden Age.” The truth, as I found researching my 1997 book, Demanding Medical Excellence: Doctors and Accountability in the Information Age, was that the post-war years were a time when way too many doctors grasped for the gold.

The most common “entrepreneurial” excesses were fee splitting, where a specialist paid a kickback to the referring doctor, and ghost surgery, where a surgeon secretly paid a colleague to operate on an anesthetized patient. The first surgeon paid the “ghost” a small part of the total fee and pocketed the difference. Even worse was rampant surgical overuse, where common excesses included appendectomies for stomachaches and hysterectomies on young women with nothing more than back pain.

Although professional societies wielded far more influence than now, efforts by leaders of the AMA and the American College of Surgeons to stop these abuses repeatedly fell short. Doctors “display a consistent preoccupation with their economic insecurity,” a 1955 report by the AMA concluded with discomfiting bluntness.


GundermanThere are different ways to take the measure of a life.  John Rockefeller, the richest person in the history of mankind, once asked a neighbor, “Do you know the only thing that gives me pleasure?  It’s to see my dividends come in.”  Television magnate Ted Turner once said, “I don’t want my tombstone to read, ‘He never owned a network.’”  And musical artist Lady Gaga has described her quest as “mastering the art of fame.”  But wealth, power, and fame are not life’s only metrics, and September 4 marks the 50th anniversary of the death of one of the 20th century’s brightest counterexamples.

His name was Albert Schweitzer.  Winston Churchill once referred to him as a “genius of humanity,” and a 1947 issue of Time magazine dubbed him “the greatest man in the world.”  Though Schweitzer held four doctorates and achieved worldwide fame as a musician, theologian, medical missionary, and promoter of a philosophy of “reverence for life,” for which he received the 1952 Nobel Peace Prize, his most enduring contribution lies in his lifelong commitment — both theoretical and practical – to the suffering.

Schweitzer was born 1865 in the Alsace region of what is now eastern France, the son of a Lutheran pastor whose grandfathers were both accomplished organists.  Though already a world-renowned musician and writer, at age 30 Schweitzer decided to answer a call to missionary work, spending the next seven years of his life studying medicine.  Once he finished his medical studies, he and his new wife, Helene, traveled 4,000 miles to set up a missionary hospital in what is now Gabon in west central Africa.  There he spent most of the rest of his life, eventually dying there in 1965.


flying cadeuciiTo understand why so many medical students (and pre-meds) (and doctors) contemplate business training, let’s consider two real-life examples: Dr. Bob Kocher and Dr. Bijan Salehizadeh. Both trained as physicians, both are currently healthcare investors, and both shared their stories with Lisa Suennen and me on our Tech Tonics podcast. (Kocher’s interview can be found here; Salehizadeh’s will available at the end of the month.)

(My usual disclosure: I work at a cloud genomics company in Silicon Valley; neither my company nor I have a financial relationship with Kocher, Salehizadeh, or their firms.)

Bob Kocher: The Hospital Consultant

Kocher is currently a partner at Venrock’s Palo Alto office, and is perhaps best known for his previous role working in the White House developing the Affordable Care Act in collaboration with Zeke Emanuel and others.

When he was growing up Seattle, Kocher says, his “dream was to be a leukemia and lymphoma doctor at the Fred Hutchinson Cancer Research Center.” He went to medical school, trained in internal medicine at the Beth Israel Hospital in Boston, and was accepted into a prized oncology fellowship at the Dana Farber Cancer Institute.


Screen Shot 2015-08-24 at 8.42.46 AMDid it ever occur to some of today’s physicians that many people work awfully hard and complain a lot less than they do about “burnout” and “work-life balance”?

Did it ever occur to them that “work-life balance” is the very definition of a first-world problem, unique to a very privileged class of highly educated people, most of whom are white?

Every day, I go to work and see the example of the nurses and technicians who work right alongside me in tough thoracic surgery cases. Zanetta, for instance, is the single mother of five children. She leaves her 12-hour shift at 7 p.m. and then faces a 60-mile commute to get home. She never complains, and unfailingly takes the extra moment to get a warm blanket for a patient or cheerfully help out a colleague


Richard Gunderman goodLife is tough for physicians in solo and small group practice.  The federally mandated introduction this fall of ICD-10 requires physicians and their staffs to learn a new system of coding diseases.  “Meaningful Use,” another federal program, requires physicians to install and use electronic health records systems, which are complex and expensive.  And PQRS, the Physician Quality Reporting System, is beginning to penalize physicians for failing to report individual data for up to 110 quality measures, such as patient immunizations, each of which takes time to collect and record.

Of course, such requirements are not being imposed solely on solo and small-group physicians.  In many ways, they affect all physicians alike.  Yet the burdens of complying are disproportionately high for small groups, which cannot spread out the costs of purchasing equipment, hiring employees and consultants, and training personnel over so large a number of colleagues.  Hospitals and large medical groups can afford to hire full-time specialists to meet these challenges, but such approaches are not economically feasible for a group that consists of only a few physicians.

Such challenges are not just raining down –  they are pouring down on the heads of physicians.  Some physicians fear they smell a conspiracy to drive solo and small-group practitioners out of business.  And the problem is not just the money.  It’s also the time.  Many physicians already work long hours and simply cannot afford to shop for such systems, negotiate contracts, and enter data.  We personally know physicians who report spending two hours each evening completing records that they did not have time to attend to while they were seeing patients.


A cell phone snap of an California Emergency Room physician reacting to the death of a young patient in his care went viral on Reddit after a EMT posted the picture to the social media site on Friday.

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flying cadeuciiMany people believe that neurologists are particularly attracted to detail.  I prefer to think of the issue as one of precision rather than pointless obsessiveness.  Some years ago, I was asked to discuss a case for the New England Journal of Medicine’s series of CPCs called the Cabot Cases.

In preparing the case for publication, I found myself in an argument with the editor about the placement of an apostrophe. There were two diagnoses in this case: aphasia from a cardiac source embolism to the left cerebral hemisphere and hypercoagulability as a paraneoplastic syndrome. In my view, aphasia is a Trousseau syndrome (i.e., the word “aphasia” was suggested by Trousseau), whereas hypercoagulability as a paraneoplastic syndrome was Trousseau’s syndrome, because Trousseau both described and suffered from the disease. I am very much opposed to the trend to remove eponyms from the names of diseases and syndromes as to do so strips medicine of some of its most illustrious history.  But, only a handful of eponymic disorders deserve the apostrophe. Antonie van Leeuwenhoek’s disease (diaphragmatic myoclonus) is another example.

History in medicine is not a mere avocation. In addition to the old saw of helping to prevent the same errors from being repeatedly made, it provides us with the perspective needed to approach diagnostic and scientific challenges in our own era. It also combats hubris. In carefully researching my eleven New England Journal CPCs I have never encountered an idea that had not evolved from those before it.

In grand rounds, in medical journals, and particularly in the lay press, we are regaled with “revolutionary” ideas, but that they are completely new is an illusion. Throughout history, people have always been on the “cutting edge” and have repeatedly believed that they had some sort of huge advantage over prior generations.


The History of the Problem 

Martin SamuelsThe European University (e.g. Italy, Germany, France, England) descended from the Church. The academic hierarchy, reflected in the regalia, has its roots in organized religion.

The American University was a phenocopy of the European University, but the liberal arts college was a unique American contribution, wherein teaching was considered a legitimate academic pursuit.  Even the closest analogues in Europe (the colleges of Cambridge and Oxford) are not as purely an educational institution as the American liberal arts college.

The evolution of American medical education (adapted and updated from: Ludmerer KM. Time to Heal, Oxford University Press, Oxford, 1999) may be divided into five eras.

I.  The pre-Flexnerian era (1776- 1910) was entirely proprietary in nature. Virtually anyone with the resources could start a medical school.  There was no academic affiliations of medical school and no national standards.

II. The inter-war period (1910-1945) was characterized by an uneasy alliance between hospitals and universities.  Four major models emerged.  In the Johns Hopkins model, led by William Osler, the medical school and the hospital were married and teaching of medicine took place at the bedside. The Harvard model in which the hospitals grew up independently with only a loose alliance with the medical school, represented a hybrid between pre- and post-Flexnerian medical education.