Physicians

 

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US Healthcare is sick and getting sicker, and while its chaotic complexity suggests to many that it will need to fail big before it can be rebuilt, some simple rules may help to get it back on track. As this the time of year when many of us prepare to send our children on grandchildren off to school in the hopes that they will learn what they need to succeed, I thought we could revisit the lessons of Kindergarten and their application to healthcare. The following list, initially from “ALL I REALLY NEED TO KNOW I LEARNED IN KINDERGARTEN” by Robert Fulghum.  has been adapted (read ‘man-handled’) for applicability to US healthcare. You’ll find the original list here:  http://www.robertfulghum.com/

  • Share everything – In healthcare, this means share ALL the data, all the information, all the acquired wisdom. Interoperable systems are essential. Price transparency is the right side of history. Automated, coordinated, connected systems are essential.  Healthcare is too much of a team sport not to share all that we know, so that we can quickly understand what works, what doesn’t, and what it’s all going to cost.
  • Play fair – It isn’t fair when decisions are made without a person’s input.  It isn’t fair that a patient should bear the risks, the pain, the scars and the costs without having unfettered access to all the relevant information. Shared decision making is part of playing fair in a world where healthcare is meant to happen for patients and with patients, but not to patients.
  • Put things back where you found them. Except for things like an infected appendix or a malignant growth, this continues to make great sense.  And as we go about transforming healthcare, we must recognize that wholesale, sweeping changes are easier to envision than execute.  While progress requires change those changes that align with / enhance / expedite existing workflows will be easiest to achieve.
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Screen Shot 2014-08-21 at 11.45.17 AMCelebrating its 40 anniversary this year, Robert M. Pirsig’s Zen and the Art of Motorcycle Maintenance bears several distinctions.  It is listed in the Guinness Book of World Records as the eventual bestseller that was rejected by more publishers than any other, 121.  It went on to sell more than 5 million copies, making it the most popular philosophy book of the past 50 years.  And it focuses on a truly extraordinary topic, which its narrator refers to as a “metaphysics of quality.”

Quality is a hot topic in healthcare today.  Hospitals and healthcare systems are abuzz with the rhetoric of QA and QI (quality assessment and quality improvement), and healthcare payers including the federal government are boldly touting new initiatives intended to replace quantity with quality as the basis for rewarding providers.  Yet as Pirsig’s narrator, Phaedrus (see Plato’s dialogue of the same name), comes to realize, quality is very difficult to define.

In fact, giving an account of quality is so difficult that it drove Zen’s author mad.  And this is a man whose IQ, 170, would make him one of the most intelligent people in any health system.  The problem, of course, is that there is a big difference between intelligence and wisdom, and in the quest for wisdom, mere intelligence often leads us dangerously astray.  Something similar is happening in healthcare today, where schemes to improve quality often precede sufficient efforts to understand it.

For example, we seek to gain greater control over healthcare outcomes through measurement, only to discover, to our chagrin, that people are massaging the data to meet their numbers.  We create new programs intended to increase patient throughput, only to discover unintended perverse effects on the quality of relationships between patients and physicians.  Initiatives intended to reduce error rates turn out again and again to stifle innovation. Continue reading “Zen and the Quest For Quality”

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Dear Doctor,

The future is in your hands.

You have the opportunity to make primary care better.

More efficient.
More accessible.
And more affordable.

We know you and other primary care doctors have more responsibilities than ever. But you also have great influence, along with the ability and opportunity to change this country’s health care system for the better.

Primary care is essential to the quality of health care, and we need you now more than ever.

Maneuvering the Minefield

According to research firm Harris Interactive, “the practice of medicine is … a minefield. … Physicians today are very defensive – they feel under assault on all fronts.’’* Harris questions, “how much fight the docs have left in them. Some are still fired up … while others have already been beaten down.’’

Those who feel frustration, anger and burnout say they are squeezed by administrators, regulators, insurance companies and more. They worry about the possibility of a lawsuit that could destroy your career.

The question is: What can be done about it? Some of you may choose to remain in the status quo. Some of you have chosen to retire early or otherwise leave the field of medicine entirely. Yet some of you have said enough is enough and found specific solutions that mark a pathway forward. You sought – and found – specific solutions that mark a pathway forward.

If you’ve rejected the status quo and joined your fellows in search of innovations from other practices that you have applied at home, congratulations. You’re a physician leader who’s doing great things for your patients, your colleagues and yourself. You are undoubtedly more satisfied in your work than before, and you are quite likely providing better care.

Continue reading “An Open Letter to Primary Care Physicians”

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John Haughom MD whiteWe need to design a system of health care that optimally meets the country’s needs while also being affordable and socially acceptable. Clinicians should be at the center of this debate if care delivery is to be designed in a way that puts quality of care before financial gain.

This challenge is too important to be left to politicians and policymakers. There is an urgent need for clinicians to step up, lead the debate and design a new future for health care. Placing professional responsibility for health outcomes in the hands of clinicians, rather than bureaucrats or insurance companies with vested interests, must be an ambition for all of us. We need to find the formula that meets the needs of the patients and communities we serve. A sincere collective effort by committed clinicians to design an effective system will lead to a health care system that has a democratic mandate and the appropriate focus on optimizing the outcomes patients and society need.

As clinicians enter the debate, they should keep three things in mind.

Promote the leadership role of clinicians

We need to help politicians and policymakers recognize the role of clinical leaders in shaping a transformed but effective health care system. Clinicians must redefine the debate so that it focuses first and foremost on patients and health outcomes. Cost effective care can and should be a byproduct of optimal care. Accomplishing this will provide a strong common purpose for efforts to address the challenges of designing outcome-based funding structures and improving access to care.

Continue reading “A Time For Revolutionary Thinking”

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Tom Frieden optimizedTwo Americans who became infected with Ebola virus disease in Liberia are now at Emory University Hospital in Atlanta. They’re receiving supportive care, including careful fluid management, as their bodies wrestle with the Ebola virus. While there is no cure for Ebola, strong supportive care will increase their chances of survival.

Their arrival was carefully planned and prepared for. And their care is being closely monitored as they are being managed in strict isolation. We are confident everything is being done for their well-being, and for the safety and well-being of those treating them.

How did these and other health care workers come down with Ebola virus disease?

We may never know the precise source of their exposure.

Regardless, the occurrence of Ebola virus infection in health care workers is a sobering reminder that the preparedness of health care personnel is often a significant factor in Ebola outbreaks. Isolation and strict infection control procedures are essential to prevent spread of the disease.

There has been a lot of fear about Ebola. The health care workers who care for Ebola patients are right to be concerned – and they should use that concern to increase their awareness and motivation to practice meticulous infection control measures.

Ebola virus is transmitted through direct contact with bodily fluids of an infected person who is sick with Ebola, or exposure to objects, such as needles, that have been contaminated with infected secretions.

Travel from Affected Region

There is a risk for Ebola to be introduced to the United States via an infected traveler from Africa. If that were to happen, widespread transmission in the United States is highly unlikely due to our systematic use of strict and standard infection control precautions in health care settings, although a cluster of cases is possible if patients are not quickly isolated. Community spread is unlikely due to differences in cultural practices, such as in West Africa where community and family members handle their dead.

CDC has advised all travelers arriving from Guinea, Liberia, Nigeria, and Sierra Leone to monitor their health for 21 days and watch for fever or other symptoms consistent with Ebola. If they develop symptoms, they should call ahead to their hospital or health care provider and report their symptoms and recent travel to the affected areas so appropriate precautions can be taken.

Continue reading “The Ebola Outbreak: The CDC Director’s Guidance for Health care workers”

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flying cadeuciiThe recent debate surrounding the American Board of Medical Specialties (ABMS) Maintenance of Certification (MOC) program is a microcosm for a transformation in medical practice that is long overdue. The profession of medicine is going through a fundamental shift from a traditional craft-based practice to a more sophisticated, data-driven profession-based practice.  The solo-based practice is dying. As the ABMS program suggests, the awareness and acceptance of this shift is already occurring at the national medical board level, but it is not happening as quickly at the individual physician level. It is time for all clinicians to consider a new, more effective and more empowering approach to clinical care.

Let’s take a look at the details. As you may know, the MOC program consists of six Core Competencies for Quality Patient Care that physicians must demonstrate to maintain certification.  These competencies are over and above the traditional board certification requirements. The core competencies are professionalism, patient care, medical knowledge, practiced-based learning and improvement, interpersonal and communication skills and systems-based practice. Descriptions of each competency can be found here. In addition to being a new requirement, the program encourages a new style of practice for physicians.

The MOC program has generated considerable friction, especially among physicians, some of whom argue that the requirements place an additional burden on their increasingly burdensome work experience. Others have joined the program and are fulfilling its requirements. As of May 2014, 150,000 physicians were enrolled in the program, but tens of thousands have also signed protest petitions.

Continue reading “The Future Is Calling Us”

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flying cadeuciiAfter more than a year of conspiratorial planning that would make Francis Underwood proud, California’s trial attorneys got a number assigned to an opaquely worded ballot initiative on Drug and Alcohol Testing of Doctors. Medical Negligence Lawsuits Initiative Statute As a result, “Proposition 46” could give California voters an unwitting hand in doing what this attorney group has been unable to accomplish after 40 years of inept legislative lobbying and dubious court challenges: undermine the state’s Medical Injury and Compensation Reform Act, or MICRA.

MICRA was passed in 1978 by a Democratic-dominated legislature and signed into law by then-governor Jerry Brown in response to the collapse of the state’s medical professional liability insurance market.  MICRA didn’t change the right of injured patients to obtain unlimited economic damages for all medical costs, lost wages and lifetime earnings. What it did was limit was non-economic “pain and suffering” damages to $250,000. Up until 1978, California’s trial attorneys had used this highly speculative class of damages to rake in a third of the multi-million jackpot jury awards. That made California physicians’ malpractice insurance unavailable at any price, leading many doctors to close their practices and leave the state.

That ended with the passage of MICRA. The market stabilized and in the decades that followed, billions in health care savings from lower professional liability costs were passed through to California’s patients.

Early last year, California’s physicians had heard rumors that a ballot initiative to undo MICRA’s non-economic cap was being planned.  Little did they know that California’s trial attorneys would take their cue from political consultant-bully Chris Lehane by opening their campaign with a mass mailing of anti-MICRA cadaver toe tags. That was quickly followed by the neighbors of pediatrician and then California Medical Association President Paul Phinney receiving deceptive postcards implying he was a drug dealer.

Months later, the ballot initiative – that was 100% underwritten by the trial attorneys and their allies at a cost of $2.85 per signature – landed on California Attorney General Kamala Harris’ desk.  The initiative’s authors cleverly disguised its quadrupling of the MICRA cap to more than $1 million (“to account for inflation”) and cynically camouflaged it between two conversation-changers:  1) mandatory physician drug screening and 2) mandatory uploading of the narcotic prescription history of every California patient to an online database. Naturally, Ms. Harris rewarded her trial attorney donors by making a mockery of the state’s single-subject rule and okayed it.

Continue reading “California’s Proposition 46: Trial Attorneys Behaving Badly”

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flying cadeuciiThe answer to the doctor shortage isn’t more doctors

Yesterday, the New York Time’s Editorial Board published a piece on the shortage of physicians in the United States and what’s needed for healthcare workforce redesign.

It’s a good, concise piece about the common thinking around the gap between the needs of our growing patient population and the number of doctors available to deliver the care they need. As as an example, the article refers to a recent statement by the Association of American Medical Colleges whose models predict a shortage of 90,000 doctors in the U.S. by 2020. In Canada, the story is sometimes different where physician unemployment is growing due to inadequate infrastructure and poor workforce planning.

While I do agree that ensuring access to care is important, to think that the solution is simply more doctors comes from framing the question incorrectly.

The question shouldn’t be “how many doctors do we need for a growing population?”. Rather, the question should be “how do we care for a growing population in a cost-effective way?”

When you reframe the problem in this manner, it’s  easy to see that simply churning out more doctors isn’t the answer. In fact, with the direction healthcare is heading, those numbers are likely overestimates.

The major problem with workforce planning models is that they assume healthcare delivery of the future looks very much like healthcare delivery of the present. That the future will continue to be, in many ways, very doctor-centric.

It won’t.

Continue reading “The Answer To the Doctor Shortage Isn’t More Doctors”

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flying cadeuciiThere’s a lot of talk about quality metrics, pay for performance, value-based care and penalties for poor outcomes.

In this regard, it’s useful to ask a basic question. What is quality? Or an even simpler question, who is the better physician?

Let’s consider two fictional radiologists: Dr. Singh and Dr. Jha.

Dr. Singh is a fast reader. Her turn-around time for reports averages 15 minutes. Her reports are brief with a paucity of differential diagnoses. The language in her reports is decisive and her reports contain very few disclaimers. She has a high specificity meaning that when she flags pathology it is very likely to be present.

The problem is her sensitivity. She is known to miss subtle features of pathology.

There’s another problem. Sometimes when reading her reports one isn’t reassured that she has looked at every organ. For example, her report of a CAT scan of the abdomen once stated that “there is no appendicitis. Normal CT.” The referring physician called her wondering if she had looked at the pancreas, since he was really worried about pancreatitis not appendicitis. Dr. Singh had, but had not bothered to enlist all normal organs in the report.

Dr. Jha is not as fast a reader as Dr. Singh. His turn-around time for reports averages 45 minutes. His reports are long and verbose. He meticulously lists all organs. For example, when reporting a CAT of the abdomen of a male, he routinely mentions that “there is no gross abnormalities in the seminal vesicles and prostate,” regardless of whether pathology is suspected or absence of pathology in those organs is of clinical relevance.

He presents long list of possibilities, explaining why he thinks a diagnosis is or is not. He rarely comes down on a specific diagnosis.

Dr. Jha almost never misses pathology. He picks up tiny lung cancers, subtle thyroid cancers and tiny bleeds in the brain. He has a very high sensitivity. This means that when he calls a study normal, and he very rarely does, you can be certain that the study is normal.

The problem with Dr. Jha is specificity. He often raises false alarms such as “questionable pneumonia,” “possible early appendicitis” and “subtle high density in the brain, small punctate hemorrhage not entirely excluded.”

In fact, his colleagues have jokingly named a scan that he recommends as “The Jha Scan Redemption.” These almost always turn out to be normal.

Which radiologist is of higher quality, Dr. Singh or Dr. Jha?

Continue reading “Who Is the Better Radiologist?”

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My life changed dramatically 18 months ago when I started my new practice.  The biggest change personally was a dramatic drop in my income as I built a new business using a model that is fairly new.  That’s a tough thing to do with four kids, three of whom were in college last fall.  OK, that’s a stupid thing to do, but my stupidity has already been well-established.

Yet even if the income stayed identical to what I earned before the switch, the change in my professional life would have been nearly as dramatic.

  • I am no longer focused only on patients in my office.
  • I am no longer focused on ICD and CPT codes.
  • Saving patients money has become one of my top priorities.
  • I feel like my patients trust me more, and see me as an ally.
  • Patients accept my recommendations for less care (avoiding unnecessary testing and unnecessary medications) much easier.
  • I focus far more on preventing problems or keeping them small.
  • I laugh with my patients far more.
  • I no longer feel like a Zombie at the end of the day (and I no longer eat brains)

Continue reading “Doctors vs. Zombies”

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Matthew Holt
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Chief Medical Officer

Vikram Khanna
Editor-At-Large, Wellness

Joe Flower
Contributing Editor

Michael Millenson
Contributing Editor

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