Physicians

flying cadeuciiI am a foreign born, foreign trained doctor, serving many patients from an ethnic minority, whose native language I never mastered.

So, perhaps I am in a position to reflect a little on the modern notion that healthcare is a standardized service, which can be equally well provided by anyone, from anywhere, with any kind of medical degree and postgraduate training.

1) Doctors are People

No matter what outsiders may want to think, medicine is a pretty personal business and the personalities of patients and doctors matter, possibly more in the long term relationships of Primary Care than in orthopedics or brain surgery. Before physicians came to be viewed as interchangeable provider-employees of large corporations, small groups of like-minded physicians used to form medical groups with shared values and treatment styles. The physicians personified the spirit of their voluntary associations. Some group practices I dealt with in those days were busy, informal and low-tech, while others exuded personal restraint, procedural precision and technical sophistication. Patients gravitated toward practices and doctors they resonated with.

Continue reading “A Doctor is a Doctor is a Doctor, Right?”

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GundermanThe competition to get into medical school is fierce.  The Association of American Medical Colleges just announced that this year, nearly 50,000 students applied for just over 20,000 positions at the nation’s 141 MD-granting schools – a record.  But medical schools do not have a monopoly on selectivity.  The average student applies to approximately 15 schools, and many are accepted by more than one.  Students attempting to sort out where to apply and which admission offer to accept face a big challenge, and they often look for guidance to medical school rankings.

Among the organizations that rank medical schools, perhaps the best-known is US News and World Report (USNWR).  It ranks the nation’s most prestigious schools using the assessments of deans and chairs (20%), assessments by residency program directors (20%), research activity (grant dollars received, 30%), student selectivity (difficulty of gaining admission, 20%), and faculty resources (10%).   Based on these methods, the top three schools are Harvard, Stanford, and Johns Hopkins.

Rankings seem important, but do they tell applicants what they really need to know?  I recently sat down with a group of a dozen fourth-year medical students who represent a broad range of undergraduate backgrounds and medical specialty interests.  I posed this question: How important are medical school rankings, and are there any other factors you wish you had paid more attention to when you chose which school to attend?

Continue reading “Secrets to Chosing the Right Medical School”

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     Each year, over 20,000 US students begin medical school.  They routinely pay $50,000 or more per year for the privilege, and the average medical student graduates with a debt of over $170,000.  That’s a lot of money.  But for some who pursue careers in medicine, the financial cost has been considerably greater.  Melissa Chen, 35, a final-year radiology resident at the University of Texas San Antonio, calculates that her choice of a medical career has cost her over $2.6 million in lost wages, benefits, and added educational costs.  And yet in her mind, the sacrifice has definitely been worth it.

Continue reading “Is Becoming a Doctor Worth $2.6 Million?”

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GundermanOne of the top students at one of the nation’s largest medical schools, Ishan Gohil has made an unusual – and to many of his colleagues – inexplicable decision.  Instead of seeking to train in one of medicine’s most highly specialized and competitive fields, he says, “I elected to pursue a career in family medicine.”  Many view his choice of primary care as ill-advised, largely because family medicine is one of the least competitive fields and ranks at the bottom for income of all medical specialties.

Until his third year, Gohil had planned to pursue orthopedic surgery, which is considerably more difficult to get into than family medicine.  In 2014, the average score on Step 1 of the US Medical Licensing Exam for students entering family medicine was 218, while for orthopedic surgery it was 245 (the overall average is 230).  Average annual salary levels diverge even more widely, at $122,000 for family physicians and $488,000 for orthopedic surgeons. Continue reading “Solving the Primary Care Shortage”

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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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Joe FlowerPut the question in 1880: Will technology replace farmers? Most of them. In the 19th century, some 80% of the population worked in agriculture. Today? About 2% — and they are massively more productive.

Put it in 1980: Will technology replace office workers? Some classes of them, yes. Typists, switchboard operators, stenographers, file clerks, mail clerks — many job categories have diminished or disappeared in the last three decades. But have we stopped doing business? Do fewer people work in offices? No, but much of the rote mechanical work is carried out in vastly streamlined ways.

Similarly, technology will not replace doctors. But emerging technologies have the capacity to replace, streamline, or even render unnecessary much of the work that doctors do — in ways that actually increases the value and productivity of physicians. Imagine some of these scenarios with me:

· Next-generation EMRs that are transparent across platforms and organizations, so that doctors spend no time searching for and re-entering longitudinal records, images, or lab results; and that obviate the need for a separate coding capture function — driving down the need for physician hours of labor. Continue reading “Will Technology Replace Doctors?”

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Jack CochranIn recent weeks and months a number of articles have delved into the issue with a sense of seriousness and purpose that the doctor crisis deserves. Progress on reducing unnecessary pressures on physicians is painfully slow, but the broadest possible recognition of the problem is an important step toward dealing with it effectively.

We hold a basic belief about the future of health care: Solving the doctor crisis is a prerequisite to transforming our delivery system to improve access, equity, quality, and affordability. How can we possibly achieve the overall excellence and affordability in health care if large numbers of doctors are alienated and burned out?

Let’s be very clear: This is not about coddling doctors.

It is about preserving the ideals of the physician as healer and enhancing the professional experience – essential elements to optimizing care for patients and families. It is about acknowledging an honorable profession whose members deserve an environment in which they can serve patients to the best of their ability; an environment in which physicians can aspire to continuous improvement as engaged learners who embrace their role as active members of the Learning Coalition.

Traced Back to Medical School

The problem begins as early as medical school. Richard Gunderman, MD, recently authored an article in the Atlantic arguing that medical students:

are suffering from high rates of emotional exhaustion, depersonalization, and a diminished sense of personal accomplishment. College students choose careers in medicine because they care, because people matter to them, and because they want to make a difference. What is happening to the nearly 80,000 U.S. medical students to produce such high rates of burnout?

Dr. Gunderman argues that we “need to understand not only the changes taking place in medicine’s external landscape but the internal transformations taking place in minds and hearts. … In what ways are we bringing out the best elements in their character — courage, compassion, and wisdom — as opposed to merely exacerbating their worst impulses — envy, fear, and destructive competitiveness?”

Continue reading “Help the Doctor”

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Screen Shot 2014-09-18 at 2.28.53 PMNot accustomed to visiting hospital executive suites, I took my seat in the waiting room somewhat warily.

Seated across from me was a handsome man in a well-tailored three-piece suit, whose thoroughly professional appearance made me – in my rumpled white coat, sheaves of dog-eared paper bulging from both pockets – feel out of place.

Within a minute, an administrative secretary came out and escorted him into one of the offices. Exhausted from a long call shift and lulled by the quiet, I started to doze off. Soon roused by the sound of my own snoring, I started and looked about.

That was when I spotted the document on an adjacent chair. Its title immediately caught my eye: “How to Discourage a Doctor.”

Continue reading “How To Discourage a Doctor”

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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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