Monday, July 16, 2018

Physicians

Physicians
The doctor is in ...

“What is… Wegener’s Granulomatosis?”

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A terrific article in The New York Times Magazine this summer described the decade-long effort on the part of IBM artificial intelligence researchers to build a computer that can beat humans in the game of “Jeopardy!” Since I’m not a computer scientist, their pursuit struck me at first as, well, trivial. But as I read the story, I came to understand that the advance may herald the birth of truly usable artificial intelligence for clinical decision-making.

And that is a big deal.

I’ve lamented, including in an article in this month’s Health Affairs, on the curious omission of diagnostic errors from the patient safety radar screen. Part of the problem is that diagnostic errors are awfully hard to fix. The best we’ve been able to do is improve information flow to try to prevent handoff errors, and teach ourselves to perform meta-cognition: that is, we can think about our own thinking, so that we are aware of common pitfalls and catch them before we pull our diagnostic trigger.

These solutions are fine, but they go only so far. In the age of Google, you’d think we’d be on the cusp of developing a computer that is a better diagnostician than the average doctor. Unfortunately, computer scientists have thought we were close to this same breakthrough for the past 40 years and both they and practicing clinicians have always come away disappointed. Before getting to the Jeopardy-playing computer, I’ll start by recounting the generally sad history of artificial intelligence (AI) in medicine, some of it drawn from our chapter on diagnostic errors in Internal Bleeding:

Kill the Codes

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Oh, that clever Center for Public Integrity.  Look what they’ve gone and done now!  My, oh my.  According to the article, doctors are much of the the problem, billing “billions” of Medicare upcharges according to the center.

But what if the medical coding game itself is flawed?  Stop for a moment and imagine what it would look like if lawyers billed like doctors.  Suddenly, we see how bizarre the world of government billing codes and chart-completion mandates has become.

Not long ago I asked readers what my time is worth on a per-hour basis.  Collectively and independently, they settled on a number of about $500/hr (see the comments).  Now look for a moment at what Medicare pays, even at its highest level of billing for a physician’s time for evlauation and management of a medical problem: for 40 minutes of a physician’s time, it’s $140 (or $210/hr) before taxes.  Again, we see another disconnect as to how doctors are valued in our current system.

Doctors are working long hours to collect these fairly low fees from Medicare while jumping more hoops than ever to do so.  They have become pseudo-experts at the coding game, trying to get as much money for their extra efforts as legally possible.  But these fees paid by Medicare do not cover payments for time spent on phone calls, e-mails, and working insurance denials.   These services are still considered by our system as gratis. To partially counteract this coding problem, doctors realized (and the government insisted) that doctors use electronic medical records.

But when independent doctors set out to implement these records they quickly discovered that the expense and long-term maintenance costs of local office-based EMRs could not compete with more sophisticated systems already in use by their neighboring large health care systems.  Because of ever-increasing cost-of-living and overhead costs, not to mention the threats of large fee cuts, doctors have migrated to large health systems faster than ever.  With the fancier electronic record at those systems (streamlined for billing, collections, and marketing) fields required for higher billing codes (but not always material to the problem at hand) are completed in less time.  So are doctors really the problem?

The Art Of The Apology: What Not To Say When Things Go Wrong

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There were two high-profile apologies in the news this week — by the Leader of the Free World and by a Man Who Makes Yoga Pants.

Neither was well executed and neither was well received.

Let’s start with President Obama, who offered his belated apology on the rollout of the federal health exchange at the heart of the Affordable Care Act. After more than five weeks of shifting stories, blame and timelines, the president sat down with Chuck Todd to say “I’m sorry” for repeatedly saying some variation of, “If you like your health plan, you can keep it. Period.”

Sort of.

“I am sorry that they are finding themselves in this situation based on assurances they got from me,” he told NBC News. “We’ve got to work hard to make sure that they know we hear them and we are going to do everything we can to deal with folks who find themselves in a tough position as a consequence of this.”

Critics quickly and loudly objected to the president’s use of passive voice — and the fact that he claimed people found themselves with cancelled plans “based on assurances they got from me.” They pointed out that it wasn’t the assurances that cancelled the plans; it was the way Obama’s administration wrote the regulations that required insurance companies to cancel the plans.

In short, Obama didn’t own the cause of the pain. He only apologized for the “assurances” (which, by almost all accounts, are better known as “lies”).

Now, the Man Who Makes Yoga Pants.

Lululemon founder Chip Wilson got in hot water for blaming women’s bodies for well-publicized problems with his company’s yoga clothes, including see-through pants and pilling:

“Even our small sizes would fit an extra large, it’s really about the rubbing through the thighs, how much pressure is there … over a period of time, and how much they use it,” he said.

Well, then.

This, of course, led to a predictable backlash — particularly on the company’s Facebook page, where women shared their views of the company and Wilson’s basically saying “You’re too fat to wear our clothes.”

Concierge Medicine From A Doctor’s Perspective – David R. Donnersberger, MD, JD

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Call it boutique medicine. Retainer medicine. Platinum care. Evoking the pastoral image of a sturdy black doctor’s bag and spectacles, concierge medicine is a small but growing trend among over-worked and over-booked physicians. The practice essentially offers a limited number of patients the opportunity to pay a fixed annual fee in exchange for premium services and attention. Fees can range anywhere from $1,000 to $20,000. Concierge medicine has been dubiously received while transition necessitates limiting a physician’s patient base significantly. Imagine receiving a letter from your doctor of 30 years demanding an annual fee on top of the cost of your normal visits. Hurry your check, and you may be one of the lucky ten percent the practice will keep. Thousands of patients have been outraged to receive just this kind of letter from their family doctor.

I believe concierge medicine can indeed offer significant advantages if mixed with a dose of good, old-fashioned business practice. There exists a happy medium that allows physicians to spend increased time with patients without alienating long-term clients. In our practice, we demand no annual fee. We ask that Medicare patients pay out of pocket for their wellness visit; such payment is only covered when the patient turns 65. The patient can in turn be reimbursed on the insurance provider’s schedule.

PHARMA/PHYSICIANS: Trying to stop the biting of the feeding hand

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So there’s a bunch of rabble-rouser docs who are actually trying to enforce the often mouthed concept that doctors shouldn’t take freebies from pharma companies. They’re called No Free Lunch

And of course, given the actual views of mainstream doctors who believe that life was better when the pharma companies had no restrictions on the graft they could send their way, they are being banned by specialty societies from doing things like handing out the specialty societies own guidelines on gift-receiving to its members, and of course from buying a booth at the oh-so-well incorruptible AAFP’s convention. Jim Edwards at Brandweek has more. But let’s not be too surprised.

It’s Raining Cataracts, Hallelujah

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flying cadeuciiCMS released new data, shrouded thus far in needless secrecy: how much it pays individual physicians.

Unlike the Shroud of Turin, no one will question its authenticity. But authenticity doesn’t guarantee the data won’t intrigue, confuse, anger, perplex, confound and burn a few innocents at the stakes. That is before we conclude that more research is needed, or more colloquially stated, we still don’t have a clue.

Medicare bounty hunters, the modern day witch finders, are licking their lips for their share of the looted spoils. Academic researchers will be dissecting both wings of the bell-shaped curve of variation in payment to set the next battle between good and evil. But all eyes (pun intended) are upon Florida; specifically one particular provider.

The provider, an ophthalmologist, (you can look up the name) billed CMS for $21 million.

CMS paid ophthalmologists $ 5.6 billion. That’s more than the GDP of Burundi. CMS paid over a billion dollars for treatment of macular degeneration with Lucentis (Genentech).

Take a deep breath now. The treatment of one organ in over 65 year old American citizens is equal to the GDP of one African nation. Gini would have turned beetroot with embarrassment.

Diabolical? Scandalous? Shocking? Surprising?

None of the above, actually. If you think about it.

As we age, and age we do thanks to our lives being constantly “saved” by prevention, regulation and cures, arteries harden, brain atrophies and bones thin. And eyesight falters. Lens fog. Macula degenerates, reducing central vision making it difficult to read.

As we age, we consume more medical services. Yes, take that as an economic truism. And no, I’m not applying for membership of the Death Panel.

Here’s the thing. It’s nice to be able to see when you’re 75. It’s also nice to see when 85, and damn essential when 90.

Otherwise you might trip over the walking stick, fracture the neck of the femur, develop a clot in the deep veins, then a clot in the pulmonary arteries, then a raging pneumonia in ICU, followed by septic shock and a cardiac arrest. Then perhaps you may rest in peace. But not before a few interns have fractured half a dozen ribs during a well-intentioned but hopelessly misguided cardiopulmonary resuscitation that family members lobbied for to assuage their guilt for never visiting you in your nursing home.

Teaching Value: Medical Educators Need to Take Charge and Help Deflate Medical Bills

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At a time when one in three Americans report difficulty paying medical bills, up to $750 billion is being spent on care that does not help patients become healthier. Although physicians are routinely required to manage expensive resources, traditional medical training offers few opportunities to learn how to deliver the highest quality care at the lowest possible cost. While the gap is glaring the problem is not new.

In 1975, the department of medicine at Charlotte Memorial Hospital initiated a system to monitor medical costs generated by house officers. In the Journal of Medical Education leaders of the Charlotte initiative described how simply being aware of how clinical decisions impact the costs of care could decrease inpatient length of stay by 21%. Over the last four decades there have been dozens of similar efforts to educate medical students and residents about opportunities to improve the value of care. Some interventions were simple like the one in Charlotte, and simply revealed the cost of routine tests to their trainees. Others provided more sophisticated didactics, interrogated medical records to give trainee-specific feedback on utilization, or creatively leveraged the hospital computer order-entry systems.

Maybe Being Wrong is Better and More Human than Being Right

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St. Augustine: “Fallor ergo sum”

When I was in charge of the medical residency programs in Grand Rapids, Michigan, David Leach introduced me to the expanded Dreyfus Model of how physicians can progress from beginners to masters.  I was always struck by how master physicians freely admitted their mistakes and used them as a teaching tool.  As a young surgical and cytopathologist, my sanity was saved more than once by University of California San Francisco’s Dr. Theodore R. Miller, a true master of cytology, being willing to share with me some of his mistakes.  I do not honestly think I could have survived in diagnostic pathology without his guidance and wisdom.  Years later, I still remember Dr. Miller showing me a breast fine needle aspiration biopsy slide of fat necrosis that mimicked ductal carcinoma and a case of wrongly diagnosed pancreatic cancer that turned out to be inflammatory atypia.

Mistakes and errors are on my mind because I just finished reading some extraordinary works.

PHYSICIANS/POLICY/POLITICS: The AMA, as reliable as ever

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The AMA — well after 100 years of hisory, we’d never have seen this one coming.  

The American Medical Association has made clear that it will oppose efforts to link Medicare payments to higher-quality healthcare services unless Congress and Medicare permanently halt steadily declining payments to doctors.

PHYSICIANS: The New York Times–desperate to fill column inches

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When I think about all the problems in American health care, many of them the result of the political and clinical choices made by “older and middle-aged physicians (like myself)” (“Myself” being the author of the piece, Dr Erin Marcus from Miami) I can’t say that the non-formal attire worn by some young doctors  is exactly in the top 5000. In fact wearing a tie, as she (I think Erin is a she) points out, is actually harmful as they collect bacteria—so the chippie with the low cut top is better for the patient than the stuffy old doc wearing the tie!

But honestly, has the paper of record got nothing better to say about physicians, and no one more interesting than Dr. Marcus to invite to write about them? I’m reminded of open sores…..

Happy Thanksgiving!