Physicians

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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flying cadeuciiDespite highly skilled physicians and advanced technology, the U.S. has not yet figured out how to provide effective affordable health care to everyone. Meanwhile, the health care system is increasingly fractured and stressed—and so are our doctors. Physician burnout impacts nearly half of all seasoned physicians in practice and up to 75% of resident physicians in training1. Over water cooler conversations, as well as in my work as a psychiatrist at the University of North Carolina at Chapel Hill (UNC), I hear more and more physicians report anxiety, stress and emotional exhaustion. Many feel as if they are perpetually swimming upstream; others feel there is no joy or meaning in their work; some want to quit medicine altogether. These good doctors are in crisis in increasingly high numbers — an epidemic that requires immediate attention.

Last year, the UNC School of Medicine launched the Taking Care of Our Own program to address the problem of physician burnout and we have been met with a deluge of physicians asking for help. Burnout, however, is not a diagnosis. It is a constellation of symptoms that include emotional exhaustion, depersonalization and loss of perspective that work is meaningful2. Untreated, burnout syndrome can erode professional behavior at work and healthy relationships at home. This leads to decreased empathy and compassion, poor communication and potentially worse patient outcomes. The personal consequences include disrupted relationships with family and friends, self-medicating with alcohol or other substances, depression and an increased risk of suicide, which is higher among physicians than the general population, in part due to the stigma associated with seeking mental health treatment.

Not a day goes by without my hearing from a physician in distress who has learned about the Taking Care of Our Own program. These conversations have a striking degree of similarity. They typically begin with an apology—a statement about how embarrassing it is to ask for help in dealing with anxiety or depression; or a recent loss; or other emotional stressor that makes it too difficult for the doctor to remain professional and compassionate while managing a demanding workload.

Continue reading “Physician Burnout: It’s Time to Take Care of Our Own”

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Screen Shot 2014-06-20 at 11.28.40 AMOn the front page of last Tuesday’s Wall Street Journal was this headline:  “Taxpayers Foot Big Bills from Handful of Doctors.” It is a two-page story about a clinician whose practice drew attention from the WSJ research team that combed through the recently released Medicare Utilization and Payment database released in April. They wrote:

“Ronald S. Weaver isn’t a cardiologist. Yet 98% of the $2.3 million that the Los Angeles doctor’s practice received from Medicare in 2012 was for a cardiac procedure, according to recently released government data…The government data show that out of the thousands of cardiology providers who treated Medicare patients in 2012, just 239 billed for the procedure, and they used it on fewer than 5% of their patients. The 141 cardiologists at the Cleveland Clinic, renowned for its heart care, performed it on only 6 patients last year. Dr. Weaver’s clinic administered it to 99.5% of his Medicare patients…”

Lets face it: curiosity about what other people earn is a national pastime. Pro golfers qualify for their tournaments based on their publicly accessible official winnings. NFL agents bargain for their clients based on position-specific compensation comparables. We are frequently reminded that members of Congress “officially” earn $174,000 plus attractive perks, and of late, executive compensation for most of America’s public companies has become a major focus for Board Compensation Committee’s who are being pushed by shareholders to reign in their generous comp packages. So it’s understandable that physicians bristle at stories like this one. We would as well if in their shoes.

Here’s why the story is particularly challenging for the medical profession:

1-Physician income is high relative to what most American’s earn. Though wide-ranging across the various specialties in medical practice, the ratio of physician income to the median income in the U.S. ($51,324) is from a low of 3.6:1 for family practice to 13.9:1 for the highest earning clinicians in radiology, orthopedics and others (and that does not include their income from ownership in surgery centers, testing facilities and other services). Physicians think they deserve to be paid more than any other profession, reasoning theirs is a higher calling, their debt higher (averaging $170,000 for the 86% that borrow for medical school) and their training and expertise more valuable to society than others. Stories like this draw attention to how much physicians “might” earn and lend to suspicions that belly-aching by some in their ranks claiming they earn too little is more about greed than the greater good. Income potential is important to everyone: physicians want to earn as much as they can, and keep score against their peers and other high-earning professions. Many feel underpaid; some indeed are. But relative to what’s made in the vast majority of households, they are well paid.

Continue reading “Are Doctors Paid Too Much? Behind Medicine’s Nasty Little PR Problem”

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Screen Shot 2014-06-20 at 6.30.35 PMThroughout history, physicians have treated patients for conditions that generations of their professional successors later deemed figments of their (the physicians’) imaginations.  The list is long, but in just the last 100 years, it has included such disorders as female hysteria, homosexuality, moral insanity, neurasthenia, and vapors, among many others.  The consequences of such diagnoses were not trivial, and in some cases, patients were stigmatized, ostracized, subjected involuntarily to a variety of noxious treatments, and even incarcerated because of them.  Yet we now believe that each of these conditions was a fiction, and they are absent from today’s textbooks.

Something similar may be afoot in the profession of medicine today.  The affliction is known as conflict of interest, and medicine is thought to be suffering a pandemic of it.  In fact, its proponents argue that no physician is safe.  Its symptoms among researchers are a tendency to conduct investigations and publish results that are biased, and among clinicians, to prescribe tests and therapies that their patients do not really need.  The underlying cause of the condition is thought to be financial inducements from industry, which lead these gullible physicians and scientists to betray their personal and professional integrity without even knowing it.

For example, industry funding of research might lead physician-scientists to bias their results in ways that line the pockets of pharmaceutical companies and medical device manufacturers.  Likewise, the presence of industry representatives in offices and hospitals might lead physicians to write inappropriate prescriptions for industry-promoted drugs.  If physicians are presented with a gift such as a pen, a notepad, a book, or a free meal from an industry representative, they might be more inclined to use that company’s products in their practice.  The implication?  Physicians are insufficiently self-aware and trustworthy to put patients’ interests above their own.

Continue reading “How Conflict of Interest Became a Health Care Urban Legend”

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Bill CrounseEvery workday morning I spend 30 minutes or so reviewing my Twitter feed.

By following a select group of top healthcare news observers and thought leaders, I find that Twitter works pretty well as a filter for the news events and topics that matter most to me. Over the past couple of days, I’ve been alerted to some articles about nurses and doctors who are, shall we say, quite frustrated with electronic medical records and what they perceive as a decline in the physician-patient relationship.

One of the articles that caught my attention was about a nurses’ union, National Nurses United, that has launched a national campaign to draw attention to what they say is “an unchecked proliferation of unproven medical technology and a sharp erosion of care standards” in today’s hospitals.

Of course, their agenda and real concern seems quite transparent. It is not so much about technology itself as it is a decline in the number of Registered Nurses directly involved in caring for patients at the bedside.

The nurses’ union campaign seems to resonate with another article I came across last week about the lost art of the physical exam. That article from Kaiser Health News and the Washington Post extols some very legitimate concerns about doctors who rely too much on lab tests and medical imaging to arrive at a diagnosis instead of talking to, touching, and examining the patient.

Continue reading “Doctors and Nurses in a Twit about Technology Destroying Healthcare”

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Screen Shot 2014-06-02 at 6.14.14 PMShe hugged one daughter who was “a hugger” and avoided embracing the other daughter who wasn’t. She sat with the family, listened and supported them in their anguish.

Schwartz gave comfort to the family because she cares and has true empathy.

There’s no way that we could train her to care more. Yet too often, efforts by hospitals to improve the patient and family experience approach it purely as a technical challenge.

For instance, we provide scripts to health care professionals to help them navigate various situations, from what to say when walking into a patient’s room to service recovery when things haven’t gone as they wished.

We try to identify and broadly implement the practices that will best enhance patient experiences, such as rounding hourly in patient rooms to address pain management, bathroom visits and other needs.

These are well-intentioned and needed efforts to improve the patient experience. But they could very well backfire if we don’t simultaneously embrace the human element and tap into clinicians’ desire to be empathic healers and comforters.

I fear that we send the wrong message, for instance, when we simply hand detailed scripts to staff in low-performing units or hospitals. Subtly, we’re labeling them as someone who does not care adequately for patients, and that they need to be taught how to do better.

Here, we say, mouth these words and the patient and loved ones will believe that you care. Likewise, hourly rounding and other interventions will not be effective if we simply treat them as a box to be checked off.

Words are important, of course. And caregivers can certainly learn how to insert key words and phrases into their conversations with patients to show they care and open the door to more meaningful dialogue. However, health care is too complex and nuanced for a lengthy script to be useful.

Clinicians witness the extreme highs and lows of other people’s lives, yet like any job this becomes our everyday reality, with mundane documentation, meetings and bureaucracy. It’s easy to forget that “just like me” someone may be in the hospital for the first time, that their family members must take off work for an extended period of time to be with them, or that the outcome of their stay is a turning point in their family’s future.

When we lose sight of the connection with our common humanity, with our patients’ suffering, we can fail to connect with our patients’ needs for empathy as well as healing.  We can get so caught up in the tasks that we need to do that we don’t stop to care. While we think we are still delivering good care, patients perceive our frenzied state and decide it’s wiser not to raise valid concerns.

Continue reading “What a Nurse Taught Me about Checklists and the Doctor-Patient Relationship”

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“Patient noncompliance.” I wasn’t very familiar with this term until I started my clinical rotations. But after just the first week, I started noticing that health care providers throw this phrase around all time.

We particularly like using it as an excuse. Why did this diabetic patient require a foot amputation? Why does this patient come in monthly with congestive heart failure exacerbation? Why did this patient suffer a stroke? It’s often simply attributed to patient noncompliance.

What bothers me the most about this phrase, though, is how it’s often stated with such disdain. We act as if it’s incomprehensible that someone would ignore our evidence-based recommendations. If the patient would only bother to listen, he or she would get better. If we were patients, we would be compliant.

But that’s simply not true. We are no different from our patients. We practice our own form of noncompliance. It’s called guideline non-adherence.

Despite the fact that many guidelines are created after systematic reviews and meta-analyses – processes we would never have time to go through ourselves – we, like our own patients, are often noncompliant.

Research on guideline adherence has been around since guidelines started becoming prominent in the early 1990s. Despite the many studies and interventions to improve guideline adherence, the rates of guideline adherence still remain dismally low.

I find this particularly disconcerting. Despite my own interest in research, it makes me question the value of research. Why do we spend millions of dollars to find a better intervention that does not change how most providers deliver health care?

Continue reading “Why the Phrase “Noncompliant Patient” Bothers Me, And Should Probably Bother You Too ..”

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Osmosis Screen

Earlier this month Shiv and Ryan published a piece in the Annals of Internal Medicine, entitled What Can Medical Education Learn from Facebook and Netflix? We chose the title because, as medical students, we realized the tools our classmates are using to socialize and watch TV use more sophisticated algorithms than the tools we use to learn medicine.

What if the same mechanisms that Facebook and Netflix use—such as machine learning-based recommender systems, crowdsourcing, and intuitive interfaces—could transform how we educate our health care professionals?

For example, just as Amazon recommends products based on other items that customers have bought, we believe that supplementary resources such as questions, videos, images, mnemonics, references, and even real-life patient cases could be automatically recommended based on what students and professionals are learning in the classroom or seeing in the clinic.

That is one of the premises behind Osmosis, the flagship educational platform of Knowledge Diffusion, Shiv’s and Ryan’s startup. Osmosis uses data analytics and machine learning to deliver the best medical content to those trying to learn it, as efficiently as possible for the learner.

Since its launch in August, Osmosis has delivered over two million questions to more than 10,000 medical students around the world using a novel push notification system that syncs to student curricular schedules.

Osmosis is aggregating medical school curricula and extracurricular resources as well as generating a tremendous amount of data on student performance. The program uses adaptive algorithms and an intuitive interface to provide the best, most useful customized content to those trying to learn.

Continue reading “Another Step toward Open Health Education”

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lockett execution chamber
I give what could be lethal injections for a living.

That’s right. Nearly every day I give someone an injection of midazolam, vecuronium, and an IV solution containing potassium chloride–the three drugs in the “cocktail” that was supposed to kill convicted murderer Clayton Lockett quickly and humanely in Oklahoma.

Here’s the difference between an executioner and me. I use those medications as they are intended to be used, giving anesthesia to my patients, because I’m a physician who specializes in anesthesiology. Midazolam produces sedation and amnesia, vecuronium temporarily paralyzes muscles, and the right amount of potassium chloride is essential for normal heart function. These drugs could be deadly if I didn’t intervene.

My job is to rescue the patient with life support measures, and then to reverse the drugs’ effects when surgery is over. The “rescue” part is critical. When Michael Jackson stopped breathing and Dr. Conrad Murray didn’t rescue him in time, propofol–another anesthesia medication–turned into an inadvertently lethal injection.

When anesthesia medications are used in an execution, of course, no one steps in to rescue the inmate. This gives new meaning to the term “drug abuse”. In my opinion, the whole concept of lethal injection is a perversion of the fundamental ethics of practicing medicine.

Not for amateurs

Though lethal injection is supposed to be more humane than the electric chair or the gas chamber, often it doesn’t work as planned. Mr. Lockett died on April 29 after the injection of midazolam, vecuronium, and potassium chloride into his system. It is unclear from media reports how much of which drug he actually received. Apparently, prison staff had difficulty finding a vein.

The drugs were injected, they thought, into the large femoral vein in Mr. Lockett’s groin, which should have killed him within moments.

Continue reading “A Doctor’s Guide to Botched Executions”

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