Physicians

the doctor crisis photoDoctors get blamed a lot these days — blamed for aversion to change, for obstructing innovation, and for being self-centered. This familiar litany asserts that in the nation’s drive to transform health care, physicians are part of the problem.

While it is undeniable that doctors are part of the problem in some places, it is equally undeniable that they are leading innovation in many places and must be part of the solution everywhere.

We may well be in the midst of the most unsettling era in health care and that turbulence is bone-jarring to physicians. We argue that there is a doctor crisis in the United States today – a convergence of complex forces preventing primary care and specialty physicians from doing what they most want to do: Put their patients first at every step in the care process every time.

Barriers include overzealous regulation, bureaucracy, liability burden, reduced reimbursements, and poorly designed care delivery systems.

On the surface the notion of a doctor crisis seems altogether counterintuitive. How could there be a “crisis’’ afflicting such highly educated, well-compensated members of our society?

But the nature of the crisis emerges quite clearly when we listen to doctors. Ask about the environment in which they practice and you hear words such as “chaos,’’ “conflict,’’ and “dysfunction.’’ Based on deep interviews with doctors throughout the country, the research firm Harris Interactive reports that a majority of physicians are pessimistic about their profession; a profession Harris describes as “a minefield’’ where physicians feel burned out and “under assault on all fronts.’’

Have terms this extreme ever been used to characterize the plight of physicians in our nation? Burnout, chaos, conflict, dysfunction, minefield, under assault. How can the nation transform its health care system under such disturbing conditions?

Continue reading “The Doctor Crisis”

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flying cadeuciiAt the end of March, Congress decreed a year-long postponement of the implementation of ICD-10, a remarkably detailed and arcane new coding scheme providers would have been required to use in order to get paid by any payer in the US (“bitten by orca” is but one of the sixty thousand new codes ).

The year postponement gives caregivers and managers a little more time to prepare for a further unwelcome increase in the complexity of their non-patient care activities.

In the spirit of Jonathan Swift, who famously proposed in 1729 that the Irish sell their children as a food crop to solve the country’s chronic poverty problem , I have a suggestion about how to cope with the steady rise in complexity of the medical revenue cycle.

Beginning when ICD-10 is implemented, there should be no patient care whatsoever on Fridays, permitting nurses and physicians to spend the entire day catching up on their charting and documentation, and other administrative activities.

Physiciansnurses, and others involved in patient care already spend at least a day a week of their time on this process now, but it is interspersed within the patient care workflow, constantly distracting clinicians and interrupting patient interaction.

Hospitals are solving this problem with a medieval remedy:  scribes who follow physicians around and enter the required coding and “quality” information into the patient’s electronic record on tablets.   Healthcare might be the only industry in economic history to see a decline in worker productivity as it automated.

Continue reading “A Modest Proposal: Charting Day”

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flying cadeuciiIt was probably the most awkward question I had been asked before, and I did not have an answer…

He was a middle-aged gentleman, neatly dressed—very simple and unassuming. He blended like a lifeless statue in the waiting area. What sparked my notice of him was his accompanying robust file, crammed with familiar pink discharge slips from the ED.

He was clearly what we call a “frequent flyer”, but this would be his first visit in our surgical clinic.

I escorted him into the assessment room, exchanging the usual salutations as he edged unto the exam table, wincing with discomfort. His chief complaint read, “acute abdominal pain and constipation x 1 week.”

Vying to understand more about his issue, I asked, “Sir, how long have you had this problem?” Embarrassed, he lowered his head.

Silence.

I retreated and instead remarked, “Ok. Let’s start from today. Where do you have the most pain?”

Tenderly, his frail digits unbuttoned his shirt, exposing a wasted torso, which hoisted an extraordinarily distended abdomen. It appeared rigid and tense. I reached out to gently palpate it to confirm the realism of my observations. He flinched.  His stoic affect instantly collapsed into an aching frown.

Tears welled in his eyes. Something terrible was going on inside. Cancer.

He needed to be admitted and surgery would be very likely, if not too late. I was aplomb in my explanation of his condition, feeling proud of my thoroughness and precision. Yet, seemingly unengaged, he politely interrupted and asked, “How much will it cost to let me die?”

I paused.  It was probably the most awkward question I had been asked before, and I did not have an answer. During my training, I was taught to order tests wisely, to avoid superfluous exams and to minimize inefficiency of resources; in spite of this, I had not ever stopped to think about cost in this context.

In my mind, it was my duty to provide the best, quality care to extend life, foremost. Yet, his concern was different. How much would it cost to die?

Nothing.

Continue reading “How Much Will It Cost to Let Me Die?”

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flying cadeuciiHonest Pay for Honest Work.

Times have changed. And it’s time they change again.

In the past, medical care was more episodic than it is now. People went to see the doctor when they felt unwell. Diabetes affected mostly older patients, who didn’t live long enough with the disease to develop complications.

There were no blockbuster drugs for high cholesterol, Hepatitis C, fibromyalgia or chronic heartburn; we didn’t manage nearly as many patients on multiple medications as we do now.

In those times, a payment scale based on the length and complexity of the visit made sense, and there wasn’t much doctor-patient interaction between visits.

Today, we manage more chronic conditions, use more medications, do more laboratory monitoring, more patient education, and more administrative work on behalf of our patients than before.

Payment scales based only on what we do in the face-to-face visit have become hopelessly antiquated and stand in the way of the new demands of society – physicians providing longitudinal care for chronic conditions in patient-centered medical homes.

Continue reading “Who Should Pay Doctors?”

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flying cadeuciiAfter my last post about “the gift of cancer” I must say that CLL has felt much less like a gift this month.

Joining the ranks of those with “a diagnosis” has given me a some insight into what our patients face all the time.

Recently, I received my second dose of humility.  I capped off a truly exhausting week in the hospital with a routine lab follow-up.

The last day of my 85-hour week I had my CBC checked, and my platelets dropped from the 100s to the 30s.

My first reaction was denial.  Lab error.

Unfortunately, they dropped further the next day and I realized that the little red bumps on my legs weren’t some skin reaction, but petechiae.  Bummer.  Turns out that in addition to the 2% of people diagnosed with CLL under age 40, I also joined the 20% who develop idiopathic thrombocytopenic purpura (ITP).

The treatment of choice for ITP is prednisone 1mg/kg.  So after a visit with my oncologist, I started 80mg of prednisone.

I realized with more than a little chagrin that I have a double standard about therapeutics. I was surprised at how much I despise being on prednisone.

I had never taken it before, and I would guess that I prescribe it every week, if not every day, that I work in the hospital. I have always felt that prednisone is fine for my patients to take.

Steroids work to help clear up that asthma flare, quickly improve that gout pain, or even help with a burst of energy in the last days or weeks of life for a terminal patient.

But for me? No thank you.

Continue reading “The Gift of Cancer”

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flying cadeuciiAs health care reform rolls out, there is a growing focus on restructuring the health service delivery system in the hope of improving health care quality and “bending the cost curve.”

A key part of this focus has been on physician organization and, in particular, moving toward large, multispecialty physician groups or hospital-physician systems that can provide integrated, coordinated patient care (e.g., through “Accountable Care Organizations”).

In a recent chapter in Advances in Health Care Management’s Annual Review of Health Care Management, however, we and our co-author Jeff Goldsmith find that there is little evidence for the superiority of these integrated models in terms of patient care quality or cost-savings, and that the trends toward physician consolidation has been much less dramatic than is often thought.

Using data from a variety of sources, we find there are two separate phenomena at work in physician organization. At one end of the spectrum (bottom tail of the size distribution of physician groups), the majority of physicians continue to practice in small groups, although there has been some movement from really small practices (one to three or four physicians) to slightly larger groups (five to nine physicians).

Still, nearly two-thirds of office-based physicians continue to practice in solo settings, two-person partnerships, and small (usually single specialty) groups with five or fewer physicians.

At the other end of the spectrum (upper tail of the distribution), however, is a smaller number of very large and rapidly growing multispecialty physician groups, which are often owned by hospitals, health plans, private equity firms, or other non-physician sponsors.

These two stories of what is happening in the distribution of physician group size are described as “a tale of two tails.”

Continue reading “What We’ve Learned from Horizontal and Vertical Integration of Physicians”

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flying cadeuciiIt’s a strange business we are in.

Doctors are spending less time seeing patients, and the nation declares a doctor shortage, best remedied by having more non-physicians delivering patient care while doctors do more and more non-doctor work.

Usually, in cases of limited resources, we start talking about conservation: Make cars more fuel efficient, reduce waste in manufacturing, etc.

Funny, then, that in health care there seems to be so little discussion about how a limited supply of doctors can best serve the needs of their patients.

One hair-brained novel idea making its way through the blogs and journals right now is to have pharmacists treat high blood pressure. That would have to mean sending them back to school to learn physical exam skills and enough physiology and pathology about heart disease and kidney disease, which are often interrelated with hypertension.

Not only would this cause fragmentation of care, but it would probably soon take up enough of our pharmacists’ time that we would end up with a serious shortage of pharmacists.

Within medical offices there are many more staff members who interact with patients about their health issues: case managers, health coaches, accountable care organization nurses, medical assistants and many others are assuming more responsibilities.

We call this “working to the top of their license.”

Doctors, on the other hand, are spending more time on data entry than thirty years ago, as servants of the Big Data funnels that the Government and insurance companies put in our offices to better control where “their” money (which we all paid them) ultimately goes.

In primary care we are also spending more time on public health issues, even though this has shown little success and is quite costly. We are treating patients one at a time for lifestyle-related conditions affecting large subgroups of the population: obesity, prediabetes, prehypertension and smoking, to name a few that would be more suitable for non-physician management than hard-core hypertension.

It is high time we have a serious national debate, not yet about how many doctors we need, but what we need our doctors to do. Only then can we talk numbers.

Hans Duvefelt, MD is a Swedish-born family physician in a small town in rural Maine. He blogs regularly at A Country Doctor Writes where this piece originally appeared.

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flying cadeuciiAn article containing some ideas from The No Asshole Rule appeared in The McKinsey Quarterly some time ago and was summarized in The Economist.

This post is motivated by the question with which The Economist ends its little story: “If jerks cost firms so dearly, why are so many them employed?”

I think that it is a good question, and one that I have puzzled over a lot. To their point:

A study of American workers released in March found that 44 percent of Americans reported they have worked for an abusive boss. This study was conducted by the Reed Group for the Employment Law Alliance.

They surveyed a representative sample of 1,000 American adults within the past two weeks, which resulted in interviews with 534 workers.

Things are even worse in some occupations, notably medicine. A longitudinal study of nearly 3,000 medical students from 16 medical schools was just published in The British Medical Journal. Erica Frank and her colleagues at the Emory Medical School found that 42 percent of seniors reported being harassed by fellow students, professors, physicians, or patients; 84 percent reported they had been belittled and 40 percent reported being both harassed and belittled.

The full report is here. Similarly, a 2003 study of 461 nurses published in the journal of Orthopaedic Nursing found that 91 percent had experienced verbal abuse in the past month. Physicians were the most frequent source of such nastiness, but it also came from patients and their families, fellow nurses, and supervisors.

The No Asshole Rule suggests a few reasons why there are so many.

1. In our society, we value winners so much that, even if they are jerks, we tolerate, or even glorify, them because — so long as they keep making money or winning games — we think they are worth the trouble. Exhibit one is Coach Bob Knight and his long tenure at Indiana University. The administration didn’t have the courage to get rid of him because he won so many games, despite a history of atrocious behavior.

See this story and the associated 1997 video clip: It sure looks to me like he is choking the player. Knight brags that he “did it my way,” but I don’t want people doing things that way in my organization, no matter how great they “perform.”

Continue reading “Why Are There so Many ___________s in Medicine??”

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A long time ago, when I worked in Sweden’s Socialized health care system, there were no incentives to see more patients.

In the hospital and in the outpatient offices there were scheduled coffee breaks at 10 and at 3 o’clock, lunch was an hour, and everyone left on the dot at five. On-call work was reimbursed as time off. Any extra income would have been taxed at the prevailing marginal income tax rate of somewhere around 80%.

There was, in my view, a culture of giving less than you were able to, a lack of urgency, and a patient-unfriendly set of barriers. One example: most clinics took phone calls only for an hour or two in the morning.

After that, there was no patient access; no additions were made to providers’ schedules, even if some patients didn’t keep their appointments, not that there was a way to call and make a same-day cancellation.

As my father always said: “There must be a reward for working”.

But, high productivity can sometimes mean churning out patient visits without accomplishing much, or it can mean providing unnecessary care just to increase revenue. For example, some of my patients who spend winters in warmer climates come back with tall tales of excessive testing while away.

A recent Wall Street Journal article offers an interactive display of doctors who collect the highest Medicare payments. The difference between providers in the same specialties across the country makes interesting reading. It is hard to imagine that many individual doctors are billing Medicare more than $10,000,000 per year.

So it might make sense to insure against paying for excessive care by also demanding a certain level of quality.

But defining quality is fraught with scientific and ethical problems, since quality targets really aren’t, or shouldn’t be, the same for all of our patients.

Continue reading “How Should Doctors Get Paid? Hourly Wage, Piecework or Quality?”

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Zubin DamaniaFor the better part of a decade, I practiced inpatient hospital medicine at a large academic center (the name isn’t important, but it rhymes with Afghanistan…ford).

I used to play a game with the med students and housestaff: let’s estimate how many of our inpatients actually didn’t need hospitalization, had they simply received effective outpatient preventative care. Over the years, our totals were almost never less than 50%.

For my fellow math-challenged Americans: that’s ONE HALF! Clearly, if there were actually were any incentives to prevent disease, they sure as heck weren’t working.

In a country whose care pyramid is upside down—more specialists than primary care docs, really?—we’re squandering our physical, emotional, and economic health while spending more per capita than anyone else. Four percent of our healthcare dollars go towards primary care, with much of the remaining 95% paying for the failure of primary care. (The missing 1%? Doritos.)

Worse still, the oppressive weight of our non-system’s dysfunction falls disproportionately on the shoulders of our primary care providers—the very instruments of our potential salvation. To them, there’s little solace (and plenty of administrative intrusion) in the top-down reform efforts of accountable care organizations and “certified” patient-centered medical homes.

But what about a bottom-up, more organic effort to reboot healthcare? A focus on restoring the primacy of human relationships to medicine, empowering patients and providers alike to become potent, positive levers on a 2.8 trillion dollar economy? What if we could spend twice as much on effective, preventative primary care and still pull off a net savings in overall costs, improvements in quality, and increased patient satisfaction?

What if George Lucas had just quit after the original Star Wars series? Wouldn’t the world have been better without Jar Jar Binks?

While the latter question is truly speculative, the former ones aren’t. We’re trying to answer them in Las Vegas (hey now, I’m being serious) at Turntable Health, where we’ve partnered with Dr. Rushika Fernandopulle and Cambridge, MA based Iora Health.

We aim to get primary care right by doing the following:

Continue reading “Rebooting Primary Care From the Bottom Up”

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