An 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??”
Filed Under: THCB
Tagged: BMJ, Management, Organizational Behavior, Robert I. Sutton
Apr 19, 2014
Two weeks ago, the Kellogg School of Management was privileged to host Joe Doyle, an outstanding economist from MIT.
In a broad research portfolio, Joe has focused on the effects from differing intensity of medical treatments.
This research is shattering some long held beliefs about the relationship between health spending and outcomes.
We think that Joe’s work is not known widely enough outside of the academic community, so we are using our blog to let you know what you have been missing and, in the process, perhaps change the way you think about healthcare spending.
It is well known that the U.S. far outspends other nations on healthcare, yet the outcomes for Americans (in terms of coarse aggregate measures such as life expectancy, infant mortality, and other dimensions) are quite average.
Of course, these outcomes are not the only things that we value in health care.
A lot of our spending is on drugs and medical services that improve our quality of life and won’t show up in these aggregate outcomes. For example, more effective pain management can decrease pain and improve quality of life – often with important economic benefits.
Despite this fact, most health policy analysts have concluded that we can cut back on health spending, without harming quality on any dimension.
This is not a new idea, of course. In a famous 1978 New England Journal article, Alain Enthoven coined the term “flat of the curve medicine” to describe how the U.S. had reached the point of diminishing returns in health spending. And for nearly 30 years the Dartmouth Atlas has documented how health spending dramatically varies across communities without any apparent correlation with outcomes.
The question has always been, what health spending to cut? Garthwaite’s previous work has shown that broad regulations requiring longer hospital stays for new mothers and their babies have provided only limited benefits and that more targeted rules could save money without sacrificing quality.
Beyond some wasteful regulations, we can always point to gross examples of overspending such as the rapid proliferation of proton beam treatments. But beyond those clear examples how can one identify what is waste and what is medically necessary?
In two important papers, Joe Doyle and co-authors ask a more fundamental question – is the often cited broad variation in health spending actually wasteful at all? They find that even in healthcare, there really is no such thing as a free lunch.
His work should be mandatory reading for everyone who believes that broad spending cuts will have no adverse consequences.
For those who lack the time to read these papers, we provide the “Cliff’s Notes” versions.
Continue reading “Is Higher Spending Truly Wasteful?”
Filed Under: THCB
Tagged: Craig Garthwaite, Dartmouth Atlas Project, David Dranove, Joe Doyle, Outcomes, spending, Value, Variation
Apr 18, 2014
The American Medical Association (AMA) says the number one issue with recent data releases from HHS is that “there is currently no mechanism for physicians and other providers to review and correct their information.”
We think we have a way to fix that problem over at the DocGraph project!
Over the last two years there have been three major breakthroughs in the analysis of doctors using Open Data. The first was the original teaming and referral database obtained by DocGraph (us) under a FOIA request. The second was the prescribing data set obtained by ProPublica. Both DocGraph and Propublica worked around the 1978 injunction limiting the use of FOIA for doctor data.
The third is the new procedure pattern data set announced as the direct result of the overturning of the 1978 injunction.
We are happy to announce the release of the first “all-in-one” open doctor data browser that we are calling DocGraph Omni. We have created a public tool that allows you to browse the merger of all three major new open data sets about doctors and other healthcare providers that bill Medicare.
Now in one place you can view how a provider prescribes, how they collaborate, and which procedures they work with. Our intention to turn Omni into a browser where you can find any open data about doctors, no matter what the source.
But this is not just about “finding” the data. We have created a system that allows anyone to comment on any given data point in these data sets.
Continue reading “A New Way to Explore and Comment on Doctor Data”
Filed Under: THCB
Tagged: Data, DocGraph Omni, Fred Trotter, ONC Data Supporting Visualizations Challenge, Physician Ratings
Apr 18, 2014
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?”
Filed Under: THCB
Tagged: Cost-Quality Paradaigm, Family medicine, Hans Duvefelt, Medicare payments, Patient Centeredness, Physicians, Population Health, Quality
Apr 17, 2014
Sorry to get all Katie Couric on you, but I’m going to have a colonoscopy on Friday. I turned 40 last October and I have some family history that leads my doctor to get one done now rather than at 50.
Unlike Katie, I won’t be broadcasting mine live, but I’ll share some articles and reflections on the process and, being process focused, what could go wrong. It’s a very necessary procedure, but there are, sadly, some very unnecessary and preventable risks.
According to Dr. Wikipedia (backed by journals):
This procedure has a low (0.35%) risk of serious complications
That’s about 1 in 300 patients, put another way.
For those of you who speak Six Sigma, that’s a 99.65% first time yield and a 4.2 sigma level.
That’s not going to scare me away.
Maybe I should have asked what my physician’s complication rates are. What are the complication rates at the surgical center where this will be done? Is this safer than being at a full-blown hospital or doesn’t it matter? Should I be more of an “engaged patient?”
Should I have asked more questions of my primary care provider? Why did she refer me to this GI specialist? Is he a “Best” doctor? Does that matter?
If I treat them as a supplier (respectfully), should I be able to walk the process and see what they do to prevent, say, instrument or scope disinfection errors?
Should I have asked:
- Show me how you disinfect the equipment
- Show me your training records for the people doing this work
- Show me your equipment maintenance records
- How do you verify that the work is being done properly?
- Have you had any complaints or incidents in the past?
I had my pre-procedure phone call on Monday. Maybe I should follow up and ask a few of these questions, even if I can’t go “walk the gemba” to check things out myself. What would you do?
Of course, I didn’t have data or information available to me to know:
- Which specialist is best at this?
- Who has the highest or lowest complication rates?
- What are the prices for different doctors or locations?
I don’t know how a busy person makes an informed decision.
Continue reading “Things That Make Me Worry About My Colonoscopy”
Filed Under: THCB
Tagged: Colonoscopy, Hospitals, LEAN, Mark Graban, medical error, Patient Safety, Quality
Apr 17, 2014
Since 2000, the government and healthcare industry have sold Americans a bill of goods called workplace wellness, which turns out to have been a colossal waste of billions of dollars.
Most of this money was spent bribing employees to do things that they don’t want to do, such as submit to biometrics, answer intrusive health risk appraisals, and get preventive medical care.
The marketing pitch that wellness makes people healthier and lowers medical care costs, and thus, produces a return on investment for the employer, isn’t true. Wellness also allowed companies to position themselves as employee-friendly, even while wages stagnated and employees morphed into fungible widgets, instead of vital assets in whom employers invested for years or decades.
However, it looks to us as though at least one major US company is treating economic reality seriously, and, consequently, asking its employees to act like adults.
Let’s look at wellness by Amazon.com, which has apparently avoided conventional wellness whole cloth. Despite our best research efforts, we find no evidence that the company makes conventional wellness programming a priority for employees.
It’s a bit ironic that they don’t given the recent spate of tough publicity about the company’s employment practices.
Amazon has been lambasted lately for the plight of the warehouse workers who animate its backroom operation, where constant video surveillance, productivity demands, and getting your bag searched before you go home are the norms. Message boards also detail the pressure-cooker atmosphere of the company’s white collar space, which raises, in our minds, the pointed question of why haven’t they done wellness?
We think it’s because Amazon’s philosophy about work is straightforward: if you work here, expectations are high and relentless. Amazon’s approach to employee well-being seems to be to not have one other than we invite you to grow with us. This is counter-cultural, and it has more to recommend it than first appears obvious.
When you are competing against Walmart and Target, remaining lean and low-cost is critical; wellness drives costs up, not down.
Expecting many staff to work 50, 60, or even 70 hours per week leaves little time for discretionary visits to the doctor that are pointless even before they happen because this superfluous care will save neither lives nor money. When you are not pouring money into coercing employees to join a wellness program, you preserve capital needed to optimize the technologies and product mix that help you grab market share and crush competitors like Best Buy.
Continue reading “Amazon Shows the Way on Wellness — Treat People like Adults”
Filed Under: Tech, THCB
Tagged: Al Lewis, Amazon, Corporate culture, Drones, Jeff Bezos, Vik Khanna
Apr 16, 2014
I recently read a blog by Dr. Danielle Ofri in the New York Times “Well” blog about how as a physician she learned to respect the patient’s wishes even when they contradict her professional inclinations. It’s called Doctor Priorities vs Patient Priorities.”
She writes that the patient is looking through a “wide-angle lens” that takes in the whole of his life while the doctor’s lens is “narrowly focused on the disease that pose[s] the gravest and most immediate risk”. She saw her challenge as entering into dialogue with her patient in order better to understand the wider perspective of his whole life and to work with him to find the most acceptable way to deal with his disease.
If only Dr. Ofri were an oncologist. If only she were my oncologist. My last appointment with my onco, Dr. G, was a disaster. Not only have I not been back to her, I have not gone to any oncologist since then. Part of that is because I don’t want any treatment at this time; that’s still true.
But if I am going to be very honest, and I try to be that always, it is also because of that disastrous appointment with Dr. G.
First of all, she would not respect my decision not to have any more chemo and refused to order any scans unless I would a priori agree to chemo if she decided it was indicated. She also mocked me. It took a long time for me to tell that second bit. In fact, from that day in August 2013 until just recently—seven months!—I only told one or two other people about what happened.
The evening of that last appointment, Dr. G called me at home to continue the argument. I found myself apologizing for causing her distress. Yes, I know that’s ridiculous, but that is how I react to being bullied. Borrowing the words of a friend who really gets it, I apologize to others for their hurtful behavior and then I internalize it. I haven’t talked about Dr. G mocking me because I feel ashamed.
Continue reading “Whose Cancer Is It, Anyway?”
Filed Under: THCB
Tagged: Cancer, culture of health, doctor/ patient relationship, Oncology, provider bullying, shared decision making, Telling Knots
Apr 16, 2014
I know it seems like the obvious choice, but I would not run a randomized clinical trial.
I have recently lamented the pernicious influence, within my domain of public health practice, of hyperbolic headlines proclaiming “this,” followed unfailingly by equally and oppositely hyperbolic headlines reactively proclaiming “that.”
But we are obligated to acknowledge that there are, generally, research studies underlying the headlines, however extreme the pop culture distortions of the actual findings. So to some extent, the problem originates before ever the headlines are a gleam in an editor’s eye, with our expectant anticipation of the next clinical trial, and the next, and the next.
By all means, bring on the clinical trials! They serve us well. They advance the human condition. I run a clinical research lab — my career is devoted to just such trials.
But still, I wouldn’t conduct one if my foot caught fire.
Of course, there is a very good case for running such a study, as many vitally important questions about the right response to a foot on fire are at present unanswered. What, for instance, would be the ideal volume of water? Should it be hard water, or soft? Fluoridated, or not? A controlled trial is very tempting to address each of these.
The vessel is even more vexing. What would be the best kind of bucket? What size should it be? What color should the bucket be, what composition, and what’s the ideal kind of handle? I think the variations here are the basis for an entire research career.
Perhaps the notion of running randomized, double-blind, controlled intervention trials to determine the right response to a foot on fire seems silly to you. But if so, you must be suggesting that science does not preclude sense.
That’s rather radical thinking in some quarters.
Continue reading “What I Would Do If My Foot Caught Fire”
Filed Under: THCB
Tagged: academic research, Clinical Trials, David Katz, Evidence Based Medicine, public health, Wellness
Apr 16, 2014
For 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”
Filed Under: Physicians, THCB
Tagged: academic medical centers, culture of health, FutureMed, Incentives, Iora Health, primary care, Turntable Health, Zubin Damania
Apr 16, 2014
In September 2012, I said that Republican governors should be expanding their Medicaid programs under Obamacare.
I argued that Republicans have long called for state block grants and the flexibility to run their own Medicaid programs in what are the state “laboratories of democracy.”
I made the point that, given the then recent Supreme Court decision enabling states to opt out of the expansion, the Obama administration would be hard pressed to deny any reasonable proposal from Republican governors.
If Republicans really believed in state responsibility and flexibility for how they run their Medicaid programs, this was the opportunity to prove it. (See here.)
Since then, a few Republican governors have taken that tack and the Obama administration has been very cooperative and flexible.
This is a good place to recognize outgoing HHS Secretary Sebelius for her leadership by being willing to work with state Republicans in order to get millions of people covered who wouldn’t be getting coverage otherwise.
Good faith Republican Medicaid proposals have led to good faith responses from Sebelius’ Department of Health and Human Services (HHS) and a few done deals and other deals still in the works.
Many Republicans have said that Medicaid is not sustainable and that the feds could well cut the new Obamacare funding in future years. Sebelius responded by giving these governors an out if funding were to be cut.
Of course Medicaid is unsustainable, that’s why the states should be given the autonomy to run their own plans and deal with these challenges in any number of different ways the country can learn from.
Continue reading “Virginia Should Take Obamacare’s Money”
Filed Under: THCB, The Business of Health Care
Tagged: Arkansas, Medicaid Expansion, Robert Laszewski, The ACA, The States, Virginia
Apr 14, 2014