“As a PCP, I’ve seen the morale in my area, and I see a major crisis coming if the complaints are ignored.”
“I’ve lived in the hell that is American health care…”
A devoted physician wrote these words in reaction to a recent blog post we wrote. And he is clearly not alone.
In our new book The Doctor Crisis, we report on the widespread unhappiness, frustration, dissatisfaction, and anger of so many American physicians.
We believe this crisis is real and growing; that it is an impediment to providing the care the American people need; that dealing with the doctor crisis is fundamentally patient-centered; and that the crisis has not been recognized for the fundamental threat it poses.
Our recent feature on The Health Care Blog elicited some powerful reaction:
Rob: ”In a certain sense, individual doctors ARE victims of a system that rewards over-consumption, ridiculous documentation, attention to codes over people, and bureaucracy over partnership…”
Jeff: “Can validate what Rob has said. I’ve spent the last three years listening to physicians about the possible alternative futures for their profession, and the overwhelming desire was exactly as Rob said- an overwhelming impulse to flee…”
Some commentators wrote that doctors shouldn’t complain because they earn a lot of money, drive fancy cars and own nice homes. But that theme – accurate in many cases but certainly not all — gets us nowhere.
We think the rubber meets the road with this warning from Dr. Rob, ”…As a PCP, I’ve seen the morale in my area, and I see a major crisis coming if the complaints are ignored.”
Is Dr. Rob overstating it? We don’t think so. In fact, we think he has it exactly right. How can our system function properly if the level of job satisfaction among doctors continues to spiral downward?
Harris Interactive research describes the profession as “a minefield’’ where physicians feel burned out and “under assault on all fronts.’’ Has such extreme language ever been used to characterize the medical profession? Have doctors ever faced a time as turbulent as this?
Doctors are certainly not blameless as both Brian and Rob noted in their comments:
Brian: “…I’m concerned that you have framed your argument as though physicians are victims of the system rather than partial drivers of its characteristics …”
Rob: “…physicians as a group have been complicit in building this system, and so should bear a lot of the blame…”
So what needs to be done?
A crucial first step is for health care stakeholders to recognize and acknowledge the existence of the crisis. Doing so will get the doctor crisis on the national health care agenda. Unfortunately, the matter is not currently a priority for many, if not most, provider organizations. That needs to change.
When it does, there are some powerful solutions out there. There is no doubt, in fact, that the building blocks for a better future are out there. They are found in many provider organizations that have improved both physician and patient satisfaction while improving care.
Important progress can be seen at many organizations including some we write about in our book: HealthPartners (Minnesota), Atrius Health (Massachusetts), Virginia Mason (Washington), and Kaiser Permanente (nine states).
We draw inspiration from the work of Drs. Christine Sinsky, Tom Bodenheimer and their colleagues who identified 23 high functioning primary care practices. Their findings and recommendations, if spread throughout the country, could help transform primary care in our nation. [Annals of Family Medicine (May/June 2013) In Search of Joy in Practice: A Report of 23 High-Functioning Primary Care Practices.]
We’ll be writing much more about these solutions to the doctor crisis in the weeks and months to come.
What ideas do you have for improving both physician and patient satisfaction?
The evolution of the physician role seems to accelerate daily. In our new book, The Doctor Crisis, we characterize the expanded role for physicians as that of healer-leader-partner.
Many physicians are adapting beautifully to this shift. Others struggle mightily. Some angrily. A number of doctors consider the change fundamentally unfair – a kind of bait and switch. We got into medicine to take care of patients, and now we’re being asked not only to heal but to become effective leaders and partners, as well. It’s too much.
No question – it is a lot to ask. But how can we turn back? Unless doctors step up as healers-leaders-partners, we can’t deliver the kind of care the American people need and deserve.
We defined what we mean by the terms healer and leader in our last two posts, but what do we mean exactly by physician as partner? We write in our book “physician as partner means being a great team member and recognizes that the surest route to sustained quality care is through effective teamwork.”
We’re talking about pulling a team together to do great population health management; working across siloes to team up with nurses, pharmacists, techs, and administrators. Great physician partners are collegial, approachable, and always respectful of other team members.
Some examples include:
- Partnering with patients on shared decision making.
- Partnering with nurses in clinical teams and on a larger scale when necessary.
- An example of the latter is the partnership between the Colorado Permanente Medical Group and Exempla Healthcare to establish an accelerated nursing degree program and skills lab at Metropolitan State University of Denver.
- Partnering with physician colleagues by listening – as Dr. Cochran did in his listening tour (detailed in our book) where he sat down to talk with all 500 KP Colorado doctors to fully understand how best to fix a dysfunctional situation.
- Partnering with clinical pharmacists so that everyone is practicing at the top of their license.
An outstanding example of a physician as partner is Dr. Paul Grundy, the director of health care transformation at IBM. Dr. Grundy and his IBM colleague Dr. Martin Sepulveda partnered with a wide variety of primary care organizations to build the Patient-Centered Primary Care Collaborative – a powerful partnership for the patient-centered medical home.
We quote Dr. Grundy in our new book:
“If you put resources upstream – if you manage aspirin, blood pressure, and cholesterol upstream you have a third less need to do cardiac intervention. If you don’t manage those things, you see more cardiac disease. This isn’t rocket science!”
This is exactly what we do so well at Kaiser Permanente – manage member health upstream. A major factor in our success in this area is our physician as partner culture. Just as Kaiser Permanente embodies physician as partner, so too does the patient centered medical home. Both rely upon physicians as partners with one another as well as with administrators, health plan partners, nurses, medical assistants, clinical pharmacists, behavioral health specialists, schedulers, receptionists and many more – all partnering in the cause of great patient care.
If Kaiser Permanente is in some way a model for the patient-centered medical home that will grow in importance in the future, then Dr. Grundy is in many ways a model for the healer-leader-partner that physicians must aspire to. His portfolio is global, as befits a global company such as IBM. He is as likely to be in Beijing, Zurich or Wellington as he is in Charlotte, Chicago or Los Angeles.
The essence of what Dr. Grundy does – especially his role as a leader and partner to many organizations seeking to improve – shows the pathway forward for other doctors. The geography doesn’t matter. Whether a doctor travels the world or remains in a small clinic in a rural area, the essential ingredients for success in the new age remains the same: Physician as healer-leader-partner.
What does effective partnering look like in your organization?
Jack Cochran, MD, FACS, (@JackHCochran) is executive director of The Permanente Federation, headquartered in Oakland, California.
Charles C. Kenney is a former reporter and editor at the Boston Globe and author of several books on healthcare in the United States.
Cochran and Kenney are authors of The Doctor Crisis: How Physicians Can, and Must, Lead the Way to Better Health Care. Both write about physician leadership at kp.org/physicianleader, where this post originally appeared.
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Granp…, don’t forget the young have to pay for the change they vote for and right now the total bill is nearing the $100Trillion level. Of course much of that has to do with the actuarial cost of entitlements and things like Obamacare, so they will be left with the problem of financing an impossible debt or getting rid of the programs. The greed of incurring debts hoping they may never have to be repaid eventually catches up.
You won’t be around to remind them of their early smugness and lack of common sense.
So young, so wet behind the ears, so smug, so wrong.
As you’ll learn one day, practicing physicians eat a big bowl of change for breakfast every morning. That’s how wesurvive.
What we object to is change that is not based on evidence, but that is intended solely to deliver physicians and the health of their patients into the control of corporate greed. if you want to be part of that process, be my guest.
The world of healthcare is changing, but one wants the change in the right direction. Top down control is not the way to go. So far top down control has increased bureaucracies, increased the number of businesses feeding off the healthcare dollars, increased total healthcare costs, reduced access and is negatively affecting quality.
I hope future medical students learn how to evaluate problems and not just rely upon committees to tell them how to think and act.
The world of healthcare is changing. If you are not ready to change, thousands of us toiling in med schools are willing (since we may not know how it was 20 years ago).
I don’t see this any different than any other industry. “This is how we used to work twenty years ago” doesn’t work in other industries as well.
For those who complain about it, take a look at “Who Moved My Cheese” book.
I think a lot of the anger you are witnessing has to do with how wrong the thought leader crowd has been in regards to almost everything promised in addition to never getting around to actually putting their money where their mouth is. So when you start singing the same song, it’s just another verse in the ongoing broken promises from quality talkers. The trenches are growing weary of listening to people who ride a desk for a living telling us how to do a better job with less money, more overhead and more regulation. When you see the big systems working from the inside, you see how they are part of the problem with runaway costs.
the Whole Country has thousands of empty primary care physician slots not just limited to the VA for sure. We have under invested in primary care. We have over 20,000 die because they can not access car,. The Vets seem to bother us when they need to to lack of access and it should but what about the rest of our citizen what are they just part of the 47%.
The VA has hundreds of empty primary care physician slots that it can’t fill because of low pay and difficult working conditions. It is interesting to see the VA promoted as a model of practice management we should emulate, particularly in a thread dealing with low physician morale.
As my previous posts make clear, I’ve read the report several times. And each time my reaction is “What did I miss?” The authors present absolutely NO EVIDENCE that the doctors in the practices they profile are more satisfied, less burnt-out, more joyful than their peers. I actually am familiar with several of the practices they profile, and I assure you that there are plenty of miserable, stressed out doctors working there (in two of them, significantly more than average, in my opinion). It would be very easy for me to write an article claiming that the practice innovations described cause “misery in practice,” but it would have as little intellectual validity than what S&B have written.
This one article wouldn’t matter much, except that it’s being referenced by people who should know better as an “excellent and very important piece of work,” that it proves that this expensive, high overhead style of practice results in happy doctors. It proves nothing, it just gives us the opions and whims of the authors. This is exactly the anti-science, evidence free style of thinking (“I think it’s a good idea, so lets make it a policy”) that has given us lousy EMRs, crippling MU, worthless MOC, and everything else that is destroying the morale of practicing physicians. Articles like this are part of the problem, not the solution.
Granpappy
It’s actually the opposite of what you suggest. I think if you read the Sinsky-Bodenheimer Joy in Practice report you will readily see that. It is an excellent and very important piece of work.
“Study after countless study shows that when a patient has a primary care physician that cares about them has and uses the tools to practice comprehensive care centered on the patient needs they get the care they need at a price we can afford.”
This sounds like a bunch of contrived studies with a lot of selection problems and probably definitional problems as well.
“uses the tools to practice comprehensive care”
Please define the above.
“There is no money paid for the necessary investments in teams and health information systems ”
Really, no money?
“When one compares the U.S. health care system with those of other industrialized countries”
If the US were the same as those other countries they would be speaking German today.
“The care of these conditions is simply not that difficult. ”
The care can be extremely difficult because no two patients are identical and frequently they have more than one disease.
“For some reason, the healthcare industry and we as the buyer have demonstrated an inability to develop a sharp focus on solving core problems.”
That is very much caused by our predominantly third party payer system along with excessive governmental intervention. Employers should not have been given the exclusive right to the tax exemption for health care.
“So how do we as large employers join ”
Good managers of companies know their companies inside and out and develop good relationships with their employees, suppliers and their customers. As a rule they know very little about healthcare and insurance.
Wow As I read the tread I see so much anger from a few and so much hope from other. I think change does that. I just visited 17 practices in the middle of transformation to PCMH level care (proactive primary care) in CT, NC and VA none the doc in Ct showed me what they are doing in this short video. http://www.cipci.org/future primary care office of the future.
Patient Centered Primary Care is an effort to address the high cost/low value situation we find ourselves in as large employer buyers of care. Study after countless study shows that when a patient has a primary care physician that cares about them has and uses the tools to practice comprehensive care centered on the patient needs they get the care they need at a price we can afford. Let’s call that a Proactive Patient Centered Primary Care (PCPC) or Patient Centered Medical Home (PCMH).
But we the buyers have been part of the problem (as Pogo said so long ago I see the enemy it is us) in not demanding systems of payment and practice organization that encourage and enable the comprehensive, patient-focused primary care we desire. There is no money paid for the necessary investments in teams and health information systems so essential to the delivery of comprehensive, cost-effective, patient-centered care. Current payment methods richly reward medical procedures and discourage spending time with patients in such essential activities as history taking, physical examination, diagnosis, planning treatment, counseling, coordination, and prevention. This must change. ,
When one compares the U.S. health care system with those of other industrialized countries, one is led to the more specific conclusion that the two major problems in U.S. health care are the way we 1) fail to deliver comprehensive primary care and 2) the way primary care is financed. Our premise is that primary care is the only natural locus of control of health care quality and costs. It is the only entity that is charged with the longitudinal care of the patient. It is the only entity whose job it is to consider the whole patient, the health of the whole person, including mental and physical.
As large employers our national focus on disease management programs is a good example of the failure of primary care and the failure of our efforts to improve care as a work around of the core problem and not face the real issue head on. If stand-alone disease management programs are considered necessary today, it is because primary care is not doing its job. From a primary care perspective, the treatment of chronic conditions, such as diabetes, congestive heart failure, and asthma, with the right tools is basic and straightforward. The care of these conditions is simply not that difficult. However, the quality failures in the treatment of these conditions are well documented. Stand-alone disease management programs which are not delivered at the point of care present a Band-Aid approach to problem solving. These kinds of work a rounds instead of addressing those problems directly, have in fact created additional, expensive, fragmented responses to the primary problem.
For some reason, the healthcare industry and we as the buyer have demonstrated an inability to develop a sharp focus on solving core problems. We seem much more willing to create complicated responses to our problems than we are to fix the core problems of our delivery system. Again, disease management is a perfect example. If primary care is not delivering high quality care for those with chronic conditions, we can either find a way to work around primary care or we can find a way to fix it. Our willingness as large employers to “pay any price” for that episodic care which for example provides for a Diabetic amputation of a limb but our unwillingness to open our eyes and understand that the reason for the amputation was our failure to be willing to pay for the prevention and primary care.
Although we tend to focus on the problems we face, there are reasons for a great deal of optimism-optimism due to the opportunities we have to improve and redesign care. Medical practice redesign is happening today. It is taking hold and has become a movement that is gaining momentum. We the large employers for the first time are at the table with the national health benefit companies and primary care professional societies. Let’s seize this opportunity and make the fundamental changes we have been asking for as large employers.
While I would not argue that primary care should be all things to all
people, it should be designed to achieve much higher performance than it achieves currently. Such a redesign of primary care is possible today. However, if primary care is not successful in its core tasks of prevention, wellness, and the care of common conditions including many chronic conditions, it will not be possible to control either quality or cost of care in the United States. Again, hospital care and Part-ecialty (specialty) care are crucial to health care, but their use is all too often the failure of upstream care. And look we have to start somewhere lets get really focused and address this lack of a foundation in are primary are delivery system and build onto a PCMH the better hospital and Part-ecialty we also need.
For the first time in history, we have both the knowledge and the capabilities (if we work hand in hand with our primary care providers) to force together substantial change. We are at a unique time in the history. In five or ten years, we might well look back with amazement at the pace of the changes that are currently taking place. The route is clear: We know what to do. We know how to make the system better. The crucial question is whether we have the courage to take on this difficult solution. But are strength lies in the fact that the primary care physicians want to help us take this on a wholesale transformation at the Micro primary care practice level in exchange for payment reform at the Macro level.
So how do we as large employers join the ranks of other systems like the VA and Denmark that have driven as much as 60% of the inefficiencies out of the system?
In step lock with our partners, the primary care providers, lets make it clear to the healthcare benefit companies that we deal with that as an employer buyer it is no longer business as usual. Let also be counted on as employers to send the same message to the other large healthcare buyers Health and Human Services, CMS, Medicaid, Federal Employees, DOD TRICARE, the White House, Congress, State and local government and others.
Demand of ourselves and our Healthcare benefit companies:
Comprehensive, continuous, patient centered, personal and holistic primary care which is based on strong relationships between patients and their physician — this is foundational to good health. Practice and payment reform are the prescriptions for achieving it.
Great post, Dr. Kernisan.
It IS good that the problem is being discussed. I think why some of us are seeing red is that the solutions proposed by the original post, by the “Joy in Practice” crowd, by the PCPCC are very much in the quality metric/performance measures/team care/MOC/PCMH/population management vein: we see what they are proposing as further isolating us from our patients and only making things much worse.
Wow. “Gonads,” Joel? I am sorry to are so deeply angry that you resort to this sort of thing.
“Rather, solutions are arising that can fix healthcare”
Joe, like a magician the government and its abettors force the healthcare solution they desire for political and personal economic reasons. Why else leave the patient out of the equation? From that direction high in the clouds we hear a whole slew of solutions that are born from the same branch of the tree. None of these things are innovative. They are all trying to mimic market solutions that grow organically not from the top down.
Are you looking for an imposed solution mandated on the American population? If so you will never get the free support and innovation of American physicians and businesses. If you wish to buy their support you will get their passive support, but not their true innovative support except for the few that innovate for their personal profit while gaming the system.
If you truly are looking 360 degrees and don’t have tunnel vision you will recognize that we need organic change coming from physicians and private individuals all over the nation and letting these smaller organic changes consolidate and break down as things progress. You will not be looking for a top down solution which only offers the innovation of the very few elites that have learned their craft from the same book.
“There are numerous examples of waste”
I see you have fallen into the waste trap where the cause of our problems are blamed at least in part on waste (and fraud). That’s what you get when you don’t have a market place to tell you how much a dollar is worth.
“Population health management is definitely a medical issue”
Define population health management and pin down what that term really means. In China 100,000 pigs were slaughtered because of an epidemic in the pig population. That is population management. Keep the herd of deer at a certain level and kill the rest. That is population management as well. I await your definition for without it any comments you make cannot be of great vaue.
Patient centered homes and disease management are what Internists do. But they weren’t paid to do that. Who do you think started such nonsense? The same ones that wrote the book and mandated the solutions.
We need to stop trying to control the results which have only led to higher costs, less satisfaction and a poor distribution of health dollars. That is top down thinking. Is that the type of thinking you want to see? After over 50 years of third party payer don’t you think it is time to give back control to the patient and let the patient call the shots outside of the contrived systems that we have all become too familiar with?
You are right, because I read your posts and comment rebuttals to sell an agenda, not principles that are foundations to what health care should be as instinct.
Frankly, as long as profit motives rule conversation and policy in provider offices, everyone is screwed, except those who get a paycheck often for absolutely nothing that goes on between the patient and provider.
You want to have real frank and brutally candid discussions among those who are the “front line grunts” to health care? Start with this simple question: “when did you first become concerned about health care interventions being interfered with that directly compromised your ability to provide the best care trained to offer?”
At the risk of the comment being censored or just stricken from view, it would be answered almost word for word by those who took the Hippocratic Oath seriously at graduation: “when managed care assholes only out to siphon, if not floridly steal any and all monies from the health care system, got the validation to do so from not only bureaucratic controls, but from the timid and cowardly reactions from colleagues who looked at their wallets and purses first, then just glanced cursory at their patients.”
People who write most posts here don’t really want to fix health care and restore it to what it SHOULD be, but just maintain a status quo and maximize a business agenda that never will fit the boundaries of what is an appropriate health care agenda.
Do you say that at all in your book “The Doctor Crisis”? If you honestly and clearly do, then I just echo those points. If you don’t, then isn’t that a sizeable lapse in judgment in omitting?
I am done at this thread and this blog, sorry for the hypocrisy in this further comment, but, do you really respect honest dissent, or just want a choir shrieking your “message”?
Talk amongst yourselves if this comment is worth digesting.
And, your title could have been better, how about “Doctors facing extermination”, certainly a more grabbing headline!
Sheesh, does anyone here remember “Network” and the scene of “mad as hell and not going to take it anymore”? Or, are your gonads gone and intestines stapled?!
I’m one of those docs who burned out of FFS primary care, in part because it’s especially hard if you want to focus on medically complex older patients.
I’m very very glad to see Cochran & Kenney bringing attention to the working conditions of primary care doctors. It’s a very important job and it’s far too hard to do well. Modeling myself on Joe’s approach, here are the truths I think we will need to work with:
– Most PCPs want to do the right thing for their patients. But, they still often are doing the wrong thing. This is partly due to time pressure & stress, partly due to cognitive biases and fast thinking, partly due to (for some) not being in the habit of listening to patients and partnering with them, partly due to not being in the habit of collaborating effectively w other healthcare providers, etc.
– Many PCPs don’t agree with the above. (Reminds me of back when I was in med school and docs would vociferously object to the idea that they are influenced by pharmaceutical advertising; it took a lot of education and some pressure to change the tide on that one.)
– Finding a reasonable way to manage PCP motivation will be hard. (Mike Painter had a good THCB post re motivation and physician incentives.) Docs & others respond to autonomy and things that cultivate internal motivation. How to get PCPs to change what they are doing without crippling this? Most of us have disliked being peppered with quality metrics – I was told my elderly patients BP was too high, grr – and performance measures…takes the joy out of the work:(
– The current stress and pressure of the job makes it very hard to adapt to changes — whether they be new tech, new teamwork, better parterning w patients — and improve one’s approach.
– I believe a PCP’s job should be to act as healer-partner to individual patients. But, it often takes more emotional and cognitive energy to practice this way.
– Working with a professional team is hard work. Requires a well-set up team & training (which leadership usually skimps on), and even then it is work. I once had a doc tell me she left a well-established geriatric team practice, because “It was a pain to practice by committee.” Ok maybe she is a bad team player, but just as admin duties and email are not negligible, neither is the effort of working w a team.
– Many non-doctors have bad feelings about doctors. And as a group, doctors (via AMA and others) have certainly oft acted to protect their priviledges and power. So it will take an effort to get the public to have interest and compassion for the working conditions of PCPs.
Thanks for bringing everyone’s attention to this imp issue.
Joel,
Why the relentless negativity? And what in the real world does it mean when you write “lies become truth, and sold here onwards voraciously.”? This whole discussion started because Jack and I wrote a post about what we contend is a serious problem in health care in the United States today. We believe that all stakeholders need to get involved to preserve and enhance careers for physicians. Not to coddle but to create practice conditions that enable them to provide quality care while at the same time preventing burnout. We need to do better by docs if we are to achieve our national goals of improved access, quality, equity and affordability. That’s where this whole thing began. Your contribution has been so snarl. Just so you know, Joel, it doesn’t help even a little.
Kaiser is no shining example for how it manages psychiatric care, and that is from those in the front lines. Sad how so many buy into the managed care/business model without hesitation.
Lies become truth, and sold here onwards voraciously. And with this last sentence, I bid those who care and are genuinely committed to honest and defendable standards of care good luck at this blog. Just remember the statistical standard of random chance, 1 of 20 might actually be true and well intended. That standard fits here, in my opinion.
Be safe, be well.
Joel Hassman, MD
Board Certified Psychiatrist
We are being driven by too many fads and ideas and rules arising outside of medicine…this is why we are unhappy. Further, many of these are bad ideas that take many years to prove wrong…up with which we are fed.
Doctors did not dream of tax-deducting medical care if employers-employees paid but not allowing this if a private citizen paid. This was startling and unfair and has moved health care from a private individual affair with small doctor-patient units towards giant profit-seeking mega corporations selling health care to huge businesses. And it has caused frictional unemployment up the gazoo.
Physicians did not decide Darling v Charleston Community Memorial Hospital in 1965 which changed hospitals from a physician’s tool into an entity that had to insure and deliver quality care and had to accumulate power to do this…..power that often exceeding that of the medical staff. This resulted in the physicians’ tool, the hospital hotel, feeling that it directed the show.
Further, physicians did not allow U.S. Patents to be issued for drugs before they were proved useful which we thought completed the necessary triad of “novel, unintuitive and useful” in granting U.S. patents. This, of course, allowed early marketing and required users, providers and hospitals to fund more expensive post-marketing studies untill utility was finally decided. See Xigris.
Just a few ideas from a host…
Vik the example you site of a wretched doctor from 33 years ago seems not even remotely representative of the vast majority of physicians. Most docs are devoted to their patients and work very hard. Most went into the profession to heal and comfort. Your anti-MD view is so extreme it is difficult to take you seriously.
sr,
Good points about NPs and PAs. I would readily agree that they have a place in modern medical care, as I have used both in practice. There is currently a hot debate now because if we are saying that these mid-levels may be able to practice without supervision, what is the point of doctors spending time and money on MOC and the recertification testing?
As far as medical errors, let’s be realistic here. Doctors do not cause all medical errors, many are the result of a combination of problems. By the same token, doctors that are nonchalant about it are unethical in my opinion. Classifying all doctors as such is the same as firing or disciplining all the employees of the VA instead of the ones responsible for the inappropriate behavior.
I refuse to be a victim or classify myself as such. If doctors don’t want to play by these rules, get out or do something different in the system. We have spent so much time sniping at each other and in territory disputes, outside parties have taken over medicine.
“There are numerous examples of waste in the system, things that we would be better off without, that cost tens of billions of dollars every year, from colonoscopies for mass screening, to computer-assisted mammograms, to unnecessary stents to complex back fusion surgery for simple back pain.”
And the waste is there because doing these procedures is so lucrative. Wouldn’t a more direct method of solving the problem be to pay dramatically less for these procedures and dramatically more for cognitive work? We PCPs feel that the PCMH and other innovations are at root an attempt to blame us for a problem we neither caused nor profited from, and telling us it’s our responsibility to fix it.
Thanks for the thoughtful reply, Allan.
Let me sketch out a bit more about what I meant by “trying different methods.” I am not demanding that physicians fix society’s ills. Rather, solutions are arising that can fix healthcare, but sone of these solutions depend on doctor shifting the ways they practice, the ways they collaborate, as well as the business models they work in.
There are numerous examples of waste in the system, things that we would be better off without, that cost tens of billions of dollars every year, from colonoscopies for mass screening, to computer-assisted mammograms, to unnecessary stents to complex back fusion surgery for simple back pain. Doctors do them because they get paid on volume. Most organizations that don’t get paid on volume (e.g. Kaiser) don’t do most of them, or do them much less.
Population health management is definitely a medical issue, one which requires a much tighter relationship between the doctor and the patient, and between the primary and the rest of the medical establishment. Doctors have not typically done this because they don’t get paid to do it. Patient-centered medical homes are a method of paying them to do this.
Many of the other emerging methods of payment require doctors or hospitals to take on risk, that is, they can lose money if they manage it poorly and gain if they manage it well (which is what we expect from any other industry). To manage it well, they need to establish new work routines, new methods of dealing with patients, and new relationships between the doctors, often under some new risk-bearing business model.
Physicians have not been wildly experimental in these new methods, understandably, because they are experimental, and they are trying to make a living, have a career. Like anyone else, most of them tend to do what is tried and true when it comes to making a living. Now most doctors are clear that we really are moving into a new era, and what was tried and true — volume-based fee-for-service — may not work so well in the future. So increasingly they are trying these new ways. Many of them will not do so well, because we don’t have a lot of collective experience in how to manage these new structures. But we have to try, because we have to find the way forward to healthcare that is both much better and much cheaper.
“I guess my bottom line on this is that either you trust the system or you don’t.”
Barry, what do you do flip a coin, or do you look at the incentives to determine potential outcomes?
Dealing in general: A marginal extra test that makes a physician earn more money might help a rare patient, but in general doesn’t hurt the patient. If it does and it was unnecessary the suit will be lost. A denial of an important finding or symptom where the medical record is written up to protect from suit (HMO) is a case that loses in court.
Thus in the end from the do no harm FFS/PPO is less harmful and suits are easier to win. In the HMO model (capitated) a denial can be life threatening and no proof may exist.
End of life situation: You should control your own destiny. Should you involuntarily pay for another by being forced to take a specific plan? No.
You are right, we spend too much and do too much, but I am solely looking at this from the patient perspective and where his risks are highest. Go to that study I suggested earlier and read it. It’s on the Harp.org site. Google Ware and go to the 4 year study. Old, but as good today as it was then because the incentives haven’t changed.
Vic thank you for site. I will read it later, but not all error is malpractice and I believe he made that clear in interviews. I don’t like to minimize the errors committed in hospitals or by doctors, but we have to remember that many of these people that died and many more would have died without treatment. The complexities in medicine are tremendous and all too frequently some of the most important decisions have to be made on the spot. The best physicians with the best intentions doing the best they can can and will occasionally screw up.
Can we do better? Of course and that is what we must strive to do, but that is dependent upon society as a whole not just the hospital or the medical profession.
Are you looking for the perfect physician? Are you looking to blame physicians? What are your objectives?