Over four years of medical school, a one-year internship, a four-year radiology residency, a one-year neuroradiology fellowship, and now some time as an attending, one of my consistent takeaways has been how well (and thus how badly) the traditional academic hierarchy conforms to The Peter Principle.
The Peter Principle, formulated by Laurence J Peter in 1969, postulates that an individual’s promotion within an organizational hierarchy is predicated on their performance in their current role rather than their skills/abilities in their intended role. In other words, people are promoted until they are no longer qualified for the position they currently hold, and “managers rise to the level of their incompetence.”
In academic medicine, this is particularly compounded by the conflation of research prowess and administrative skill. Writing papers and even getting grants doesn’t necessarily correlate with the skills necessary to successfully manage humans in a clinical division or department. I don’t think it would be an overstatement to suggest that they may even be inversely correlated. But this is precisely what happens when research is a fiat currency for meaningful academic advancement.
The business world, and particularly the tech giants of Silicon Valley, have widely promoted (and perhaps oversold) their organizational agility, which in many cases has been at least partially attributed to their relatively flat organizational structure: the more hurdles and mid-level managers any idea has to go through, the less likely it is for anything important to get done. A strict hierarchy promotes stability primarily through inertia but consequently strangles change and holds back individual productivity and creativity. The primary function of managers is to preserve their position within management. As Upton Sinclair wrote in The Jungle: “It is difficult to get a man to understand something when his salary depends upon his not understanding it.” (which incidentally is a perfect summary of everything that is wrong in healthcare and politics).
U.S. physicians report that more than 20 percent of overall medical
care is not needed.
The Congressional Budget Office recently estimated that up to
30 percent of the costs of medical care delivered in the U.S. pay for tests,
procedures, doctor visits, hospital stays, and other services that may not
actually improve patient health.
Unnecessary medical treatment impacts the healthcare industry through
decreased physician productivity, increased cost of medical care, and
additional work for front office staff and other healthcare professionals.
Most of today’s
primary care is, in retail terms, a loss leader — a well-oiled doorway to the
wildly expensive sick care system. For decades, practitioners have been forced
into production factories, seeing as many patients, ordering as many tests, and
sending as many referrals as possible to specialists. Patients, likewise, have
avoided going in for regular visits for fear of the price tag attached, often
waiting until they’re in such bad shape that urgent (and much more expensive)
care is necessary.
The system as it
stands isn’t delivering primary care in a way that serves patients, providers,
employers, or insurers as well as it could. To improve health at individual and
population levels, the system needs to be disrupted. Primary care needs to play a much larger role in healthcare, and it
needs to be delivered in a way that doesn’t make patients feel isolated,
neglected, or dismissed.
care is making a comeback — the kind that doesn’t just treat symptoms, but sees
trust, engagement, and behavior change as a path to health.
The chest CT report was a bit worrisome. Henry had “pleural based masses” that had grown since his previous scan, which had been ordered by another doctor for unrelated reasons. But as Henry’s PCP, it had become my job to follow up on an emergency room doctor’s incidental finding. The radiologist recommended a PET scan to see if there was increased metabolic activity, which would mean the spots were likely cancerous.
So the head of radiology says this is needed. But I am the treating physician, so I have to put the order in. In my clunky EMR I search for an appropriate diagnostic code in situations like this. This software (Greenway) is not like Google; if you don’t search for exactly what the bureaucratic term is, but use clinical terms instead, it doesn’t suggest alternatives (unrelated everyday example – what a doctor calls a laceration is “open wound” in insurance speak but the computer doesn’t know they’re the same thing).
So here I am, trying to find the appropriate ICD-10 code to buy Henry a PET scan. Why can’t I find the diagnosis code I used to get the recent CT order in when I placed it, months ago? I cruise down the list of diagnoses in his EMR “chart”. There, I find every diagnosis that was ever entered. They are not listed alphabetically or chronologically. The list appears totally random, although perhaps the list is organized alphanumerically by ICD-10, although they are not not displayed in my search box, but that wouldn’t do me any good anyway since I don’t have more than five ICD-10 codes memorized.
In the 2020 Summer Olympics, we will undoubtedly see large, red circles down the arms and backs of many Olympians. These spots are a side-effect of cupping, a treatment originating from traditional Chinese medicine (TCM) to reduce pain. TCM is a globally used Complementary and Alternative Medicine (CAM), but it still battles its critics who think it is only a belief system, rather than a legitimate medical practice. Even so, the usage of TCM continues to grow. This led the National Institute of Health (NIH) to sponsor a meeting in 1997 to determine the efficacy of acupuncture, paving the way in CAM research. Today, there are now over 50 schools dedicated to teaching Chinese acupuncture in the US under the Accreditation Commission for Acupuncture & Oriental Medicine.
While TCM has seen immense growth and integration around the globe throughout the last twenty years, other forms of CAM continue to struggle for acceptance in the U.S. In this article we will focus on Native American/Indigenous traditional medical practices. Indigenous and non-Indigenous patients should not have to choose between traditional and allopathic medicine, but rather have them working harmoniously from prevention to diagnosis to treatment plan.
It was not until August of 1978 that federally recognized tribal members were officially able to openly practice their Indigenous traditional medicine (the knowledge and practices of Indigenous people that prevent or eliminate physical, mental and social diseases) when the American Indian Religious Freedom Act (AIRFA) was passed. Prior to 1978, the federal government’s Department of Interior could convict a medicine man to a minimum of 10 days in prison if he encouraged others to follow traditional practices.
It is difficult to comprehend that tribes throughout the U.S. were only given the ability to openly exercise their medicinal practices 41 years ago when the “healing traditions of indigenous Native Americans have been practiced on this continent for 12,000 years ago and possibly for more than 40,000 years.”
Since the passage of AIRFA, many tribally run clinics and hospitals are finding ways to incorporate Indigenous traditional healing into their treatment plans, when requested by patients.
Imagine a massive public health crisis in the United States that affects tens of thousands of people. Now imagine that the government had a simple tool at its disposal that could prevent this kind of physical and psychological trauma. You might think that I’m writing about America’s deadly outbreak of gun violence, which has made headlines this summer from Dayton to El Paso.
But actually I’m talking about a different crisis that affects even more people – all of them children — and which could be sharply reduced with one simple step that lacks the bitter political animus of the gun debate. The issue at hand involves babies born to mothers who used opioids during pregnancy – babies who tend to develop a condition called Neonatal Abstinence Syndrome, or NAS.
Experts say that state and federal governments have grossly underestimated the number of NAS babies currently born in the United States, as the addiction crisis triggered by Big Pharma’s greed in pushing painkillers refuses to fade. They say an accurate accounting would find a minimum of 250,000 children — and possibly two or three times that every year born with NAS. These kids will face chronic symptoms such as trembling and seizures, gastrointestinal problems, and an inability to sleep. Their numbers are more than eight times higher than the last official estimate from the government.
For more than a year now, I’ve been working with a team of attorneyscalled the Opioid Justice Team who are fighting for any settlement of the massive court fight pitting more than 2,000 localities against Big Pharma to include a medical monitoring fund for the estimated hundreds of thousands of kids born with NAS syndrome. But our team has also been pushing for radical measures that would prevent many of these unfortunate cases.
Imagine if your bank handled all your online transactions for free but charged you only when you visited your local branch – and then kept pestering you to come in, pay money and chat with them every three months or at least once a year if you wanted to keep your accounts active.
Of course that’s not how banks operate. There are small ongoing charges (or margins off the interest they pay you) for keeping your money and for making it possible to do almost everything from your iPhone these days. Yes, there may be additional charges for things that can’t be done without the bank’s personalized assistance, but those things happen at your request, not by the bank’s insistence.
Compare that with primary care. The bulk of our income is “patient revenue”, what patients and their insurance companies pay us for services we provide “face to face”. We may also have grants if we are Federally Qualified Health Centers, mostly meant to cover sliding fee discounts and what we call “enabling services” – care coordination, loosely speaking.
Only a small fraction of our income comes from meeting quality or compliance “targets”, and those monies only come to us after we have reached those goals – they don’t help us create the needed infrastructure to get there.
Then look at how medical providers are scheduled and paid. We all have productivity targets, RVUs (Relative Value Units – number and complexity of visits combined) if our employer is paid that way and usually just straight visit counts in FQHCs (because all visits are reimbursed at the same rate there). Sometimes we have quality bonuses or incentives, which truthfully may be the combined result of both our own AND other staff members’ efforts.
How easy is it for physicians to choose wisely and reject low value care? Who decides what’s wise and what’s unwise? In this episode Saurabh Jha (aka @RogueRad) speaks with William Sullivan MD JD. Dr. Sullivan is an emergency physician and an attorney specializing in healthcare issues. Dr. Sullivan represents physicians and has published many articles on legal aspects of medicine. He is a past president of the Illinois College of Emergency Physicians and a past chair and current member of the American College of Emergency Physicians’ Medical Legal Committee.
It’s a funny world we live in. Lots of people make a handsome living, defining their work and setting their own fees and hours with little or no formal education or certification
There are personal and executive coaches, wealth advisers, marketing experts, closet organizers and all kinds of people offering to help us run our lives.
In each of these fields, the expectation is that the provider of such services has his or her own “take” or perspective and offers advice that is individual, unique and as far removed from cookie cutter dogma as possible. Why pay for something generic that lots of people offer everywhere you turn?
So why is it, in this day of paying lip service to “personalized medicine”, genetic mapping, the human biome and psychoneuroimmunology that we expect our healthcare to be standardized and utterly predictable?
And why is it that we are so willing to fragment our care, using convenient care clinics, health apps, specialists who don’t communicate with each other and so on? Does anybody believe it makes sense to have your life coach tell you to have a latte if you feel like it because it makes you happy and your financial adviser scorn you for wasting money, never mind your health coach talking about all those unnecessary calories?
In today’s world, almost all knowledge and information is available, for free, instantly and from anywhere on the planet. But this has not eliminated our need for “experts”. It used to be that we paid experts for knowing the facts, but now we pay them for sorting and making sense of them, because there are too many facts and too much data out there to make anything self explanatory.
By MATTHEW S. ELLMAN, MD and JULIE R. ROSENBAUM, MD
What if firearm deaths could be reduced by
visits to the doctor? More than 35,000 Americans are killed annually by
gunfire, about 60% of which are from suicide. The remaining deaths are mostly
from accidental injury or homicide. Mass shootings represent only a tiny
fraction of that number.
There’s a lot physicians can do to reduce
these numbers. Typically, medical organizations such as the AMA recommend
counseling patients on firearm safety. But there is another way to use
medical expertise to help reduce harm from firearms: physicians should evaluate
patients interested in purchasing firearms. The idea would be to reduce the
number of guns that get into the hands of people who might be a danger to
themselves or others due to medical or psychiatric conditions. This
proposal has precedents: physicians currently perform comparable standardized
evaluations for licensing when personal or public safety may be at risk, for
example, for commercial truck drivers, airplane pilots, and adults planning to
adopt a child. Similar to these models, a subset of physicians would be
certified to conduct standardized evaluations as a prerequisite for gun
As a primary care physicians with decades
of practice experience, we have seen the ravages of gun violence in our
patients too many times. A 50-year-old man shot in the spinal cord 30 years ago
who is paraplegic and wheelchair-dependent. A 42-year-old woman who sends her
teenage son to school every day by Uber because another son was shot to death
walking in their neighborhood. A teacher from Sandy Hook who struggles to cope
with post-traumatic stress disorder.
Physicians can contribute their expertise toward determining objective medical impairments impacting safe gun ownership. These include undiagnosed or unstable psychiatric conditions such as suicidal or homicidal states, memory or cognitive impairments, or problems such as very poor vision, all of which may render an individual incapable of safely storing and firing a gun. In this model, the clinical role would be limited in scope. The physician would complete a standardized evaluation and offer recommendations to an appropriate regulatory body; the physician would not be the final decisionmaker regarding licensing. An appeal process would be assured for those individuals who disagree with the assessment.
If medical journals are the religious texts that guide me as a physician, the New York Times has become the secular source of illumination for my relationship to my country and the world I live in.
That doesn’t exactly mean that I feel like a citizen of the world. Quite the opposite, particularly now, with just me and my horses sharing our existence on a peaceful plot of land within walking distance of the Canadian border; my physical world seems quite small even though I am aware, sometimes painfully but with an obvious distance, of the calamity of our planet.
Early Sunday morning, drinking coffee in bed as the gray morning light revealed the outline of the trees and pasture outside my window, I read the Times on my iPad as usual and came across an article titled “What makes people charismatic and how you can be too”.
The article claims that charisma can be learned and cultivated, and that thought resonated with me as I think often about how we as physicians have roles to fill in the stories of diseases and transitions in our patients lives. I try to be the kind of doctor each patient needs as I walk into each exam room.
The article mentions three pillars of charisma: Presence, Power and Warmth.
As I think of my current third guiding light in addition to my medical journals and the New York Times, my DVD collection of the Marcus Welby, M.D. shows, which is shorthand for his character and all the other role models I carry mental images and video clips of, Charisma is definitely something we need to consider and cultivate in our careers.