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.
Leave your bias aside and take a look into the healthcare future with me. No, artificial intelligence, augmented intelligence and machine learning will not replace the radiologist. It will allow clinicians to.
The year is 2035 (plus or minus 5 years), the world is waking up after a few years of economic hardship and maybe even some dreaded stagflation. This is an important accelerant to where we are going, economic hardship, because it will destroy most radiology AI startups that have thrived on quantitative easing polices and excessive liquidity of the last decade creating a bubble in this space. When the bubble pops, few small to midsize AI companies will survive but the ones who remain will consolidate and reap the rewards. This will almost certainly be big tech who can purchase assets/algorithms across a wide breadth of radiology and integrate/standardize them better than anyone. When the burst happens some of the best algorithms for pulmonary embolism, stroke, knee MRI, intracranial hemorrhage etc. etc. will become available to consolidate, on the “cheap”.
Hospitals can now purchase AI equipment that is highly effective both in cost and function, and its only getting better for them. It doesn’t make sense to do so now but soon it will. Consolidation in healthcare has led to greater purchasing power from groups and hospitals. The “roads and bridges” that would be needed to connect such systems are being built and deals will soon be struck with GE, Google, IBM etc., powerhouse hundred-billion-dollar companies, that will provide AI cloud-based services. RadPartners is already starting to provide natural language processing and imaging data to partners; that’s right, you speak into the Dictaphone and it is recorded, synced with the image you dictated, processed with everyone else to find all the commonalities in descriptors to eventually replace you. It is like the transcriptionists ghost of the past has come back to haunt us and no one cried for them. Prices will be competitive, and adoption will be fast, much faster than most believe.
Now we have some patients who arrive for imaging, as outpatients, ER visits, inpatients; it does not matter the premise is the same. Ms. Jones has chest pain, elevated d-dimer, history of Lupus anti-coagulant and left femoral DVT. Likely her chart has already been analyzed by a cloud-based AI (merlonintelligence.com/intelligent-screening/) and the probability of her having a PE is high, this is relayed to the clinician (PA, NP, MD, DO) and the study is ordered. She’s sent for a CT angiogram PE protocol imaging study. This is important to understand because there will be no role for the radiologist at this level. The recommendation for imaging will be a machine learning algorithm based off more data and papers than any one radiologist could ever read; and it will be instantaneous and fluid. Correct studies will be recommended and “incorrectly” ordered studies will need justifications without radiologist validation.
“Kijan ou ye? How are you?” I asked my patient, a fifty-five year-old Haitian-American woman living in Dorchester, Massachusetts. It was 2008. I had been her primary care doctor for two years and was working with her to reduce her blood pressure and cholesterol levels. “Papi mal dok– I’m doing ok doc.” We talked for 15 minutes, reviewed her vital signs and medications, and made a plan. I then electronically transmitted a new prescription to her pharmacy. The encounter was like thousands of others I’d had as a physician, except for one key difference– I was in Rwanda, 7,000 miles away from Dorchester and 6 hours ahead of the East Coast time zone.
At the time, I knew that telemedicine – the practice of providing healthcare without the provider being physically present with the patient – was a resourceful means of working with rural populations that have limited access to healthcare. However, I had no idea that just ten years down the road, many health professionals and policymakers would laud the emerging tech field as the answer to inaccessible healthcare for rural communities. While I’m aware of telemedicine’s promising benefits, I’m certain that it cannot, on its own, solve the most pressing issues that continue to afflict the rural poor and underserved.
Ever since the invention of the telephone, providers have been practicing telemedicine. However, not until the advent of advanced technologies such as high-speed internet, smartphones, and remote-controlled robotic surgery, has the field of telemedicine started to beg the question: “Do we still need in-person interactions between patient and doctor to provide high quality healthcare?” This question is particularly important for patients who live in rural areas, where a chronic shortage of providers has existed for decades.
In business literature I have seen the phrase “getting paid for who you are instead of what you do”. This implies that some people bring value because of the depth of their knowledge and their appreciation of all the nuances in their field, the authority with which they render their opinion or because of their ability to influence others.
This is the antithesis of commoditization. Many industries have become less commoditized in this postindustrial era, but not medicine. Who in our culture would say that a car is a car is a car, or that a meal is a meal is a meal?
The differences between services with the same CPT code for the same ICD-10 code aren’t, hopefully, quite that vast. But they’re also not always the same or of the same value. There is a huge difference between “I don’t know what that spot is, but it looks harmless” and “It’s a dermatofibroma, a harmless clump of scar tissue that, even though it’s not cancerous, sometimes grows back if you remove it, so we leave them alone if they don’t get in your way”.
I always feel a twinge of dissatisfaction when, after a visit, a patient says “Thanks for your time”. It always makes me wonder, on some level, “did my patient not get anything out of this other than the passage of time, did we not accomplish anything”?
It’s no secret that healthcare providers are among the
hardest working of all professionals – their skill and intelligence are matched
only by their creativity and commitment to their patients. But the healthcare
IT sector, while it has made an effort to assist, has failed to support our
providers – doctors, nurses and caregivers – with technology solutions that
meet the increasing demands for better, faster, more efficient patient healthcare
delivery. Instead, we have cast these providers in the dark, forcing them to
function blindly, devoid of necessary information, pushing many of them to the
brink of what they can withstand as professionals, pushing them to burnout.
The thing about providers is that, in addition to being
hardworking, dedicated, and outstanding professionals, they are incredibly
creative and innovative, willing to embrace new technologies and workflows – as
long as they can add value to their patients. So how about we – the broader healthcare
IT solutions vendor community – focus on delivering technologies that don’t
force them to compromise care and efficiency for the sake of security, or
compliance and access to data?
We need to do so to address an industry crisis. Physician
burnout is on the rise, and it’s increasingly clear that overworked providers have
reached the breaking point. They spend valuable minutes battling technology on
virtual desktops, mobile devices, biomedical equipment, and clinical SaaS
applications – typing in usernames and passwords, loading various apps, and
more. All the while, standing beside a patient that is desperately seeking
Right now, nearly one-half of all physicians (44 percent) report
having feelings of burnout (according to Medscape‘s 2019 National
Physicians Burnout & Depression Report). While these numbers should
alarm everyone, what the healthcare IT industry should be especially concerned
about is that a leading cause of this physician burnout are tools that hinder provider
productivity. Instead of simplifying work for doctors and nurses, technology
tools are having the opposite effect. Isn’t technology supposed to make things
As Robert Muller’s testimony before Congress made clear, we
owe President Trump a debt of gratitude on two counts. First, his unlawful and
predatory actions have clearly exposed the fault lines in our still young
Democracy. As the Founders well realized, the road would be rocky on our way to
“a more perfect union”, and checks and balances would, sooner or later, be
counter-checked and thrown out of balance.
On the second count, Trump has most effectively revealed
weaknesses that are neither structural nor easily repaired with the wave of the
wand. Those weaknesses are cultural and deeply embedded in a portion of our
citizenry. The weakness he has so easily exposed is within us. It is reflected
in our stubborn embrace of prejudice, our tolerance of family separations at
the border, our penchant for violence and romanticism of firearms, our
suspicion of “good government”, and –unlike any other developed nation – our
historic desire to withhold access to health services to our fellow Americans.
In the dust-up that followed the New York Times publication of Ross Douthat’s May 16, 2017 article, “The 25th Amendment Solution for Removing Trump”, Dahlia Lithwick wrote in SLATE, “Donald Trump isn’t the disease that plagues modern America, he’s the symptom. Let’s stop calling it a disability and call it what it is: What we are now.”
Recently a long-time health advocate from California told me
she did not believe that the majority of doctors would support a universal
health care system in some form due to their conservative bend. I disagreed.
It is true that, to become a physician involves significant
investment of time and effort, and deferring a decade worth of earnings to
pursue a training program that, at times, resembles war-zone conditions can
create an ultra-focus on future earnings. But it is also true that these
individuals, increasingly salaried and employed within organizations struggling
to improve their collective performance, deliver (most of the time) three
critical virtues in our society.
I would urge THCB-ers to read Reframing Healthcare by Dr. Zeev Neuwirth. While much of the territory he covers will be familiar to those of us with an interest in healthcare reform (meaning just about everyone reading this blog), Chapter 5 breaks new ground in the field of primary care.
Primary care is perhaps the sorest spot in healthcare, the
sorest of industries. Primary care providers (PCPs) are underpaid,
dissatisfied, and in short supply. (The supply issue could be solved in part if
employers didn’t pay employees
bonuses to get useless annual checkups or fine them if they don’t, of
They are also expected to stay up to date on a myriad of
topics, but lack the time in which to do that and typically don’t get
compensated for it. Plus, there are a million other “asks” that have nothing to
do with seeing actual patients.
For instance, I’ve gone back and forth three times with my
PCP as she tries to get Optum to cover 60 5-milligram zolpidems (Ambien)
instead of 30 10-milligram pills. (I already cut the 5 mg. pills in half. Not
fair or good medicine to ask patients to try to slice those tiny 10 mg pills
into quarters. And not sure why Optum would incentivize patients to take more
of this habit-forming medicine instead of less.)
This can’t be fun for her. No wonder PCPs burn out and leave
the practice faster than other specialties. What some of my physician
colleagues call the “joy of practice” is simply not there.