American anesthesiology reached a significant milestone last year, though many of us probably missed it at the time.
In February, 2014, the number of nurse anesthetists in the United States for the first time exceeded the number of physician anesthesiologists. Not only are there more nurses than physicians in the field of anesthesia today, the number of nurses entering the field is growing at a faster rate than the number of physicians. Since December, 2012, the number of nurse anesthetists has grown by 12.1 percent compared to 5.8 percent for physician anesthesiologists.
The numbers—about 46,600 nurse anesthetists and 45,700 physician anesthesiologists—reported in the National Provider Identifier (NPI) dataset for January, 2015, probably understate the growing disparity. Today, more and more physicians are leaving the front lines of medicine, many obtaining additional qualifications such as MBA degrees and embarking on new careers in hospital administration or business.
Physician anesthesiologists can expect that fewer of us every year will continue to work in the model of personally providing anesthesia care to individual patients. Clinical practice is likely to skew even more toward the anesthesia care team model, already dominant in every part of the US except the west coast, with supervision of nurse anesthetists and anesthesiologist assistants.
We hear a lot about how US medicine is broken, from how much we spend annually ($4 trillion) for unimpressive outcomes, to the growing epidemic of obesity and diabetes, to problematic financial models, to the growing malaise amongst doctors.
Across US health care, a lot of smart people are crafting solutions to these problems, but in my view the reality is that many of them are generating efficiencies on top of a broken product.
The real problem is that conventional primary care as it’s practiced today no longer serves the needs of most people, be they wealthy or under-served, be they patient or provider.
I am starting Parsley Health, a new kind of medical practice that directly addresses these problems, first by providing something called Functional Medicine rather than traditional primary care, and second by providing functional medicine in a tech driven, modern and affordable way.
What is Functional Medicine?
I became a functional medicine doctor because early on I recognized two major limitations of the conventional medicine.
This was a comment I submitted submitted to this proposed set of regulations on health plans participating in the ACA. (Use ctrl-F to search “provider directory” within the page). HHS is proposing forcing insurers to make their provider directories more accurate and machine readable, and it would be great for consumers if that was made the case–especially if APIs (which means basically giving access for other computers to read them) were mandated–here’s why:
Subject–Immediately updated provider directories machine readable via APIs should be mandated for health insurers.
Finding accurate information about providers is one of the hardest things for consumers to do while interacting with the health care system. While regulation cannot fix all of these issues, these proposed regulations in section 156.230 can greatly help, But they should be strengthened by requiring (under subsection 2) that health insurers immediately add new information about providers in their networks to a publicly available machine readable database accessible via a freely available API.
Currently companies trying to aid consumers in provider search and selection tell us that the information pertaining to which providers are in a particular network is the least accurate of all data they can receive. For consumers the biggest question for plan selection is trying to find out which provider is in their plan, and at the least this requires searching multiple websites. Worse, particular insurer’s plans can even have the same name but can have different networks (in one instance in our personal experience Aetna in New York state had two different plans with effectively the same name but different networks). This is essentially impenetrable for consumers and that is assuming that the information on the websites is accurate or timely–which it is often not.
It is a heart pounding, head spinning, edge of your seat page-turner; the sort of rare saga that takes your breath away as it changes you, forever. It hints at a radically different future, a completely new world a few years away, which will disrupt the lives of every man, woman and child. Available now, from the National Coordinator for Health Information Technology (ONC), Office of the Secretary, United States Department of Health and Human Services, is finally, without further ado; the Federal Health IT Strategic Plan 2015 – 2020.
You think I am kidding. A satirical dig at another monstrous, useless, governmental report? Absolutely not. The concepts outlined in this blueprint will transform healthcare. It is a tight, clear, document, which at only 28 pages, delivers almost as much change per word as the Declaration of Independence. This may be the most powerful application yet of computerized information technology.
If you want to know where healthcare and health IT are headed, The Plan is absolutely worth a read.
I have only one complaint; it is coated with too much sugar. Restricted by policy structure and jargon, the report does not go far enough.
On September 28, 1864, exactly 150 years ago this weekend, the first meeting of the International Workingmen’s Association (IWA) was convened at St. Martin’s Hall, London. Among the attendees was a relatively obscure German journalist by the name of Karl Marx. Though Marx did not speak during the meeting, he soon began playing a crucial role in the life of the organization, in part because he was assigned the task of drafting its founding documents.
The work of the IWA and Marx is increasingly relevant to the practice of medicine today, largely because of the rapidly shrinking percentage of US physicians who own their own practices. This moves physicians into the category of what Marx and his associates called, “working people.” According to data from the American Medical Association, in 1983 76% of physicians were self-employed, a number that had fallen in 2012 to 53%. And the trend is accelerating. It is estimated that in 2014, 3 in 4 newly hired physicians will go to work for hospitals and health systems.
To put this change in Marx’s terms, the rapid fall in physician self-employment means that a shrinking percentage of physicians own what he called the means of production. In his view, this alienates workers – in this case physicians – from other physicians, themselves, the work they do, and from patients. Whether we agree with Marx on every point, his writings on this topic provides a provocative perspective from which to survey the changing landscape of contemporary medicine.
Not accustomed to visiting hospital executive suites, I took my seat in the waiting room somewhat warily.
Seated across from me was a handsome man in a well-tailored three-piece suit, whose thoroughly professional appearance made me – in my rumpled white coat, sheaves of dog-eared paper bulging from both pockets – feel out of place.
Within a minute, an administrative secretary came out and escorted him into one of the offices. Exhausted from a long call shift and lulled by the quiet, I started to doze off. Soon roused by the sound of my own snoring, I stared and looked about.
That was when I spotted the document on an adjacent chair. Its title immediately caught my eye: “How to Discourage a Doctor.”
When I write or speak about healthcare transformation, I am often asked why I do not criticize more. Criticize health system leadership. Criticize governmental policies. Criticize burdensome regulations. It’s a long list. Why avoid criticism? The answer is simple. Discerning emerging solutions is much more productive and fun.
We are living during a very interesting period in the history of health care. No doubt, it is a time of great transition. We are passing from one time to another. Transition periods are important, yet they are hard to define because it’s difficult to determine exactly when they start and when they end. To understand the transition healthcare is now experiencing, we must do our best to understand what is on either side of it.
The traditional approach to delivering care has served us well and accomplished great things over the past century. Yet, it is also being overwhelmed by complexity and producing inconsistent quality, unacceptable levels of harm, too much waste and spiraling costs.
The traditional method of delivering care is struggling and another is emerging to take its place. Because the traditional approach has served us well and accomplished great things, we want to believe that the present state will continue forever. Because conditions have changed, this will not happen. We are in need of a new approach. An approach that carries the best of the past forward, yet also addresses present day challenges. It just might be that on the other side of this current transition is potentially a time unmatched by any other in the history of healthcare. Thanks to visionary clinical leaders at institutions across the country, there is growing evidence this is not only possible; it is likely.
Who does the future belong to? If we look closely at other transition periods in history, two groups of people are apparent. The first are what we recognize as critics. They are people whose response to the need for change is criticism. Critics always exist, but in a time of transition they tend to multiply. What do they criticize? They criticize the new, they criticize the change, they criticize the change for being unnecessary or too fast, or they criticize the change for being too slow. They criticize anything and everything. Critics are abundant. The question we should consider is, “Will criticism solve problems?” Typically, it does not. While constructive criticism has its place, it alone is not likely to accomplish much especially when the world is yearning for innovative solutions.
Everywhere we turn these days it seems “Big Data” is being touted as a solution for physicians and physician groups who want to participate in Accountable Care Organizations, (ACOs) and/or accountable care-like contracts with payers.
We disagree, and think the accumulated experience about what works and what doesn’t work for care management suggests that a “Small Data” approach might be good enough for many medical groups, while being more immediately implementable and a lot less costly. We’re not convinced, in other words, that the problem for ACOs is a scarcity of data or second rate analytics. Rather, the problem is that we are not taking advantage of, and using more intelligently, the data and analytics already in place, or nearly in place.
For those of you who are interested in the concept of Big Data, Steve Lohr recently wrote a good overview in his column in the New York Times, in which he said:
“Big Data is a shorthand label that typically means applying the tools of artificial intelligence, like machine learning, to vast new troves of data beyond that captured in standard databases. The new data sources include Web-browsing data trails, social network communications, sensor data and surveillance data.”
Applied to health care and ACOs, the proponents of Big Data suggest that some version of IBM’s now-famous Watson, teamed up with arrays of sensors and a very large clinical data repository containing virtually every known fact about all of the patients seen by the medical group, is a needed investment. Of course, many of these data are not currently available in structured, that is computable, format. So one of the costly requirements that Big Data may impose on us results from the need to convert large amounts of unstructured or poorly structured data to structured data. But when that is accomplished, so advocates tell us, Big Data is not only good for quality care, but is “absolutely essential” for attaining the cost efficiency needed by doctors and nurses to have a positive and money-making experience with accountable care shared-savings, gain-share, or risk contracts.
Throughout history, physicians have treated patients for conditions that generations of their professional successors later deemed figments of their (the physicians’) imaginations. The list is long, but in just the last 100 years, it has included such disorders as female hysteria, homosexuality, moral insanity, neurasthenia, and vapors, among many others. The consequences of such diagnoses were not trivial, and in some cases, patients were stigmatized, ostracized, subjected involuntarily to a variety of noxious treatments, and even incarcerated because of them. Yet we now believe that each of these conditions was a fiction, and they are absent from today’s textbooks.
Something similar may be afoot in the profession of medicine today. The affliction is known as conflict of interest, and medicine is thought to be suffering a pandemic of it. In fact, its proponents argue that no physician is safe. Its symptoms among researchers are a tendency to conduct investigations and publish results that are biased, and among clinicians, to prescribe tests and therapies that their patients do not really need. The underlying cause of the condition is thought to be financial inducements from industry, which lead these gullible physicians and scientists to betray their personal and professional integrity without even knowing it.
For example, industry funding of research might lead physician-scientists to bias their results in ways that line the pockets of pharmaceutical companies and medical device manufacturers. Likewise, the presence of industry representatives in offices and hospitals might lead physicians to write inappropriate prescriptions for industry-promoted drugs. If physicians are presented with a gift such as a pen, a notepad, a book, or a free meal from an industry representative, they might be more inclined to use that company’s products in their practice. The implication? Physicians are insufficiently self-aware and trustworthy to put patients’ interests above their own.