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Tag: Physicians

Actually, It’s a Great Time to Be a Doctor

Is this a good time to be a physician? Absolutely! In fact, I believe there has never been a better time to practice medicine. I hold this belief despite the barrage of negative comments and predictions from doomsayers remarking on the sorry state of health care in its current state.

Before I tell you why I’m so optimistic, I’d like to acknowledge one fact: practicing medicine is more complex and difficult than ever, however, this fact doesn’t dampen my enthusiasm. There is no doubt that over the past two decades a great many changes in the health care environment have consumed doctors’ time, distracted us from our core task of providing care, and impacted our incomes.

Meanwhile, patients’ expectations of the health care industry and of their physicians are changing. An increasing number of people want more involvement in their own health care and want to partner with their physician. So it is not hard to understand how practicing medicine can feel more challenging than ever.

For example: results from a national survey reported in the Archives of Internal Medicine in 2012 indicated that US physicians suffer from more burnout than other American workers.

Burnout, in this report, was defined by “loss of enthusiasm for work, feelings of cynicism, and a low sense of personal accomplishment”; 45.8% of responding physicians had at least 1 of these symptoms.

So why am I so optimistic?

Because when I read these survey results, and others like them, bureaucracy and complexity are often cited as the reasons why physicians are unhappy. Not patient care.

While these factors (bureaucracy and complexity) can momentarily take physicians away from their passion of practicing medicine, it is the passion of a physician, precisely, that fuels my optimism for the state of health care today.

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The Note Taker’s Dilemma

The year is 2020, or sometime in the future when the healthcare system is better, much better. Patients have access to their medical notes, are encouraged to read the notes regularly and ask physicians relevant questions. This is to facilitate patient-centered participatory medicine (PCPM), previously known as shared decision making. In fact, note reading by patients is now a quality metric for CMS.

The CEO of the Cheesecake Hospital Conglomeration, one of the hospital oligopolies, has set up a Bureau for Transparency and Protection of Patients from Complex Medical Terminology. The goal is to risk manage troublesome medical writing that could result in poor satisfaction scores, complaint or a lawsuit.

Mr. Upright (MU) is the Inquisitor General for the bureau. He has called the author (SJ), a repeat offender, to his office to discuss elements of his medical record keeping.

Disclaimer: Any resemblance to future events is purely coincidental. The narration is merely a reflection of the author’s paranoid affect and a tendency to believe in conspiracy theories.

MU: Dr. Jha, you’ve been summoned because your open medical notes do not meet the standards for empathy and compassionate care and seem devoid of a reflection on the complex interplay between social determinants of health.

SJ: Has a patient complained?

MU: No. But that’s what the bureau is trying to prevent. We protect patients from physicians. Actually, we protect physicians from their most dangerous enemy: themselves.

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What Makes a Good Doctor? And Can We Measure It?

I recently spoke to a quality measures development organization and it got me thinking — what makes a good doctor, and how do we measure it?

In thinking about this, I reflected on how far we have come on quality measurement.  A decade or so ago, many physicians didn’t think the quality of their care could be measured and any attempt to do so was “bean counting” folly at best or destructive and dangerous at worse.  Yet, in the last decade, we have seen a sea change.

We have developed hundreds of quality measures and physicians are grumblingly accepting that quality measurement is here to stay.  But the unease with quality measurement has not gone away and here’s why.  If you ask “quality experts” what good care looks like for a patient with diabetes, they might apply the following criteria:  good hemoglobin A1C control, regular checking of cholesterol, effective LDL control, smoking cessation counseling, and use of an ACE Inhibitor or ARB in subsets of patients with diabetes.

Yet, when I think about great clinicians that I know – do I ask myself who achieves the best hemoglobin A1C control? No. Those measures – all evidence-based, all closely tied to better patient outcomes –don’t really feel like they measure the quality of the physician.

So where’s the disconnect?  What does make a good doctor?  Unsure, I asked Twitter:

good doctor twitter

Over 200 answers came rolling in.
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Doctors Without State Borders: Practicing Across State Lines

In the United States, a tangled web of federal and state regulations controls physician licensing.  Although federal standards govern medical training and testing, each state has its own licensing board, and doctors must procure a license for every state in which they practice medicine (with some limited exceptions for physicians from bordering states, for consultations, and during emergencies).

This bifurcated system makes it difficult for physicians to care for patients in other states, and in particular impedes the practice of telemedicine. The status quo creates excessive administrative burdens and like contributes to worse health outcomes, higher costs, and reduced access to health care.

We believe that, short of the federal government implementing a single national licensing scheme, states should adopt mutual recognition agreements in which they honor each other’s physician licenses.  To encourage states to adopt such a system, we suggest that the federal Center for Medicare and Medicaid Innovation (CMMI) create an Innovation Model to pilot the use of telemedicine to provide access to underserved communities by offering funding to states that sign mutual recognition agreements.

The Current System And Its Drawbacks

State licensure of physicians has been widespread in the United States since the late nineteenth century.  Licensure laws were ostensibly enacted to protect the public from medical incompetence and to control the unrestrained entry into the practice of medicine that existed during the Civil War.  However, it no longer makes sense to require a separate medical license for each state.

Today, medical standards are evidence-based, and guidelines for medical training are set nationally through the Accreditation Council for Graduate Medical Education, the Centers for Medicare and Medicaid Services’ Graduate Medical Education standards, and the Liaison Committee on Medical Education.  All U.S. physicians must pass either the United States Medical Licensure Examinations or the Comprehensive Osteopathic Medical Licensing Examination.

Although the basic standards for initial physician licensure are uniform across states, states impose a patchwork of requirements for acquiring and maintaining licenses. These requirements are varied and burdensome and deter doctors from obtaining the licenses required to practice across state lines.

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Bigger Hospitals Mean Bigger Hospitals with Higher Prices. Not Better Care.

Hospitals are busily merging with other hospitals and buying up groups of doctors. They claim that size brings efficiency and the opportunity to deliver more “value-based” care — and fewer unnecessary services.

They argue that they have to get bigger to cut waste. What’s the evidence that bigger hospitals offer better value? Not a lot.

If you think of value as some combination of needed services delivered for the right price, large hospitals are no better than small hospitals on both counts.

The Dartmouth Atlas of Health Care and other sources have shown time and again that some of the biggest and best-known U.S. hospitals are no less guilty of subjecting patients to useless tests and marginal treatments.

Larger hospitals are also very good at raising prices. In 2010, an analysis for the Massachusetts attorney general found no correlation between price and quality of care.

study published recently in Health Affairs offered similar results for the rest of the country: On average, higher-priced hospitals are bigger, but offer no better quality of care.

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Ode to the Fat Man

Here is a sweeping generalization: When doctors write for the lay public they tend towards tiresome self-flagellation.

Samuel Shem’s House of God is an exception; a refreshing read.

Perhaps he wrote for physicians so he wrote with such open face honesty.

In today’s politically correct world, Shem would have been castigated as an ageist for his brilliant acronym, GOMER (Get out of My Emergency Room), for peri-ninety year olds with advanced dementia who are skirting that narrow zone between St. Peter’s Gate and fractured ribs post-CPR.

Time for a pronouncement for medical students: There are two things you must do before starting your internship. Pass your USMLEs and read House of God.

I have read Shem’s classic twice. I remember the Rules of House of God more reliably than I recall the names of the carpal bones.

My first read was a few days in to my internship in elderly care medicine. The hospital was a rickety establishment in Britain’s National Health Service, not quite the Best Medical School that Shem described. But I seemed to share the same clinical experiences as Roy Basch, Shem’s Gomer-phobic protagonist.

There was a deluge of Gomers on New Year’s Eve; the old practice of granny dumping. I had to justify admission by finding nitrates in their urine for suspected urinary tract infection (grandson attending New Year’s bash still does not have an ICD code), or the vaguest T wave changes on EKG (unstable angina is a useful bet in a 90 year old).

If medical taxonomy could not be clinically justified there was always “acopia.”

Shem was remarkably prescient.

Take rule 13:
“The delivery of good medical care is to do as much nothing as possible.”  This was before physicians were inserting stents through rock hard femoral arteries to give patients an aggregate of two extra hours of survival.

Basch’s elderly patients would do the best precisely because his caring was the least aggressive. He would occasionally forget to prepare them with laxatives for a barium enema, saving them from dehydration and its cascade.

If Shem realized in the seventies that nothing was more futile than an investigation leading to a futile treatment, God knows what he would have written today.

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Don’t Be Fooled, Prospects for Long-Term SGR Fix Still Dim

In light of Thursday’s bicameral, bipartisan release of a Medicare physician payment policy to permanently replace the Sustainable Growth Rate (SGR) formula – an achievement to be celebrated in its own right – some are seeing momentum toward passage of such a deal before the current doc fix  expires on March 31.

But the scope of what the committees issued Thursday represents as much of a step back as a step forward, at least relative to their aspirations and timeline for accomplishing them.

Once the appointment of Senator Baucus to be Ambassador to China was announced, the committees agreed to make it “as far as they could” toward a comprehensive SGR replacement policy prior to his confirmation, including identifying offsets to pay for the $125-150 billion (over 10 years) bill. For those who missed it, Senator Baucus was confirmed on Thursday.

Only in the past week did the key committees acknowledge that achieving agreement on offsets by this deadline was unattainable, but finalization of the so-called “extenders,” a hodge podge of Medicare payment plus-ups and other polices perennially included with the doc fix, was still the goal.

(Recall that the Senate Finance Committee passed an SGR replacement bill with extenders in December, but their House counterparts have yet to do so.)

In negotiations on that extenders element, House Republican leads reportedly would not agree to include beneficiary-oriented policies, such as funding for outreach to Medicare enrollees regarding low-income subsidy programs and for Family-to-Family Health Information Centers.

While some Democrats involved in the talks may have been inclined to make this concession, others sharply objected, scuttling a deal on this front and demonstrating the difficulty of compromise on this relatively non-controversial topic.

Furthermore, and has always been the assumption, identifying offsets for the package continues to be an exponentially heavier lift than any other aspect of the process. On that front, the key camps have outlined their broad parameters for what they might accept.

House Republican leads desire and likely require meaningful cuts to ACA-related spending as well as a substantial balance of Medicare beneficiary-impacting cuts, such as those relating to premiums and coinsurance.

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Too Many American Physicians Or Too Few?

The goal of the Affordable Care Act, also known as “Obamacare,” is to make affordable, quality health care coverage available to more Americans. But how many physicians will America need to satisfy this new demand?

The debate over doctor supply rages on with very little conclusive evidence to prove one case or the other.

Those experts who see a shortage point to America’s aging population – and their growing medical needs – as evidence of a looming dearth in doctors. Many suggest this shortage already exists, particularly in rural and inner city areas. And still others note America maintains a lower ratio of physicians compared to its European counterparts.

This combination of factors led the American Association of Medical Colleges to project a physician shortage of more than 90,000 by 2020.

On the other side of the argument are health policy experts who believe the answer isn’t in ratcheting up the nation’s physician count. It’s in eliminating unnecessary care while improving overall productivity.

The solution, they say, exists in the shift away from fee-for-service solo practices to more group practices, away from manually kept medical records to electronic medical records (EMR), and away from avoidable office visits to increased virtual visits through mobile and video technologies. Meanwhile, they note physicians could further increase productivity by using both licensed and unlicensed staff, as well as encouraging patient self-care where appropriate.

The Doctor Divide: Global And Domestic Insights

Among the 34 member countries of the Organization for Economic Co-operation and Development (OECD), the U.S. ranks 30th in total medical graduates and 20th in practicing physicians per 1,000 people.

Despite these pedestrian totals, there is one area where the U.S. dominates. It ranks first in the proportion of specialists to generalists – and there’s not a close second.

These figures don’t resolve the debate on America’s need for physicians but they do reveal an important rift in the ratio of U.S. specialists to primary care practitioners.

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Is There Really a Physician Shortage?

Large coverage expansions under the Affordable Care Act have reignited concerns about physician shortages. The Association of American Medical Colleges (AAMC) continues to forecast large shortfalls (130,000 by 2025) and has pushed for additional Medicare funding of residency slots as a key solution.

These shortage estimates result from models that forecast future supply of, and demand for, physicians – largely based on past trends and current practice. While useful exercises, they do not necessarily imply that intervening to boost physician supply would be worth the investment. Here are a few reasons why.

1. Most physician shortage forecast models assume insurance coverage expansions under the ACA will generate large increases in demand for physicians. The standard underlying assumption is that each newly insured individual will roughly double their demand for care upon becoming insured (based on the observation that the uninsured currently use about half as much care). However, the best studies of this – those using randomized trials or observed behavior following health insurance changes – tend to find increases closer to one-third rather than a doubling.

2. A recent article in Health Affairs found that the growing use of telehealth technologies, such as virtual office visits and diagnoses, could reduce demand for physicians by 25% or more.

3. New models of care, such as the patient-centered medical home and the nurse-managed health center, appear to provide equally effective primary care but with fewer physicians. If these models, fostered by the ACA, continue to grow, they could reduce predicted physician shortages by half.

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How Clinical Guidelines Can Fail Both Doctors and Patients

Any confusion over the recent news of cholesterol guidelines in the U.S. is perfectly understandable. On the one hand, the guidelines suggest that nearly half the population should use statins to stave off heart attacks and strokes. On the other, use of the drugs is not with potential side effects and, to many, will offer no substantive benefits. The controversy highlights a problem mired in an outdated way of thinking about health care and the doctor-patient relationship.

Guidelines came about after generations of physicians wanted to bring something more than “opinion and experience” to the patient’s bedside. In the late 1960s legislation for the U.S. Food and Drug Administration was amended to call for a demonstration of efficacy and an assessment of benefits and risk as prerequisite to the licensing of any pharmaceutical. Modern clinical science resulted, first slowly and now with an avalanche of clinical trials, each pouring forth outcome data galore.

The Burden of Clinical Data

Clinicians are expected to stay current with this wealth of information. The modern medical curriculum instructs all budding physicians on how to evaluate the quality and the clinical relevance of all such contributions to the body of clinical science. Because some (or perhaps many) find this exercise overwhelming, there are organizations—many academic and some without any discernible relationships with purveyors that could pose a conflict of interest—that attempt to bundle the information in a fashion that might be relevant to particular physicians or physicians in particular specialties. Some of this bundling is quite systematic, some quite helter-skelter.

Occasionally there is a contribution to the literature that offers an unequivocal advantage for a particular patient group. More often, the bundlers are faced with a heterogeneous literature that often demonstrates little, if any, efficacy. Faced with these circumstances, biostatistics has offered up many a method to impute more value to the literature than is apparent at first blush. The result is that all this bundling adds to an enormous and ever-expanding secondary literature.

What is the clinician to do?

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