April 22 marks the 400th anniversary of the death of the greatest novelist who ever lived, Miguel de Cervantes. Though the day will pace unnoticed by most physicians, it is in fact one many should note. Why? Because both his life and work can serve as vital sources of inspiration and resilience for health professionals everywhere.
In a 2002 Nobel Institute survey, 100 of the world’s most highly regarded writers named his Don Quixote the greatest novel of all time, outscoring its nearest rivals –works by Dickens, Tolstoy, and Joyce – by more than 50%. Said the head judge who announced the results, “If there is one novel you should read before you die, it is Don Quixote.”
A decade ago, electronic health records were aggressively promoted for a number of reasons.Proponents claimed that they would facilitate the sharing of health information, reduce error rates in healthcare, increase healthcare efficiency, and lower costs.Enthusiasts included the technology companies, consultants, and IT specialists who stood to reap substantial financial rewards from a system-wide switch to electronic records.
Even some health professionals shared in the enthusiasm.Compared to the three ring-binders that once held the medical records of many hospitalized patients, electronic records would reduce errors attributable to poor penmanship, improve the speed with which health professionals could access information, and serve as searchable information repositories, enabling new breakthroughs through the mining of “big data.”
To promote the transition to electronic records, the federal government launched what it called its “Meaningful Use” program, a system of financial rewards and penalties intended to ensure that patients would benefit.Naturally, this raised an important question: if digitizing health records was such a good idea, why did the federal government need to impose penalties for health professionals who failed to adopt them?Perhaps electronic health records were not so self-evidently beneficial as proponents suggested.
Good intentions do not necessarily lead to good results.A case in point is the milestones initiative of the Accreditation Council of Graduate Medical Education and its various medical specialty boards, which are working together in an attempt to improve the quality of graduate medical education.In practice, however, the milestones are often not proving to be a valuable indicator of learner progress and are in fact acting like millstones around the necks of trainees and program directors.
The goals behind the milestones initiative are laudable.Introduced as part of the Next Accreditation System (NAS), they were intended to shift attention of learners and educators from processes to outcomes.They would foster self-directed learning and assessment and provide more helpful feedback.In theory, programs that were doing well would face less burdensome oversight and under-performing ones would receive more prompt and helpful guidance.
In practice, however, the milestones initiative has reminded many program directors and trainees of the onerous impact of maintenance of certification programs enacted by the American Board of Medical Specialties.Simply put, when the lofty rhetoric of initial assurances is set aside, the risks and costs of such initiatives appear to many to exceed the benefits by an unacceptably high margin.In many cases, this can be traced to a failure to assess outcomes before implementing system-wide change.
Many hospitals around the nation have been stung by dreadful physician engagement scores. Engagement is a problem not only for demoralized physicians, but for healthcare organizations, their employees, and everyone they serve. They should take note, because low levels of engagement are associated with higher physician turnover, increased error rates, poorer rates of patient cooperation in treatment, and lower levels of patient satisfaction.
Definitions of engagement vary, but it generally includes pride, loyalty, and commitment. When engagement scores are low, physicians take little pride in the hospital, would not recommend it to a job-seeking colleague, and believe that the hospital’s mission and vision are not in sync the needs of patients. On the other hand, engaged physicians are more likely to perform better in every area, including patient care, education, and research, which benefits everyone.
To better understand the roots of poor physician engagement, I recently sat down for a conversation with a large group of students from the Indiana University Kelley Business of Medicine MBA program. Its students are practicing physicians from around the country who have realized that to improve patient care they need to become better leaders. Many work in hospitals that have identified engagement challenges and are attempting to develop solutions to the problem.
There are different ways to take the measure of a life. John Rockefeller, the richest person in the history of mankind, once asked a neighbor, “Do you know the only thing that gives me pleasure? It’s to see my dividends come in.” Television magnate Ted Turner once said, “I don’t want my tombstone to read, ‘He never owned a network.’” And musical artist Lady Gaga has described her quest as “mastering the art of fame.” But wealth, power, and fame are not life’s only metrics, and September 4 marks the 50th anniversary of the death of one of the 20th century’s brightest counterexamples.
His name was Albert Schweitzer. Winston Churchill once referred to him as a “genius of humanity,” and a 1947 issue of Time magazine dubbed him “the greatest man in the world.” Though Schweitzer held four doctorates and achieved worldwide fame as a musician, theologian, medical missionary, and promoter of a philosophy of “reverence for life,” for which he received the 1952 Nobel Peace Prize, his most enduring contribution lies in his lifelong commitment — both theoretical and practical – to the suffering.
Schweitzer was born 1865 in the Alsace region of what is now eastern France, the son of a Lutheran pastor whose grandfathers were both accomplished organists. Though already a world-renowned musician and writer, at age 30 Schweitzer decided to answer a call to missionary work, spending the next seven years of his life studying medicine. Once he finished his medical studies, he and his new wife, Helene, traveled 4,000 miles to set up a missionary hospital in what is now Gabon in west central Africa. There he spent most of the rest of his life, eventually dying there in 1965.
Life is tough for physicians in solo and small group practice. The federally mandated introduction this fall of ICD-10 requires physicians and their staffs to learn a new system of coding diseases. “Meaningful Use,” another federal program, requires physicians to install and use electronic health records systems, which are complex and expensive. And PQRS, the Physician Quality Reporting System, is beginning to penalize physicians for failing to report individual data for up to 110 quality measures, such as patient immunizations, each of which takes time to collect and record.
Of course, such requirements are not being imposed solely on solo and small-group physicians. In many ways, they affect all physicians alike. Yet the burdens of complying are disproportionately high for small groups, which cannot spread out the costs of purchasing equipment, hiring employees and consultants, and training personnel over so large a number of colleagues. Hospitals and large medical groups can afford to hire full-time specialists to meet these challenges, but such approaches are not economically feasible for a group that consists of only a few physicians.
Such challenges are not just raining down – they are pouring down on the heads of physicians. Some physicians fear they smell a conspiracy to drive solo and small-group practitioners out of business. And the problem is not just the money. It’s also the time. Many physicians already work long hours and simply cannot afford to shop for such systems, negotiate contracts, and enter data. We personally know physicians who report spending two hours each evening completing records that they did not have time to attend to while they were seeing patients.
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 started 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.”
Beginning about 5 years ago, many US medical schools introduced severe restrictions on marketing activities by pharmaceutical companies and medical device manufacturers.
These measures often prohibited representatives of such firms from entering patient care areas and even medical school facilities, with the exception of tightly controlled training activities, and then by appointment only. In some cases, medical schools have issued outright bans against industry support of educational activities.
What is the rationale behind such actions? It boils down to a concern that industry funding may inappropriately influence both medical education and patient care. For example, a physician visited by an industry representative might be more likely to prescribe one of the firm’s drugs. In announcing a ban on such activities, one school likened the industry to Don Juan, worrying that physicians might prescribe drugs because they were “seduced by industry,” and not because “it’s best for the patient.”
There is evidence that even physicians who believe their decision making is not biased by marketing are in fact affected by it. Moreover, a good deal of such marketing is not exactly purely scientific. A perusal of medical journals reveals a plethora of full-page ads featuring slogans such as:
“Simplicity is clear information at your fingertips,” and highlighting images such as a physician walking down a hallway with a tiger, describing the featured drug as a “powerful partner.”
Such marketing is not inexpensive. Placing a full-page ad in a medical journal typically costs around $4,000. On the other hand, as an air traveler I have come across a number of slick full-page airline magazines ads touting medical schools and their affiliated hospitals.
When Michael injured his knee, he did what any responsible person would do. He was not incapacitated, and though the knee was painful and swollen, he could get around pretty well on it. So he waited a few days to see if it would get better. When it didn’t, he saw his primary care physician, who examined it and quite reasonably referred him to an orthopedic surgeon. The orthopedic surgeon considered ordering an MRI of the knee but worried that insurance would not cover a substantial portion of the $1,500 price tag, so he suggested a less expensive alternative: a six-week course of physical therapy that would cost only $600 – a quite responsible course of action.
At the end of this period of time, Michael was still experiencing pain and intermittent swelling. The orthopedic surgeon made another quite responsible decision and ordered the MRI exam, which showed a torn meniscus. The orthopedic surgeon could have recommended arthroscopic surgery, which would have earned him a handsome fee and generated revenue for his physician-owned surgery center. Instead he again acted quite responsibly, advising Michael that the surgery would actually increase the pain and swelling for a time and probably not improve his long-term outcome. Based on this advice, Michael declined surgery.
Though everyone in this case proceeded responsibly, the ultimate outcome was inefficient and costly. Many factors contributed, but perhaps the most important was the fact that Michael’s physician outlined choices based on an inaccurate understanding of the costs associated with his recommendations. The orthopedic surgeon thought that the cost of six weeks of physical therapy was 60% less than the MRI. In fact, however, the actual payment for the MRI from the insurance company would be only $300, not the “retail” price of $1,500. What appeared to be the less expensive option was actually twice as expensive, and it delayed definitive diagnosis by six weeks.
This story is emblematic of a larger problem in contemporary healthcare. No one – not the patients, the physicians, the hospitals, or the payers – really understands in a thorough way the true costs of their decisions. After receiving care, patients routinely receive by mail multi-page “explanations of benefits” that show huge differences between list prices and actual payments. Most find it baffling to try to determine who is paying how much for what. Physician practices and hospitals get calls every day from panicked patients who believe that they are being billed for exorbitant costs, when in fact most or all of the charges will be paid by insurance at a huge discount.
Chicago Cubs fans of a certain vintage will never forget broadcaster Harry Carey’s signature line, “Holy cow!” Some have speculated that the exclamation may have originated in Hinduism, one of the world’s major religions, whose adherents worldwide number approximately one billion. Hindus regard cows as maternal, caring figures, symbols of selfless giving in the form of milk, curds, butter, and other important products.
One of the most important figures in the faith, Krishna, is said to have been a cowherd, and one of his names, Govinda, means protector of cows. In short, cows are sacred to Hindus, and their slaughter is banned in virtually all Indian states.
Medicine, too, has its sacred cows, which are well known to physicians, nurses, and patients visited by medical teams on their hospital rounds. In this case, the cow is not an animal but a machine. In particular, it is the computer on wheels, or COW, a contraption that usually consists of a laptop computer mounted on a height-adjustable pole with a rolling base. It is used to enter, store and retrieve medical information, including patients’ diagnoses, vital signs, medications, and laboratory results, as well as to record new orders.
As the team moves from room to room and floor to floor, the COW is pushed right along. The COW is often treated with a degree of deference seemingly bordering on reverence. For one thing, people in hallways and patients’ rooms are constantly making way for the COW. As an expensive and essential piece of equipment, it is handled gingerly. Often only the senior member of the medical team or his or her lieutenant touches the COW.
Others know that they have said something important when they see the chief keyboarding the information into the COW. Sometimes it plays an almost oracular role. When questions arise to which no one knows the answer, such as the date of a patient’s admission or the time course of a fever, they often consult the COW. Just as cows wandering the streets of Indian cities often obstruct traffic, so healthcare’s COWS can and often do get in the way of good medicine. Continue reading…