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Are Female Physicians Underpaid?

In a new study published in JAMA, my colleagues and I found that even after accounting for productivity, women working as physician researchers at American Medical Schools are paid $13,000 less per year than their male colleagues, a difference that amounts to hundreds of thousands of dollars over the course of their careers.

But does this difference stand as evidence of discrimination?

Many claims of gender inequity in pay have suffered from an apples vs. oranges problem.  For example, consider gender disparities across different careers.  Many traditional male careers, like construction work, pay better than traditionally female careers, like nursing and teaching.  It’s plausible that these disparities result, at least in part, from societal bias about how relatively important it is for men and women to make enough money to provide for their families.  However, these disparities could also result from more justifiable factors.  Maybe the physical demands of the work differ in important ways, or perhaps the marketplace is simply responding to supply and demand.

Medical experts have long noticed gender disparities in physician pay.  Traditionally male fields like neurosurgery pay substantially more than fields preferred by more women, such as general pediatrics.  If women are voluntarily choosing lower paying fields—perhaps for lifestyle reasons or maybe because they don’t value money as much as men do—then it’s arguable that we should not fret over pay disparities.  It’s America, after all, where people have the right to choose.

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A Funny Thing Happened on the Way to Meaningful Use

This July will mark the 16th anniversary of the installation of our electronic medical record.

Yup.  I am that weird.

Over the first 10-14 years of my run as doctor uber-nerd, I believed that widespread adoption of EHR would be one of main things to drive efficiency in health care.  I told anyone I could corner about our drive to improve the quality of our care, while keeping our cash-flow out of the red.  I preached the fact that it is possible for a small, privately owned practice to successfully adopt EHR while increasing revenue.  I heard people say it was only possible within a large hospital system, but saw many of those installations decrease office efficiency and quality of care.  I heard people say primary care doctors couldn’t afford EHR, while we had not only done well with our installation, but did so with one of the more expensive products at the time.  To me, it was just a matter of time before everyone finally saw that I was right.

The passage of the EHR incentive program (aka “meaningful use” criteria) was a huge validation for me: EHR was so good that the government would pay doctors to adopt it.  I figured that once docs finally could implement an EHR without threatening their financial solvency, they would all become believers like me.

But something funny happened on the way to meaningful use: I changed my mind.  No, I didn’t stop thinking that EHR was a very powerful tool that could transform care.  I didn’t pine for the days of paper charts (whatever they are).  I certainly didn’t mind it when I got the check from the government for doing something I had already done without any incentive.  What changed was my belief that government incentives could make things better. They haven’t.  In fact, they’ve made things much worse.

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The NFL Concussion Crisis & The Doctor-Patient Relationship

If you are reading this then you are already well aware of the current concussion crisis in the NFL. No matter where on the spectrum your opinions lie regarding this topic, there is one question that still remains: How did we get here? Surely if something has gone wrong then there must be someone to blame for it. Was it the league’s fault? The coaches? The players? The doctors? Maybe it is the injury itself that’s to blame? Perhaps it was just the perfect storm of a number of factors that put us in this situation? To truly get to the bottom of this, it is important to have a better understanding of the doctor-patient relationship. Not just in general, but specifically as it applies to concussed athletes in the NFL. Ultimately we may not find blame here, but we should at least shed some light on the realities of the situation.

As a sports medicine physician, I have taken care of thousands of concussed athletes at all levels. Eight year old hockey players, high school soccer players, collegiate football players, professional moto-cross racers and skaters, you name it. For all of them, the doctor-patient dynamic is similar. However, for the NFL players, that dynamic is entirely different. Let’s begin by looking at the usual non-NFL doctor-patient relationship.

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Why Doctors Interrupt

A few weeks ago I called a neurosurgeon to discuss a patient’s recent headaches.  My patient had been seen in the emergency room several days prior with the worst headache of his life. A complete work-up had not revealed a cause for the headache.  Although he was found to have a small aneurysm on CT angiogram, there was no evidence of bleeding by lumbar puncture.  The story, however, was slightly more complex than this. There had been several other findings that remained unexplained.  One of the findings led me to discuss the patient’s case with a cardiologist.  My patient had also undergone cervical spine decompression surgery several months prior to treat cervical myelopathy.  I wanted to engage the neurosurgeon and get his professional opinion about my patient’s headache, which had now recurred several days after his ER visit.

The surgeon was cordial, but about 5 seconds into my story he seemed inpatient and interrupted me.  “I heard about this guy,” he said, “What he needs is to be seen by one of our neurovascular specialists.”  I had more I wanted to say, but the doctor did not seem to want to listen.  I raised my voice slightly, interrupted him before he had a chance to end the conversation, and bulldozed through, telling the rest of the story in about two minutes.  “Now we’re talking,” he said, as I explained further about a family history of clotting and my concern about a dural thrombus as a potential etiology.  Together we formulated a plan that I was satisfied with–though the interaction left me with a feeling of unease.

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Calculating Risk

Thursday I traversed the frozen surface of the pond for perhaps the last time this season. The ice is thinning quickly. I had on my rubber boots and stayed what I felt to be a safe distance from shore: should I break through, the water would not be over my head. I got some fantastic photos and considered the little adventure a success. However, over dinner that evening when I mentioned that I’d been on the pond earlier, David and Peter were furious. Peter wouldn’t calm down until I promised I wouldn’t go out again.

I have always considered fear the enemy; something to conquer and overcome and I’ve had a lot of practice. Being risk adverse and scrappy has been an asset now that I have lung cancer.  As a participant in a phase I clinical trial, there is the potential for unforeseen and possibly life threatening side effects of treatment itself. Before you are given your first dose of an experimental drug, you must read through and sign consent forms which acknowledge this risk. It is something most healthy persons would never do. When you have a terminal illness, it is similar to coming to the edge of a ravine with a tiger on your trail. Between you and safety is a rickety bridge that may or may not support your weight. However, even chancy passage is an easy decision when the alternative is certain death.

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What The Emergence of an EMR Giant Means For the Future of Healthcare Innovation

(Note: the following commentary was co-authored with Tory Wolff, a founding partner of Recon Strategy, a healthcare strategy consulting firm in Boston; Tory and I gratefully acknowledge the insightful feedback provided by Jay Chyung of Recon Strategy.)

Medicine has been notoriously slow to embrace the electronic medical record (EMR), but, spurred by tax incentives and the prospect of cost and outcomes accountability, the use of electronic medical records (EMRs) is finally catching on.

There are a large number of EMR vendors, who offer systems that are either the traditional client server model (where the medical center hosts the system) or a product which can be delivered via Software as a Service (SaaS) architecture, similar to what salesforce.com did for customer relationship management (CRM).

Historically, the lack of extensive standards have allowed hospital idiosyncrasies to be hard-coded into systems.  Any one company’s EMR system isn’t particularly compatible with the EMR system from another company, resulting in – or, more fairly, perpetuating – the Tower of Babel that effectively exists as medical practices often lack the ability to share basic information easily with one another.

There’s widespread recognition that information exchange must improve – the challenge is how to get there.

One much-discussed approach are health information exchanges (HIE’s), defined by the Department of Health and Human Services as “Efforts to rapidly build capacity for exchanging health information across the health care system both within and across states.”

With some public funding and local contributions, public HIE’s can point to some successes (the Indiana Health Information Exchange, IHIE, is a leading example, as described here).  The Direct Project – a national effort to coordinate health information exchange spearheaded by the Office of the National Coordinator for Health IT – also seems to be making progress.  But the public HIEs are a long way from providing robust, rich and sustainable data exchange.

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Why the Public’s Growing Disdain for the Supreme Court May Help Obamacare

The public’s growing disdain of the Supreme Court increases the odds that a majority will uphold the constitutionality of Obamacare.

The latest New York Times CBS Poll shows just 44 percent of Americans approve the job the Supreme Court is doing. Fully three-quarters say justices’ decisions are sometimes influenced by their personal political views.

The trend is clearly downward. Approval of the Court reached 66 percent in the late 1980s, and by 2000 had slipped to around 50 percent.

As the Times points out, the decline may stem in part from Americans’ growing distrust in recent years of major institutions in general and the government in particular.

But it’s just as likely to reflect a sense that the Court is more political, especially after it divided in such partisan ways in the 5-4 decisions Bush v. Gore (which decided the 2000 presidential race) and Citizen’s United (which in 2010 opened the floodgates to unlimited campaign spending).

Americans’ diminishing respect for the Court can be heard on the right and left of our increasingly polarized political spectrum.

A few months ago, while a candidate for the Republican presidential nomination, Newt Gingrich stated that the political branches were “not bound” by the Supreme Court. Gingrich is known for making bizarre claims. The remarkable thing about this one was the silence with which it was greeted, not only by other Republican hopefuls but also by Democrats.

Last week I was on a left-leaning radio talk show whose host suddenly went on a riff about how the Constitution doesn’t really give the Supreme Court the power to overturn laws for being unconstitutional, and it shouldn’t have that power.

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Missive from the DMZ

Not everything about improving health care is breathlessly hanging on one high stakes decision.

The Supreme Court will rule soon enough on the constitutional challenges to the Affordable Care Act. Meanwhile, even amid the drama and bitter struggles, progress can occur in health care improvement—like the ever increasing adoption of health information technology. Believe it or not, there is broad agreement about using this technology in health care. Scott Gottlieb and J.D. Kleinke in a recent Wall Street Journal opinion said it well, “. . . promotion of health information technology is one of the only demilitarized zones in Washington—consistently attracting bipartisan support . . . .”

So, this rare consensus seems real and durable, but what is actually happening in the hallowed HIT ground where both sides have somewhat oddly come to a policy truce?

Since May of 2004 when President George W. Bush established the Office of the National Coordinator for Health Information Technology (ONC) we’ve witnessed a slow but relentless upturn in adoption. That progress dramatically accelerated with attention and funding in the American Reinvestment and Recovery Act in 2009. Since 2006, the Robert Wood Johnson Foundation (RWJF) in collaboration with ONC has supported an ongoing, independent effort to monitor the national adoption of the electronic health record.

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The Psychology of Persuading Physicians

Over the 11 years I spent building the network at Epocrates, I learned a lot about physician behavior, motivation and the use of incentives.  And while influencing nearly 50% of U.S. physicians to use a product requires that it meet a true need, fit into their workflow and be extremely easy to use – building one of the most trusted brands in healthcare goes beyond the product.  It’s about being fanatical about understanding your users, engaging them at the right time, helping them support you and ultimately creating incredible loyalty.

Though we had a very analytical approach to user acquisition and brand strategy, I want to focus this article on something more fundamental – behavioral psychology.   Truly understanding not just physician behavior but human behavior was core to the business at Epocrates and permeated throughout our business, marketing and product strategy.  We focused early on in engaging physicians as consumers – B2C rather than B2B. Though a significant percentage of MDs are characterized as “small business owners”, we saw them as consumers first – hence, understanding human behavior, motivation, and influence drove product adoption and usage.

I was reminded of this recently listening to Dr. Robert Cialdini, speak at the 4th Annual Consumer Medicine Summit.   If you haven’t read it, “Influence: The Psychology of Persuasion” is one of those dog eared marketing “bibles” that has remained on my shelf for years because its lessons on how to influence people are universal and timeless.  In fact, I made it required reading for some members of my team. (Future postings on other favorites such as Nudge and Predictably Irrational, coming soon!).

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Attention Innovators: The My Air, My Health HHS/EPA Challenge is Open!

When I came to work for EPA as an American Association for the Advancement of Science fellow, I hoped to connect my social science background with my passion for the environment.  In my time on EPA’s Innovation Team, I’ve found such connections in places I never expected.  I’ve grown particularly excited about our work on portable air quality sensors.

As a psychologist, I have learned that people care about a problem more, and come up with better solutions, when they see how it affects them personally.  Air pollution is a great example—when people can measure particulates on their jogging route, it’s far more meaningful than just hearing about the issue on the news.

The My Air, My Health Challenge, announced yesterday by EPA’s Science Advisor Dr. Glenn Paulson and Dr. Linda Birnbaum of the National Institute of Environmental Health Science, aims to gather the best work in this area, and bring it to the next level.

The challenge calls on academics, industry researchers, and garage-lab do-it-yourselfers to connect wearable air and health sensors, allowing citizens and communities to collect highly localized data and create a meaningful picture of how the environment affects their well-being.

The data integration and analysis component of the challenge is particularly exciting.

A few weeks ago, I was privileged to attend the Apps and Sensors for Air Pollution workshop in Research Triangle Park, NC.  There, I listened to cutting edge sensor developers talk about their work.  They had some fascinating projects, ranging from cheap ozone monitors carried by students to a community initiative measuring black carbon in the homes of elders.  Our challenge took its final shape from these experts’ input.

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