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A Culture of Fear and Intimidation: Reforming Medical Education

Mar 20, 2010• 21

By MAGGIE MAHAR

Even as we set out to reform U.S. health care, we continue to train medical students as if they were going to work in the old, broken system. Today, everything about medical education needs to be re-thought, from how we select students for admission to med schools to what we teach them about how to provide safe, patient-centered care.

A shocking new report from the Lucien Institute at the National Patient Safety Foundation reveals how today’s medical schools fail their students as it lifts the curtain on a culture of “abuse, shame and blame” that undermines professional morale, inhibits teamwork– and ultimately puts patient safety at risk. (Thanks to Dr. Diane Meier for calling attention to this report on Twitter.)

“Achieving safety in the work environment requires much more than implementing new rules and procedures,” the report observes. “It requires developing and sustaining cultures of safety that engender trust and embrace reporting , transparency, and disciplined practices. It also requires anatmosphere of respect among the health care disciplines and a fundamental ability of all practitioners to work together in teams.”

The white paper, entitled “Unmet Needs: Teaching Physicians to Provide Safe Patient Care” was prepared by an “Expert Roundtable on Reforming Medical Education” that included a broad array of medical education leaders, students, patients, representatives from key organizations, experts from related fields, and members of the Institute. The Roundtable met in extended in-depth sessions in Boston in October 2008 and June 2009 before reaching a consensus regarding the current state of medical education—and what medical education should ideally become.

The Roundtable participants acknowledge that med school students frequently are abused and demeaned and that this behavior is widespread. Each year, the Association of American Medical Colleges conducts a survey of medical students asking questions such as have you been “publicly belittled or humiliated?” From 2004 to 2008, 12.7% to 16.7% of students answered “yes,” with “female respondents reporting higher rates” of abuse. Most often, students were humiliated by clinical faculty and residents (66% and 67%, respectively), followed by smaller but significant percentages of nurses and patients.

Could It Be That the System (Gasp) Works?

Mar 20, 2010• 41

By BOB WACHTER, MD

Heading into the final weekend of Mr. Toad’s Wild Ride, who could have guessed that in a year that brought us Death Panels, Pickup Trucks, “You Lie”, The Cornhusker Compromise, Bart Stupak (boy, that must have been a tough name to grow up with), and the Senate Parliamentarian-as-Rock-Star, we would be on the cusp of passing a perfectly acceptable healthcare reform bill, a once-in-a-generation legislative achievement.

Unmistakably, the mojo has shifted back to the Democrats – it is amazing how a dour and monolithic opposition can cause even Dems to unite for a common cause. Our President has also learned a few lessons, including the importance of symbols, populism, and singing with one’s diaphragm. (We knew we were in trouble a few weeks ago when Rahm started being criticized for not being sufficiently Machiavellian.) With yesterday’s CBO figures showing that the reform plan will save nearly $150 billion, even fence-sitting Democrats now see more political risk in saying No than Yes. That, of course, is the most relevant calculus, and with it more and more of the Blue Dogs are entering the Yes column each day.Continue reading…

Vote Yes

Mar 19, 2010• 24

By BRIAN KLEPPER & DAVID C. KIBBE

One of us was at a local diner yesterday, when a good friend and health plan broker walked up to say hello. This guy delivers premium increases every day to employers, and understands how broken things are. “I hope Congress votes yes,” he said flatly. “We’ve got to finally move beyond the status quo and try to change the system.”

As conflicted as we are over it, we agree and we hope the reforms pass. The die is now cast, so there is no point in continuing to urge a different approach. As terribly flawed as it is on cost controls, the bill represents two very important things that, in our opinion, the nation desperately needs.

First, it will significantly open access, bringing America much closer to universal coverage and making personal financial distress a much less likely outcome of sickness or injury. As Nicholas Kristof pointed out Wednesday, that alone will dramatically improve the health of the nation. Widespread uninsurance and under-insurance have been a national disgrace for decades. Passing this bill would be a commitment to move beyond that shame.

Second, we believe the President is attempting to deal with many difficult problems thoughtfully and in good faith within an extremely toxic political environment. We want to see him succeed, because we think that his approach is good for America.

The bill is not what we hoped for. We’re disappointed in the behaviors of both parties. But after a year of wrangling, it is what is possible now. There is no reason the bill’s inadequacies can’t be revisited.

Snatching victory from the jaws of defeat?

Mar 19, 2010• 18

By MATTHEW HOLT

Sometime pretty soon Nancy Pelosi’s team will have figured out if they have the votes and will be moving what’s basically the Senate bill onto the House floor. Those of you who remember late 2003 may remember that the last piece of major health care legislation (Medicare Part D) didn’t have the votes when it went to the floor—but The Hammer (Tom Delay)—kept the vote open for 3 hours to make sure it got done. I don’t think Pelosi’s style is quite as brutal as Delay’s but between her and Rahm Emmanuel, plus the somewhat more measured tones of Obama, it looks like enough Dems will come around. Probably.

Now whether the things gets passed by votes, proclamation or shouting doesn’t really matter. In fact some very far reaching legislation has got passed that way and had long term implications. For example in 1937 Marijuana was made illegal with no vote; the one question asked in Congress was whether the AMA was in favor of the ban. It wasn’t but the answer came back that it was, and consequently there are the better part of a million arrests a year and most of rural northern California lives off it as a cash crop. We have our weird “democracy” and Mussolini got the trains running on time.Continue reading…

Do the Wrong Thing

Mar 18, 2010• 28

By ROBERT LASZEWSKI

As the Democrats make their final push to pass their health care bill many of them, and most notably the President, are arguing that it should be passed because it is the “right thing to do whatever the polls say.”

Their argument is powerful: We will never get the perfect bill. If this fails who knows how long it will be before we have another big proposal up for a vote. There are millions of uninsured unable to get coverage because of preexisting conditions or the inability to pay the big premiums and this bill would help them.

Any big health care bill will be full of compromises—political or otherwise. But this bill doesn’t even come close to deserving to be called “health care reform.”Continue reading…

The Paradox of Technology in Healthcare

Mar 18, 2010• 21

By THOMAS GOETZ

One of the great humdingers in the current debate over healthcare reform is the duplicitous role of technology in increasing costs. Sophisticated medical technologies save thousands of lives every year, giving us scans that spot tumors early and devices that keep our hearts beating and our blood flowing.

But these miracle technologies come with a paradox. In nearly every sector of the economy, technology drives costs down – just as your digital camera gets cheaper and better every year, so technology drives down the cost of manufacturing, the cost of retailing, the cost of research. But for some reason, in healthcare, technology has the opposite effect; it doesn’t cut costs, it raises them. In fact, medical technologies – from CT scans to stents to biologics – are a significant factor in the 10% annual growth rate of healthcare spending, a rate that’s nearly triple the pace of inflation. (Overall, the US is now estimated to spend a stunning $2.7 trillion on healthcare in 2010.)

This was made clear once again last week, when a Massachusetts state audit found that healthcare costs rose 20% from 2006 to 2008, largely because of new imaging technologies. The single largest increase was for digital mammography, a new – and expensive – way to screen for breast cancer.

What’s going on here? Why can’t technology work its magic in healthcare, the way it does in the rest of the economy?

Dear Mr President, Medicare Stinks

Mar 17, 2010• 39

By ROB LAMBERTS

Dear Mr. President:

The physicians and management in our office had a discussion this morning about the upcoming audits physicians are facing from CMS. I had to wait for my blood pressure to get out of dangerous range to write this letter. The frustration, fear, and powerlessness I felt made me really question whether it is worth continuing to see my Medicare patients.

I am a primary care physician and about 20% of my patients are covered by Medicare. As a whole, they are wonderful people, but difficult patients. The elderly are truly a delight to talk to, learn from, and care for; I consider it an honor to be their doctor. But the complexity of a person’s medical problems goes up exponentially as they near the end of their life. This means that I spend more time per patient for my Medicare population – which is OK if I can be paid for my extra time and effort.

But here is the message we physicians are being given:

Medicare auditors will be knocking at our doors, and if there are “problems” with our charting we will be told to send money back to CMS for our whole Medicare population. We are obligated to prove that we did not defraud Medicare to reclaim the money for the work we did. This is, obviously, consistent with the cornerstone of the American legal system, “A person is presumed guilty unless they can prove that they are innocent.”

The “problems” they are looking for are inconsistencies in the charting and the billing we do. These “inconsistencies” are not just egregious attempts at stealing money from Medicare, they are little things like this:

The Top Ten Immediate Benefits Americans Will Receive When Health Care Reform Passes

Mar 17, 2010• 73

By MAGGIE MAHAR

Yesterday, the Democratic Caucus of the House listed the provisions of the health reform bill that will take effect “as soon as health care passes,”

The legislation would:

Prohibit pre-existing condition exclusions for children in all new plans
Provide immediate access to insurance for uninsured Americans who are uninsured because of a pre-existing condition through a temporary high-risk pool;
Prohibit dropping people from coverage when they get sick in all individual plans
Lower seniors prescription drug prices by beginning to close the donut hole
Offer tax credits to small businesses to purchase coverage
Eliminate lifetime limits and restrictive annual limits on benefits in all plans
Require plans to cover an enrollee’s dependent children until age
Require new plans to cover preventive services and immunization without cost-sharing
Ensure consumers have access to an effective internal and external appeals process to appeal new insurance plan decisions
Require premium rebates to enrollees from insurers with high administrative expenditures and require public disclosure of the percent of premiums applied to overhead costs.“By enacting these provisions right away, and others over time” the Caucus declares, “we will be able to lower costs for everyone and give all Americans and small businesses more control over their health care choice.”

Maggie Mahar is an award winning journalist and author. A frequent contributor to THCB, her work has appeared in the New York Times, Barron’s and Institutional Investor. She is the author of “Money-Driven Medicine: The Real Reason Why Healthcare Costs So Much,” an examination of the economic forces driving the health care system. A fellow at the Century Foundation, Maggie is also the author the increasingly influential HealthBeat blog, one of our favorite health care reads, where this piece first appeared.

Price Controls Do Not Work

Mar 17, 2010• 28

By PAUL LEVY

If there is anything about economics that has been proven over and over, it is that price controls do not work. The unintended consequences are usually worse than the problem that led to the solution in the first place.

Massachusetts legislators, feeling the frustration of higher insurance premiums, are now considering a bill to limit doctor and hospital reimbursement payments to 110% of Medicare rates, or perhaps some other percentage of Medicare rates. The problem with this is that Medicare rates are not fully compensatory to doctors and hospitals and have contributed to the increase in private insurance company rates. This was one of the conclusions reached by the Attorney General in her extensive investigation of these matters.Continue reading…

George Clooney Was Onto Something

Mar 17, 2010• 5

By JESSIE GRUMAN

In the Oscar-nominated movie “Up in the Air,” Ryan Bingham (aka George Clooney), travels around the country firing employees for company bosses who don’t have the stomach to do it themselves -– the ones who prefer to “outsource the downsizing function.”

He finds his own job threatened by a hotshot business school graduate who convinces the president of their company that it would be more efficient to do the long-distance layoffs via the Internet.

Sitting in a hotel bar, our hero makes a passionate speech to his young colleague about how important it is to fire people face-to-face: that a look in the eye, a few words that personalize the institutional rejection and a handshake allow them to maintain some small shred of dignity at the very moment they lose their identity as a valued employee.

This speech resonates with me as I contemplate the waves of e-mail notices in my inbox announcing new electronic tools and personalized Web-based services and sites that can help me take care of myself. I can take a picture of my rash with my iPhone and send it to my dermatologist. I can check online to see when I had my last tetanus shot or schedule my next mammogram. I like interacting with my doctors by e-mail about minor matters. And if I lived in the empty plains of Eastern Montana, I would probably often prefer a telemedicine visit with a doctor or nurse over a 10-hour round-trip drive for a 20-minute in-person appointment.Continue reading…