Health Leaders Media recently published an article about “the latest idea in healthcare: the informed shared medical decision.” While this “latest idea” is actually as old as the Hippocratic Oath, the notion that we need to create an extra layer of bureaucracy to enforce it is even more ridiculous. The author argues that physicians and surgeons are recommending too many procedures for their patients, without offering them full disclosure about their non-procedural options. This trend can be easily solved, she says, by blocking patient access to surgical consultants:
“The surgeon isn’t part of the process. Instead, patients would learn from experts—perhaps hired by the health system or the payers—whether they meet indications for the procedure or whether there are feasible alternatives.”
So surgeons familiar with the nuances of an individual’s case, and who perform the procedure themselves, are not to be consulted during the risk/benefit analysis phase of a “shared” decision. Instead, the “real experts” – people hired by insurance companies or the government – should provide information to the patient.
I understand that surgeons and interventionalists have potential financial incentives to perform procedures, but in my experience the fear of complications, poor outcomes, or patient harm is enough to prevent most doctors from performing unnecessary invasive therapies. Not to mention that many of us actually want to do the right thing, and have more than enough patients who clearly qualify for procedures than to try to pressure those who don’t need them into having them done.
And if you think that “experts hired by a health insurance company or government agency” will be more objective in their recommendations, then you’re seriously out of touch. Incentives to block and deny treatments for enhanced profit margins – or to curtail government spending – are stronger than a surgeons’ need to line her pockets. When you take the human element out of shared decision-making, then you lose accountability – people become numbers, and procedures are a cost center. Patients should have the right to look their provider in the eye and receive an explanation as to what their options are, and the risks and benefits of each choice.
I believe in a ground up, not a top down, approach to reducing unnecessary testing and treatment. Physicians and their professional organizations should be actively involved in promoting evidence-based practices that benefit patients and engage them in informed decision making. Such organizations already exist, and I’d like to see their role expand.
The last thing we need is another bureaucratic layer inserted in the physician-patient relationship. Let’s hold each other accountable for doing the right thing, and let the insurance company and government “experts” take on more meaningful jobs in clinical care giving.
Hospitals can be dangerous and inefficient; therefore it is easy to connect with Atul Gawande’s recent New Yorker essay “BigMed” suggesting that the streamlined, production processes found at the Cheesecake Factory can and likely will be applied to healthcare. Yet hospital care should not be confused with the full spectrum of healthcare. One must make the distinction between the cognitive process of medical diagnosis occurring in exam rooms, with the procedural basis of surgical care and hospital recovery. While Dr. Gawande has provided a wonderful revealing portrait of cost-effective, fast, food preparation and delivery at the Cheesecake Factory, he has focused on the process of creating the meal, not the process of deciding what meal to make. Successful surgery, for the wrong diagnosis, is a problem. If we are to solve some of healthcare’s largest failings we should focus on what happens as physicians try to address their patient’s problems, diagnose and make decisions, at the table of medicine called the exam room.
Consider the continuum of the patient encounter, from first symptoms, through diagnosis and therapy at a restaurant called Med. At Med I spend all of my shifts with my patrons at my tables. This is an unusual restaurant since the patrons are never sure of what they want to eat and appear every 20 minutes with ever changing lists of unique groups of ingredients to share with me. There are varying ingredients and thousands of meals that can be created. The patrons know the ingredients, but not the meal that they would like to eat. From memory I respond to the customers list of ingredients and ask many questions, take the pulse and other vital signs of the customer, order blood samples, radiographic studies and then decide for the patron which meal their ingredients add up to. All from memory. At Med, restaurant patrons also ask for foods and “food tests” they have seen on television all purported to be risk free. Further complicating the process is my customer is not out for a fun and relaxing evening, they are in small booths in skimpy, open at the back gowns, often anxious and uncertain if they will be harmed or poisoned by my foods, or simply receive a meal they do not want. Some are in pain and some are depressed, while other customers are totally unrealistic about the meal that is to be delivered. You see at Restaurant Med, where patrons only can speak to their wait staff about ingredients, and demand the modern but unhelpful ovens they heard about from friends and the media, it is really difficult to create meals that patrons thoroughly enjoy.
An appendectomy should be consistently performed and priced, but how do we consistently perform and price considering the ambiguity inherent in diagnosis itself? Unlike a restaurant, where customers choose a meal by ordering a meal, at restaurant Med some higher force gives an unfortunate person an undifferentiated and undiagnosed problem that needs and deserves an answer. As it turns out, none of the patrons really want to be eating at restaurant Med, as they always receive a meal they did not ask for.
Patients do not choose their diagnoses from menus; doctors must discover and diagnose them.
If your waiter tries to memorize all the orders at all the tables, you might get the wrong meal, and if your server is in a hurry, thai dipping sauce might be spilled on your new silk blouse. Likewise if physicians are in a rush, they might not take a thorough history, perform a complete physical exam, or have an accurate and thorough list of diagnostic possibilities, ultimately resulting in the wrong diagnosis. If your physician believes he or she can memorize all the questions, tied to all the possible diagnoses you also might receive the wrong diagnosis. With that wrong diagnosis you might end up in a hospital more efficient than the Cheesecake Factory with doctors efficiently ordering unnecessary tests, and performing wrong surgeries for the wrong diagnosis all with the ease and speed of the best assembly line on the planet.
Diagnostic and patient management error caused by cognitive mistakes in the exam room are all too often overlooked and unmentioned in the discussion of repairing our broken healthcare system. There are over a billion outpatient visits in the US each year, and numerous studies have shown 15-20% of these visits have an inaccurate diagnosis. Autopsy data proves this, malpractice insurers know this, and policy makers avoid it. Add diagnostic error in the emergency room and walk-in clinics to error in the out-patient offices of medicine and you have more than 200 million errors. If we are to resolve some of healthcare’s deepest woes we need to address diagnostic errors and the decision-making occurring at the restaurant table of medicine, the exam room. A bright light needs to be shined on the simple fact that there is too much to know, to ask and to apply during a 15 minute encounter unless the patient has the simplest of medical questions or problems. Medical informaticists, researchers and innovative companies are focusing on this essential limitation of medical decision-making by designing information systems to be used by physicians at the point of care, during the patient encounter. Problem oriented systems can also be designed for use by patients in advance of the visit, and the future holds home-based information coordinated with professional clinical decision support. These new information tools are beginning to take the guessing out of which ingredients (symptoms) relate to the meals that the patient ultimately receives (diagnosis and treatment). If medical care is truly to be driven back to primary care we need to arm the waiters of medicine with purposefully designed tools and training to resolve ambiguity, aid diagnosis and inform therapy in the exam room.
Art Papier MD
Art Papier MD is CEO of Logical Images the developer of www.visualdx.com a clinical decision support system, Associate Professor of Dermatology and Medical Informatics at the University of Rochester College of Medicine, and a Director of the Society To Improve Diagnosis In Medicine (SIDM) http://www.improvediagnosis.org/
Now that Mitt Romney has announced that Paul Ryan is his VP pick, I thought it would be helpful to repost some video and transcripts from a healthcare reform conference that I organized in 2009. Paul Ryan was our keynote speaker at the National Press Club, and I found him to be a bright, articulate, and humble person. I remember that he was eager to please, and that he came to the conference early so that he would have time to listen to the physicians and nurses who had traveled from across the country to speak out about healthcare reform.
I hope the video and transcript give you some insight into his take on (what is now) Obamacare. Enjoy!
*** Congressman Paul Ryan addressed the crowd at Better Health’s “Healthcare Reform: Putting Patients First” event. This is a transcript of his speech: ***
This event is a landmark in how we get discussion and debate going in the 21st century. We are communicating with the grass roots, with medical bloggers here in this room and across the country.
Let me tell you this: I don’t want government interfering in the relationship between doctors and patients…and I don’t want insurance companies interfering either! I want a vibrant health care market that lets patients choose the health care options that are right for them and their loved ones. I want a free market democracy that puts patients first. We can have this, and I’ll say something more about that in a minute.
Right now Congress is rushing through a health care overhaul that goes in the opposite direction. It’s important to analyze the relative financial costs and benefits of these proposals, but our greater challenge is not the dollars and cents. It goes to the issue of continuing the tradition of excellent health care that medical practitioners now provide. It’s about the equal dignity of each human person…and the future of America as a free society. The American character, and the principles of freedom & democracy which protect & preserve it, may be lost beyond recovery if Congress chooses the wrong path on health care reform—the path down which I believe the Obama Administration seems determined to lead our country.
Public health has always been a government priority. Our Constitution’s Framers saw every individual as having a “right of personal security” which includes being protected against acts that may harm personal health. This right is part of the natural right to life, and it is government’s very purpose to secure our natural rights to live, to be free, and to pursue happiness.
Now here is where believers in big government make their big mistake. The right of each person to protection of health does not imply that government must provide health care. The right to have food in order to live doesn’t require government to own the farms and raise the crops. Government’s obligation is normally met by establishing the conditions for free markets to thrive. Societies with economic freedom almost always have a growing abundance of goods and services at affordable costs for the largest number. When free markets seem to be failing to meet this test – and I’d argue today’s health care delivery is an example – government should not supply the need itself. It should correct its own interventions and liberate choice and competition.
We know from survey after survey that a vast majority of Americans are personally satisfied with the quality of their own health care. The problem is really with health care delivery, which is growing too costly and leaving many people without coverage. The proponents of government-run health care claim there are only two alternatives: either enact their plan or do nothing. This is false. Government bureaucracy is not the answer to insurance company bureaucracy.
An authentic solution to the problem of affordability should be guided by the principles of moral and political freedom… respect doctor and patient privacy…restrain spending…and channel the energy of our free market system, not dry it up. There is no lack of sensible alternative solutions proposed by Republicans to put patients first. Senators Coburn and Burr, and Congressman Nunes and I have offered one, called “The Patients’ Choice Act.” It’s an example of how to eliminate government-driven market distortions that exclude many from affordable health care delivery. More uninsured Americans can be covered by spending current dollars more wisely and efficiently than by throwing trillions more at the problem. Our health care delivery alternatives are based on timeless American moral and political truths.
In essence, we believe that the dollars and decisions should flow through the individual patient, not from the government. I want to see a market where providers truly compete against each other for our business as consumers and patients – not a bureaucratized system where health care providers vie for government favor as patients wait in line.
When federal bureaucracy replaces consumer choice and competition, services are distorted and costs escalate. Consider Medicare and Medicaid. Real cost control has become a national nightmare. Fraud has proliferated despite every effort to stop it. Program costs are always underestimated. In 1966, the cost of Medicare to the taxpayers was about $3 billion. Congress estimated that by 1990, Medicare would cost taxpayers only about 12 billion in real dollars. The actual cost? Nearly nine times as high — $107 billion. By 2006, Medicare reached $401 billion, while Medicaid added another $309 billion for a total of $710 billion. The failure to control Medicare’s costs shows us why we should look to free markets and decentralization for the answers.
The health care programs being pushed by the Democrats are outrageously expensive and fiscally irresponsible. Like Medicare and Medicaid, they will fail to control health care costs. They will exacerbate our growing debt. They will require crushing taxes. Their approach would spend trillions more dollars, mandate that all but the smallest of businesses provide health insurance, require every American to pay for health insurance or punish them for not buying it, impose a massive new tax burden on employers & heath care practitioners, and make our entitlement crisis worse by adding yet another open-ended entitlement.
The so-called “public option” is presented as a way of “keeping private insurance honest”. Well, if this is their idea of “honesty,” we’re in really big trouble. The “public option” isn’t honest. It is designed to make private insurers go away.
Government has four huge powers that force free market competitors out of business. First, the government does not pay taxes and the private competitors do. Second, it forces competitors to establish high capital reserves while the government has none. Third, the government does not have to account for employee wage and benefit costs – private competitors do. Fourth, the government gets to dictate the prices it pays, which are much lower than its competitors.
It isn’t “honest competition” when government serves as both referee and player in the same game. Before the game begins, you know who will win. Unfortunately, it’s the people who lose. According to one independent study from a reputable actuarial firm, two out of three Americans will lose the health coverage they now have in three years if the House bill becomes law.
Government-monopolized health service contradicts everything America stands for. It conflicts with our people’s character…it conflicts with moral principles…it conflicts with market freedom…it conflicts with democracy…and it conflicts with American health care excellence that still draws patients from socialist utopias for medical treatments in this country.
Bureaucratized health care is not compassionate health care. Let me say that again: bureaucratized health care is uncompassionate, impersonal, and inflexible. When government agents make decisions about how to treat the sick, they don’t decide according to need…they decide according to a budget-driven calculus. Bureaucratic indifference replaces compassionate caregiving by loved ones under free markets offering a range of health services. We need to restore personal, patient-centered health care, the very opposite of the plan now moving through Congress.
The question really before us is about power. Where does the power go? In other words, where do the money and decisions come from? Right now, the nucleus of power in health care lies with third parties – insurers, employers, administrators. Patients and doctors are at the fringe. Should this power be shifted to the government OR to patients and doctors?
It’s a truly critical question. The answer will determine how competition in health care works. Will doctors, hospitals, and patients contend for government favors? A better reimbursement? Coverage of a new cancer treatment? Approval of a new process? The currency in this power structure is political connections, interest group politics, and bureaucratic dictates. OR will providers compete with each other based on price, quality, and outcome for the patient’s business? The currency in this power structure is value, results, and achievement. These principles work in every other market when used – why not health care?
In this debate, direction is destiny. And the destination of the bill now before Congress is government-run health care.
The logic of this bill will require government rationing of health care resources. Last February, the Economic Stimulus package set up a new agency to do this, the Council for Comparative Effectiveness Research, or CCER, modeled on Britain’s National Institute for Health and Clinical Excellence—they call it “NICE”. CCER’s stated purpose is to identify medical practices that produce outcomes that work as opposed to those that don’t work. As long as there is a competitive private health care market, better information on price and quality could help bring much needed transparency to healthcare in America. But under the government-run plan, providers will not be paid for health care which CCER disapproves of. Once competing plans have been driven out, CCER’s approval or disapproval will dictate the care providers may offer, automatically denying treatments for certain categories of patients.
England’s NICE is now a rationing bureaucracy. Under NICE rationing, the government has capped the amount that may be spent on treatments to extend someone’s life by six months. The amount is $22,000, an arbitrary number arrived at not by medical professionals but by government accountants.
The idea that the government should make decisions about how long people should live is deeply offensive to everything America stands for. It is wrong to conclude that because health care resources are limited, therefore the federal government must ration care. This is what free markets are for: finite goods and services, including health care, are rationed by each person judging their unique needs as they allocate their own resources among competing producers. But should government do this with its “one-size-fits-all” template? I believe government rationing is morally and politically abhorrent. It denies basic personal rights. The sick, special needs patients, and seniors – those most at risk when the government involves itself in these tough decisions – deserve better. Like it or not, once government-run health care is a fait accompli, government rationing becomes the logical endpoint.
Now I want to speak from the heart to every provider of health-related services, including doctors and nurses, assistants, educators, hospitals and clinics. Many of you have traveled great lengths to join us today. You will be profoundly affected by the outcome of this debate. EITHER US health care will travel down a path directed by Washington, where you take your orders and instructions from the federal government – a path like that of our friends to the North and many in Europe – OR health care will be reformed to empower practitioners to pursue health care excellence. Countries that have chosen nationalized health services have wiped out individual competition and stunted innovation, by eliminating the incentives to outperform. By law or in effect, medical professionals become government wage earners without adequate reward for exceeding average standards.
Government-driven health care threatens providers in at least three ways:
First: Every aspect of government-monopolized medicine inevitably will be reduced to “cookie cutter” standards. As providers, you know patients’ conditions are not exactly the same. Treatments must be tailored to unique needs. Health care excellence like this is only possible under a vibrant free market.
Second: The cost and price structure of nationalized medical services are distorted by price controls dictated by political demands for low rates of reimbursement. The principal result is to shrink supplies of price controlled human and material resources – fewer doctors, medicines, & hospitals. Then government must manage the decline. The shortages must be spread around by deciding who shall receive and who shall be denied life-saving support. Patients with greater needs and groups deemed less worthy of treatment are the first victims.
Third: Government-run health services build barriers to talented young men and women considering a career in medicine. Today there is a growing need for more talented medical practitioners to care for aging boomers. America needs young people with ability and skill to take on the long years of education and incur substantial student loans to serve our growing need for health care. The best and brightest won’t do this just to become de facto government employees whose practice and reimbursement are dictated by Congress.
If government-run health care becomes law, it will prove lethal to America’s health care providers. We will be on the path to socialized medicine. The Congressional majority ridicules the claim that this is their objective, but the government-run plan which they propose as “an important tool to discipline insurance companies,” in the President’s own words, must lead step-by-step down that road. Mocking a fact does not make it untrue.
Some of the biggest health care organizations are trying to cut a “deal” with the Administration and Congressional leaders. With all due respect, they should know better. This is a fool’s errand. All they can salvage is a temporary stay of execution…because a government takeover of health care in the United States will either squeeze out or take over all private sector providers, large and small.
What is at stake in this battle goes far beyond health care. This debate encapsulates the defining issue of our generation: do we reform and strengthen American free market democracy, or abandon it for European-style social welfare?
If the majority party wanted more competition, why propose government insurance instead of enabling more non-profit insurance?
If they had no intention of transforming the system into Medicare for all, why do they tie all payments to Medicare?
If they were so worried about our skyrocketing national debt and the burden on the next generation, why do they want to create an entirely new entitlement that would deal a staggering blow to our economy – an entitlement that rivals the size and liabilities of Medicare and Medicaid? Just yesterday the Director of the nonpartisan Congressional Budget Office told the Senate that their health care plan would worsen the overall fiscal outlook, and his review so far of the House proposal draws the same conclusion. It makes the fiscal situation even worse.
The fact is, this is ultimately not about health care but about promoting an ideological objective. This nation, founded on the self-evident truth that unalienable rights were granted to all not by government but by “nature and nature’s God,” is to be remade into a “benevolent” social welfare state. Federal health care is but the first step. Until now, people in other countries that have chosen that path might at least come to the United States. But where will Americans go when the US also has government-run health care? There will be no place of freedom left to us.
Every day America’s health care professionals meet the critical medical needs of our people with selfless dedication and passion. They would jump in front of a bus to save their patients. They deserve not just thanks but our recognition that their excellent care cannot continue under a government monopoly.
This is not the time to stand to one side. Providers themselves must engage in the struggle for the future of their high profession and commitment to the wellness of our people.
August is the time for action. This is the time when Americans either engage this debate and tell Congress they reject government-run health care…or sit silently by while Congress forces it on them. The President and Congressional leaders are saying this has to be done immediately – it has to be done right now – and leave the details to them – they know best. Well, whether your pet peeve is Iraq or bailouts or the so-called stimulus, we’ve all heard that line before. You know what they say: fool me once, shame on you. Fool me twice – or in the current political environment – 3 or 4 times – shame on me. Will we heed this lesson?
I am initiating this call to every person and group involved in health care: you must act now! Doctors, your patients trust you, they will listen to your “prescription.” Ask them. They’ll jam the Congressional switchboards. They have done it before and need to do this from now through August. They will defeat this threat to everything America has stood for.
Let’s get government health care off the table. Then we can address real reforms to bring patient-based health care back to America.
Dr. Pauline Chen recently wrote an interesting, if not slightly sterile, article about the prevalence of bullying in medical school. A survey published by JAMA in 1990 suggested that 85% of medical students had experienced some kind of mistreatment during their third year of training, and a quarter of the respondents said that they would have chosen a different profession had they known in advance about the extent of mistreatment they would experience.
One medical school (UCLA) took these sobering statistics to heart and implemented an anti-bullying program of sorts. Thirteen years after it was initiated, more than half of all medical students still said that they had been intimidated or physically or verbally harassed.
I recently wrote a fairly tongue-in-cheek blog post about why doctors are jerks. But I didn’t really delve into the more sinister side of the bullying culture. Some of my experiences in medical training were soul-suckingly bad, and just to add some flavor to Dr. Chen’s analysis, let me share some real-life anecdotes.
My worst experiences in medical training occurred during Ob/Gyn rotations. I don’t know if this has been the experience of other medical students, or if my gender had anything to do with it, but I spent time with a group of female residents who were so toxic to med students that the department chairman actually warned us about them ahead of time in a private meeting. He let us know that these residents had a history of “hazing” medical students, particularly females. I had always been a very conscientious and hard working student, so I presumed that they wouldn’t have much to criticize. My plan was to work hard, keep my head down, and get out unscathed. Unfortunately, nothing went as planned.
The tone was set for me the first day when I witnessed a female, Asian anesthesia resident slap a pregnant Hispanic woman who was in labor. The woman was frightened and spoke no English and was beginning to hyperventilate from pain. The resident was trying to put in an epidural anesthetic and the woman was moving around too much for her to get the needle safely into position. So instead of calling for a translator, the resident started raising her voice, eventually screaming at the woman to calm down. The woman was crying uncontrollably, so the resident slapped her, and told her that she was “going to lose her baby” if she didn’t shut up. The husband was also terrified and could understand some English. He translated to his wife that she was going to lose the baby and started begging her to be calm. I stood in the doorway with my mouth open. The resident told me to get the f-out of there as she threw her gloves at me.
I suppose the humiliation of being caught abusing a patient was enough to channel her hate towards me, so she told the Ob/Gyn residents that I was an incompetent medical student. For the rest of the month I was targeted by the hazing team, and like a pack of wolves they descended, bound to make my every moment a living hell. During the delivery of my first baby (a touching experience that moved me to tears), the new mom experienced a small tear during the birthing process. The residents blamed it on me, and convinced me that I had personally caused her harm by not “supporting her perineum” correctly. I was mortified and fell for the lie – hook, line, and sinker.
When a woman went into labor it was customary for the residents to page the medical student on call and have him or her assist with the vaginal birth or c-section. My peers were paged in a timely manner, while I was either paged at random times or paged to the wrong parts of the hospital so that I appeared to be late to several deliveries (especially when a senior physician evaluator was present to witness it). Once I caught on to this I had to remain awake 24/7 at the nursing station (rather than the more secluded med student lounge) so that I could follow visual cues regarding where and when to assist. After several shifts without sleep the residents began locking the chairs in their lounge so that I would have no where to sit or rest, but would be forced to remain standing “on guard” all night.
One page was particularly painful at the time (but almost laughable in retrospect). A resident took it upon herself to page me just to tell me some important news: I was the worst medical student in the history of the program.
Of course, my final resident evaluation was dripping with venom. I recall statements such as, “Valerie suffers from narcolepsy,” and “she is uniformly late and is never prepared… she doesn’t answers her emergency pages… she occupies valuable space at the nursing station instead of remaining in the medical student on-call room… her performance in deliveries borders on dangerous.” And on it went. I wish I had the maturity to take all of that in stride at the time and see that these women were nuts, and it had nothing to do with me personally. But I was too close to it then, and I bore the pain with a stiff upper lip.
I still think about that poor patient who was slapped, and I kick myself for not standing up to the resident who hit her. I guess I was in such shock that I didn’t know what to do. But living through this abuse helped me to become a stronger patient advocate during my residency years. Just two years after my brush with the Ob/Gyn residents, I gained a reputation for being the intern you never f-with. I know I saved the lives of some who were slipping through the cracks of the system, and I was willing to call in the hospital ethics committee if I had to. Yes, that pregnant woman’s suffering was not totally in vain – because she helped me to find my own cojones. And for that, I will always be grateful.
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