June 24th, 2009 by EvanFalchukJD in Better Health Network
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Steven Pearlstein actually wrote that in the Washington Post on Wednesday, right after (another) long rant against physicians. At the end, he offers doctors an olive branch. Or maybe its an offer he thinks doctors can’t refuse:
The choice for doctors now is quite clear: They can agree to give up a modest amount of autonomy and income, embrace more collaboration in the way they practice medicine and take their rightful place at the center of a reform effort that will allow them to focus more on patient care. Or they can continue to blame everyone else and remain — stubbornly — a part of the problem.
After reading Pearlstein’s columns, I’m still sure not why he has such a problem with doctors. I am beginning to think it’s because he just misunderstands them.
Pearlstein is convinced that doctors go into medicine for the same reasons investment bankers go to Wall Street: to make money.
Docs seem to take it as a given that physicians in the United States should earn twice as much as doctors in the rest of the world — and five times more than their patients, on average. Mention these facts and you are guaranteed to get a lecture about the crushing debt burden that young docs face upon completion of their medical training. Offer to trade free medical education for a 20 percent reduction in physician fees, and you won’t find many takers.
Pearlstein has no source for these claims, but let’s assume they’re true, and do the math. The government says that there are 633,000 doctors in the United States, and they earned median salaries between $135,000 and $320,000 a year. If we take a number in the middle — say $200,000 — that means that American doctors earn about $125 billion a year. A big number, but total health care expenses in the United States are over $2 trillion, which means doctors represent about 5% of the total. Can physician salaries really be driving our health care problems?
It seems unlikely. But Pearlstein is desperate for it to be true, so he keeps trying to discount all of the other possible causes of our problems as examples of conspiracies or arrogance or sloppiness:
For example, medical malpractice litigation is a problem…
But one of the reasons malpractice suits are still necessary is because doctors have transformed local professional review boards, which are supposed to protect patients, into nothing more than mutual protection societies
The “infelixible bureaucratic processes” that insurers impose are a problem….
But given that there is overwhelming evidence that doctors tend to order up tests, perform surgeries and prescribe treatments whose costs far outweigh the benefits, you can hardly blame the insurers.
We think it is good to have “clever and creative” doctors…..
but . . . we could all have better health at a lower cost if docs were less inclined toward the medical equivalent of the diving catch and simply were more disciplined about kneeling down for routine ground balls.
Doctors should be applauded for embracing evidence-based medicine…
however, practicing physicians still think that nothing should interfere with the sacred right of doctors and patients to make all medical decisions, even when they are wrong.
Pearlstein’s views on how doctors think are fundamentally flawed. He thinks of them like stock brokers, pushing questionable stock to make commissions for themselves. He’s thought of all the different ways doctors are abusing the system to their own advantage, but he doesn’t seem to have thought that maybe, possibly, he’s wrong.
So, yes, some doctors abuse the privilege of being asked to help their patients. But the overwhelming majority don’t. They want to spend as much time as they can with their patients, collecting information, thinking about their problem, and offering good, sound advice. They are bothered by the involvement of the insurance company or the government or the plaintiff’s lawyer not because they believe they have a “sacred right” to total independence. Or because they think the way to fix health care is to give them “free rein to treat their patients . . . run the hospitals and set their own fees.”
No, it is because these things actually interfere with the doctor’s ability to think, process and decide with their patient on the right things to do.
Pearlstein and other would-be reformers of our health care system need to reconsider their assumptions on what motivates doctors. Maybe it’s something Pearlstein should ask some of his friends about.
*This blog post was originally published at See First Blog*
June 24th, 2009 by AlanDappenMD in Primary Care Wednesdays
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For 18 years, primary care providers steadily have been eclipsed by “specialists.” It is no longer rare to hear calls for these competent generalists to drive straight to the scrap heap in order to be refitted as procedural, money-making Humvees. What may be implied by this scenario is that primary care providers are selling out so as to allow nurse practitioners to be a more economical, efficient and smarter primary care provider. In fact, such ideas are not impossible if primary care doesn’t take control of their own destiny and invest in their own future. Technology will prove such a pivotal investment.
In my June 10 post, I discussed the five cornerstones of 21st century medical care as presented by a book published by the Institutes of Medicine entitled Crossing the Quality Chasm: A New Health Systems for the 21st Century. The first cornerstone presented a communication-centered medical practice and abandoned the traditional brick-and-mortar idea that “the answers to all medical questions must be delayed until the patient is seen in the office.” Rather than the doctor being the last person to know what’s happening to a patient, a communication-centered model puts doctors at the front of the office, answering phones, emails and internet-generated questions through the day, allowing the practitioner to be the first ones to know what’s happening with our patients. This model could eliminate up to 66% of today’s office visits while simultaneously improving speed of delivery of care, convenience, access, quality and reduce costs.
The second cornerstone that primary care needs to invest in and build is an advanced information management system, which still does not exist. An electronic medical record (EMR) that replaces a paper chart does not adequately explain the real potential of a tool that could transform the generalist.
Information in the communication-centered practice is managed differently than in traditional models. The health care provider, surrounded by phones and computers, is linked to a powerful network with electronic medical records, health information databases, sensitivity-specificity measurements, medical literature, and information about local facilities such as laboratories, pharmacies x-rays, and consultants and their costs, just to name a few linkages.
Imagine information no longer limited by what is in the doctor’s head, but rather, doctors who can access and find the answer to any medical question within seconds by having bookmarks that extend through an entire medical library, and searching for answers would be as easy as: The evidence based guidelines treatment for this problem is “click”… The differential diagnosis for night sweats is “click”… The medicines known to cause “weird smells” as a side effect are “click”… The cost of that test is “click”… The three labs closest to your home where I could fax the order are “click”…The sensitivity and specificity for this test or that symptom or that physical finding to be associated with lupus is “click”…The recommended treatment for this fracture is “click”…The three best articles for helping patients manage and educate themselves about their cholesterol are “click”… The telephone number to arrange setting up the test is, “click”… The facts and comparison for this medicine is… “click” The video link demonstrating the Canalith repositioning maneuvers is in your email box… “click.” Primary care providers help patients work through this information, discerning what is of utmost importance to their medical situation and issue. As it is said, “The role of the expert is to know what to ignore.”
Excellent primary health care requires continuous communication between doctors and patients so as to respond through the evolving and unpredictable twists and turns of illness and treatment . Doctors likewise need connection to the highest quality information and recording systems so as to actualize the science of best “healers”. The idea that doctors should always know the answer to a problem by using memory alone is as misguided as insisting mathematicians return to pencil and paper calculations to prove that they are “real” mathematicians. Despite the potential, primary health care has remained timid to challenge the unexamined assumptions behind the limits of Hippocrates medical practice. Were Hippocrates to return today I imagine him asking, “What have you done?”
Our patients need doctors to step up to the plate and go to bat for them. We as doctors need it too.
Until next week, I remain yours in primary care,
Alan Dappen, MD
June 3rd, 2009 by AlanDappenMD in Primary Care Wednesdays
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Between what is said and what is not, the truth lies in waiting. Palpate the silence. Hear the double meaning. Smell the hesitation. See the nostrils flare. Watch the direction of the gaze. Feel the tension.
The truth vibrates in myriad ways. It is deep, below the surface. Frank Herbert’s novel Dune illustrates the concept with fascinating fiction. Imagine a people –the Bene Gesserit — genetically bred and trained as seers into the unconsciousness, sensors of the truth, like breathing lie detectors. Little did I know that such truth seers are not just a part of fiction, and although a rarity, live and walk amongst us.
I have met such a seer. Towards the end of my residency training, a gifted psychologist was assigned to follow me as a routine part of our training. I’d become competent and efficient in administering my craft. “My doctoring will impress her,” I thought with some pomp.
Right before the first person we saw, she told me, “Pretend I’m not in the room.” Then, for the duration of the morning, she silently observed the patients I saw and my interaction all while in the back of the room.
After seeing a few patients, we’d break and talk. The patients I saw, I felt, were representative of standard primary care issues: Joe forgets to take his medication. Susan can’t quit smoking. Elaine has unexplained abdominal pain. My medical paradigm explained that Joe, like most people, can’t comply taking continuous medications. Susan is addicted, not interested in quitting smoking until she’s good and ready. Elaine’s pelvic pain is mysterious but not worrisome.
I’m stunned when, after my medical analysis, the psychologist paused, emitting a rueful smile. She sighed knowingly and responded, “Actually, Joe is angry at his wife and defies her by refusing to comply. Susan has unresolved issues with her father who’s probably an alcoholic. Elaine’s pain suggests sexual molestation.”
“Give me a break!” cried a voice from inside of me. And as the days rolled along there were other voices too. “I am a family doctor. This is not medicine! I don’t have time for this! Just what you’d expect from a psychologist; too much Freud!”
As the weeks turned, I reluctantly see her hit nail after nail on the head. She saw complex patterns in people’s behaviors and complaints that I’m too blind, and too unwilling, to see.
With this new, almost astonishing, dimension to medicine, I see, for the first time, art, compassion, insight, and intuition as equal partners to the formulas of science. I slowly wonder what it truly means to be called “a doctor,” when so much is missed in the science of “performance.” I am captivated, begging to know: How does she see? Can I learn? Is she gifted or crazy?
We are in the final days of my tutelage when we meet an enraged Sharon, in follow-up from the emergency room after a miscarriage. She didn’t know she was pregnant, began to bleed, and ended-up in the ER. She was pushed into a back room, left alone for a long time, bleeding heavily. She felt abandoned, angry, and humiliated. The ER attending staff, she insists to me, made her feel like a “slut.” I listen and then promise to investigate and call her back.
In the post-patient meeting I explained to the Bene Gesserit (as I now secretly called my psychologist mentor), “Delays occurred in the ER’s treatment of Sharon and she was over reacting but never in danger.”
“Right about the danger,” the Bene Gesserit concedes, “Wrong about what happened. Sharon had an affair her husband found out about it through the miscarriage.”
Having been humbled too many times, my resistance drops. “What did I miss can you show me?” I beg.
“You sense her over-reaction, her anger, yet dismissed it. Something else fuels her rage. Close your eyes. Pretend to be having a miscarriage right now. I’ll coach you through it.”
“This will be tough.” I think, “I am a man and can’t really miscarry and am sitting in the doctor’s lounge with plenty of colleagues enjoying this play acting.” I close my eyes and settle into a foreign reality. It doesn’t take long to be guided to bells ringing in my head. “I don’t feel like a slut.”
The Bene ignores me and continues, “The vibrations are always there if you tune your antenna to the right frequency. People are pools of water with surface and depth. Illness arises within a context. Ripples on the surface are the symptoms caused from objects thrown-in or vibrations from the past arising to the surface. To reveal this union between the physical and emotional bodies is a unique potential of a healer. “
Sharon’s husband visited my office three days later, chief complaint chest pain. The betrayal was written all through him and verified as forecasted by my mentor. Unnerved I began in earnest to train my own antenna as to reach my fullest possible potential as a healer, a potential only realized by committing the time to listen comprehensively, intuitively, respectfully needed to do so.
Medical care today is all about the quantitative: 10-minute office visits, performance-based measurements, and only the facts. Medical problems are often not simple algebra formulas where the sum equals its parts. Many times healing requires the art of listening, intuition, trust, insight, empathy, grace and even spirituality. It’s not neat, nor quantifiable, but many have journeyed through life enough to know it’s true. Even after all the science has spoken, the art hides itself in myriad ways, patiently waiting.
Until next week, I remain yours in primary care,
Alan Dappen, MD
May 20th, 2009 by SteveSimmonsMD in Primary Care Wednesdays
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The impetus for government to control healthcare costs should be obvious to us all and intervention now appears unavoidable. Two issues will soon come to light: the exorbitant costs to fight disease at the end of life, often when the approach of death is barely retarded and the wide disparity in costs between different geographical regions of our country for similarly aged patients. It is estimated that 27% of Medicare’s annual $327 billion budget – one fourth of its operating budget – goes to care for patients in their final year of life while Medicare averages $20,000 more dollars for patients in Manhattan than in some rural areas of our country.
With this in mind, I share a deep concern with many of my colleagues that part of the healthcare reform debate will turn to the rationing of healthcare. This appears a logical progression from the proposed establishment of guidelines and advisory committees currently allowed for in the Health Reform bill already passed. The question as to who should receive possibly futile care is not clear, rather it is fraught with complexity, often relying as much on evidence-based research as it is on assessments made by the medical practitioner in light of the relationship the doctor has with the patient.
At the heart of the rationing issue are two, often warring, sides of medicine: art and science. Medicine began as an art thousands of years ago, and moved more towards science when, in Ancient Greece, Hippocrates taught physicians to observe the results of their treatments and make adjustments. However, art should not be removed from medicine, for this is where the doctor-patient relationship comes to play, serving as a cornerstone of effective and humane medicine. It would be impossible for physicians to uphold the noble traditions of the medical profession, adequately serve society, or preserve the dignity of human life if doctors were to become, purely, scientists. As long as we are treating people, medicine should never become solely a science.
Rationing, however, would be based purely on science, completely devoid of any art and, I believe, serve as a blow against the sanctity of the medical profession. Setting up rationing guidelines as they pertain to the end of life would circumvent patient’s trust in the doctor-patient relationship and risk the very soul of medicine by negating the importance of the doctor-patient relationship. Evidence-based recommendations can and should be set forth pertaining to protocols for offering treatments as the end of life seems near. This would likely reduce some of the high and disparate costs in caring for our elders; however, it is important to consider the input of a doctor aware of the needs and desires of his patient.
I come to this argument both as a physician and from personal experience. Several years ago, my 75 year old father was hospitalized four times over five months. His medical team, led by a kind and experienced surgeon, unburdened by guidelines or anyone else’s recommendations, gave him a chance despite long odds against his survival. Medically speaking, I am still surprised he made it out of the hospital to live a normal life again. During the subsequent five years, he has welcomed three grandchildren into our family; I would challenge anyone to assign a monetary value for that life experience. My professional and personal experience leaves me quite sure that he would have fallen a victim of any rationing guidelines that could ever exist.
In short, as the average life span increases most of us nurture the hope to live longer, cheering as science opens the door to seemingly innumerable advancements. Yet are we, as a society, equipped, whether it be emotionally or fiscally, to handle the decisions that must be made as the end of life draws near? More importantly, should government be allowed to set up strict guidelines without an active debate from physicians and patients? These guidelines could sacrifice what has long been and should still remain most important to healthcare: the doctor-patient relationship.
