June 25th, 2009 by KevinMD in Better Health Network, Health Policy
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Health policy experts have never been shy about their antagonism towards doctors.
The focus now appears to be on physician pay, with the Washington Post’s Steven Pearlstein, for one, continuing his anti-physician columns. Derek Thompson, over at The Atlantic (via @AllergyNotes), continues the assault, with a recent blog entry wondering if doctors deserve to be paid less.
I touched upon this topic last year, in a USA Today op-ed, Doctors’ pay cuts save little in health care costs, and paraphrased prominent Princeton economist Uwe Reinhardt saying that cutting physician pay 20 percent will only result in 2 percent of health care savings. And besides, if the current system stays in place, doctors whose pay is cut will simply respond by doing more procedures.
Furthermore, many health policy experts bring out the tired statistic comparing American physician salaries with those abroad. The problem is that these are not apples-to-apples comparisons. Both the cost of medical school and malpractice insurance are exponentially higher Stateside. Fully subsidize medical school and bring malpractice premiums down to the levels of other countries first, before talking about tackling doctors’ pay.
Until then, comparing physician salaries with those in Europe is a largely meaningless exercise, and only serves to expose many health wonks’ innate contempt for the medical profession.
*This blog post was originally published at KevinMD.com*
June 10th, 2009 by EvanFalchukJD in Better Health Network
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Did you know that doctors are paid too much, wrongly complain about medical school debt, and falsely believe there is a medical malpractice crisis?
Did you know that doctors are hopelessly conflicted sellers of medical care, motivated by the search for extra income?
Well, then you haven’t read the Washington Post’s Steven Pearlstein’s work on health care reform.
“It’s the doctors, stupid,” he begins his column today. At once, he recycles the tiredest of political phrases and tells his readers exactly what he thinks of them. But it’s not the column that is most telling, it’s the live web discussion that followed. I participated in it, and can share with you the highlights. It’s a revealing insight into the thinking of a mainstream DC columnist.
To save you the trouble, here’s a summary of Pearlstein’s views: Doctors learn a craft that they owe to the rest of us as a public good. But instead of doing this, they take advantage of knowledge to make as much money as they can. They do it willfully – like an insider-trading stock broker – but they also do it because they just aren’t all that competent at what they do.
Think I’m making this up? Read:
On medical school debt:
I think we allow doctors to make too much of their debt. . . In major metropolitan areas, that debt looks pretty small when compared to the lifetime earnings that doctors accumulate in private practice over many years. They more than make up for their investment, as it were. But they use this debt to justify their elevated incomes for the next 30 years — and make no mistake about it, doctors in the U.S. do make ALOT more than docs elsewhere, on average. . . . My suggestion is that we socialize the cost of medical education, that is have the government pay for it, in exchange for a couple of years of community service. That way, we get the community service and we eliminate the No. 1 reason given by docs to justify getting paid more than docs everywhere else.
According to the Bureau of Labor Statistics, a freshly minted family care doctor has a median wage of less than $140,000 a year. According to the AMA, these same doctors have, on average, about $140,000 in educational debt. Thirty years seems about how long it would take to pay off that debt, and you can forget about buying a house, a car, or paying for your own kids’ school under those circumstances. I’m sure many medical students would love the Joel Fleischman plan, but we should do that because maybe it will help more people become doctors, not because we think doctors are exaggerating the impact of debt equal to 100% of your gross pay.
On how our system ought to allocate medical resources:
There is no reason why people can’t travel an hour to a big hospital to have a baby, for example, in a big modern maternity ward that does lots of deliveries and has enough volume to be able to afford all the latest equipment in case something goes wrong. I mean how many times in your life do you have a baby that you can’t drive an hour to have it done, rather than insisting that every community hospital have its own maternity ward. It’s just one example of the inefficiency built into the system by people — that would be you and me — who insist on things that, in the end, don’t have ANY impact on the quality of care. In fact they have negative impact.
I don’t know if Pearlstein has ever had a baby before, but just being an hour away from a hospital is unthinkable for most expectant moms in the weeks prior to delivery. And what is someone to do who lives an hour away and has a complication during the pregnancy? Pearlstein’s prescription seems to be that they should eat cake.
On the freedom of patients to choose their medical care:
The emphasis on being able to choose your own doctor in every instance is another, as if most of us have a clue as to who are the best docs and who aren’t. These are the kinds of irrational things we need to try to work out of the system, because they wind up being very costly.
Yes, for goodness’ sake, let’s get rid of the irrational desire of a sick person to want to pick their own doctor. Even Senator Kennedy’s “American Choices Act” guarantees the right of patients to choose their own doctor. I don’t know where Pearlstein is on the political spectrum with this view, except perhaps a certain territory between China and South Korea.
On how doctors are hopelessly conflicted in giving medical advice by their desire to make money:
But first we need the evidence to show that it isn’t a good idea. Then, once we have the evidence the doc has to follow the protocol and explain to the family why it’s not a good idea and not merely blame the big, bad insurance company for being so heartless–which, by the way, a lot of docs do, so they can look like the good guys. Of course they’d love to do the surgery in many cases because they’d like the business and the extra income, so they are hopelessly conflicted. . . . .
[B]uying medical care is not like buying lawn furniture. . . in medical care you rely to an extraordinary extent on the advice of the doctors (i.e. the sellers). And its also not an area where you are inclined to be very price-sensitive — is anyone going to go the the Wal-Mart of surgeons if they think their life may depend on it. . . . But it is NOT true that a well-informed consumner will always make the right choice about medical options — they still need the advice of doctors, who under the current system have a very noticeable conflict of interest.
I’m actually not sure that Pearlstein has even been inside of a Wal-Mart. Because they consistently have high quality merchandise at the lowest prices. In fact, if more hospitals worked like Wal-Mart the problems that plague our health care system today probably wouldn’t exist.
Responding to a commenter who said that the notion that defensive medicine is a large expense is “totally false:”
Indeed. But doctors don’t believe this, no matter what evidence you present them.
Yes, evidence is like kryptonite to doctors.
I asked Pearlstein if a doctor ran over his dog or something. He didn’t directly respond, simply saying “Maybe you should talk to Atul [Gawande].”
Now that’s the only sensible thing he said.
June 10th, 2009 by EvanFalchukJD in Better Health Network, Health Policy
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The OSHA-ization of health care quality continues.
A research group and a consulting firm have been hired by the state of Massachusetts to head up a new initiative to publish cost and quality information on Massachusetts doctors. But the quality measures they will use are the same old ones we have seen for a long time. They mean very little to most patients, and even less to doctors as a measure of how good their work may be.
To understand what I mean, look at what is being measured.
For the category “Adult Diagnostic and Preventative Care,” there are only four quality measures. They are:
- rates of colorectal screening tests
- the number of patients in an insured population who lowered their blood pressure in a given year
- correct imaging test use for lower back pain
- rates of use of a spirometry test for COPD
The good news is Massachusetts doctors do better than the national average on these measures. The bad news is it’s hard to say what that means as far as how good any doctor is who is measured this way.
Maybe it’s better in women’s health. There, the four quality measures are:
- rates of breast cancer screening for women 40-69
- rates of cervical cancer screening for women 21-64
- rates of chlamydia screening for women 16-20
- rates of chlamydia screening for women 21-25
Hmm. So if I am a 30 year-old woman trying to figure out how good my doctor is, the only thing that is being measured is whether he does a cervical cancer screening on me or not. How about pediatrics?
- rates of well visits
- correct antibiotic use for upper respiratory infections
- follow-up with children starting medications for ADHD
I could go on, but there’s a pattern. All of these “quality” measures are crunching medical billing data and styling it as a quality metric. And so every metric is going to be focused on things that are easily measurable by a review of those bills.
But there’s a more disturbing pattern. The information is simply not valuable to consumers. Worse, I think it is deeply misleading. A medical group that does chlamydia screenings on 100% of its patients may be good or bad – or it just may be smart enough to know that if they do the state of Massachusetts will rate them with five gold stars. But consumers won’t be able to tell the difference. All they will know is that practice A is “high quality,” while practice B isn’t. Some doctors are starting to sound the alarm about this.
And this is the larger point. Our health care is organized in a way that systematically undervalues the thinking, processing and deciding aspects of medicine- the things that really matter to you when you’re a patient who is sick trying to get help. Our system treats medicine as an assembly-line process amenable to assembly-line metrics. But it’s not.
Doctors, like others in professions requiring judgment and reflection, need time to think, and ought to be judged by how well they do that. Since the leading cause of misdiagnosis is a failure of synthesis – a failure by the doctor to put together available information in a way that leads them to the right conclusion – our system ought to be built around helping make sure this happens each and every time.
So, instead of a web site where you could see how often a medical practice does chlamydia screenings, imagine you could find out how often doctors at a hospital got their patients the right diagnosis and treatment? Now that would be a useful way to measure quality.
*This blog post was originally published at See First Blog*
June 9th, 2009 by Bryan Vartabedian, M.D. in Better Health Network
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Let’s face it, Twitter isn’t that hard to figure out. The interface is intuitive and a little time on the application makes its basic function pretty obvious. But there are a couple of things that medical newbie’s might keep in mind before taking the leap on to Twitter. While I didn’t find myself in any kind of trouble, I had to figure a few things out on my own.
1. Follow and listen. Twitter is as much about listening as it is about talking. The best thing you can do to see how doctors are using microblogging to advance their platforms, practices and passions is look and listen. Pick a group of doctors (look at my follow list for some ideas) and follow them for a couple of weeks to see exactly what they do and how they interact with others. Don’t reinvent the wheel.
2. Goof around now, but ultimately think how you want to use it. You likely won’t have any idea about how to use Twitter when you first jump in. And that’s okay. You can’t understand it’s power until you reach a sweet spot of followers and cultivate relationships that have some history and meaning (in Twitter terms, of course). Ultimately you do want to think about connecting with those who will put you where you want to be – whether it’s just raising your profile as an author or specifically drawing patients for lapband surgery, or whatever. But also keep in mind that you may start by goofing off and never stop … like me.
3. You can follow whoever you darn well please. The world is full of self-ordained social media experts who spend their days working to make you feel like you don’t follow enough people. If you’re a physician with a real job you’re too busy to follow 30,000 people. Keep your eye on the ball and think about the network you want to develop. Whatever you do, don’t believe the nonsense that it’s ‘bad etiquette’ to not follow someone who follows you.
4. Your patients and your hospital are listening. Social media is interesting. While we type in the privacy of our boxer shorts, the world reads what we write. And that includes your patients. While my grandmother used to tell me before going out, ‘don’t do anything you wouldn’t do in front of the Virgin Mary, I’m telling you, don’t Tweet anything you wouldn’t want your patients to see. You represent your personal brand, practice, and profession with that very first tweet. Keep in mind that some hospitals have social media/blogging policies. You might look into this before taking the plunge. If you keep your hospital/institution off your bio, commit to never discuss anything relating to patients and always vow to be a really nice guy you should be good.
5. What happens on Twitter stays on Twitter. Remember that everything you type will remain etched in the infosphere for eternity. This can be retrieved by future employers, partners, soon-to-be-ex-spouses or anyone else interested in seeing or exploiting what you’re really about. Exercise intelligent transparency. Be smart and use your frontal lobe before hitting ‘update’.
I was interviewed by the AMA News last week on doctors and Twitter and that’s what got me thinkin’ about this post. I get a charge out of helping doctors recognize the power of connecting beyond their immediate environment. I hope this helps.
*This blog post was originally published at 33 Charts*
June 8th, 2009 by Shadowfax in Better Health Network, Opinion
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Bob Wachter, who I generally like and admire, takes on the topic of hospital peer review, stimulated by a
report issued by Public Citizen’s Health, that hospitals rarely report physicians to the National Practitioner Data Bank:
Wachter’s World : Is Hospital Peer Review a Sham? Well, Mostly Yes
Although the public cannot access NPDB reports on individual physicians, healthcare organizations (mostly hospitals) ping the database about 4 million times per year. When it was inaugurated, the best estimates (including those of the AMA) were that the NPDB would receive 5,000-10,000 physician reports each year.
Not so much. Since its launch two decades ago, NPDB reports have averaged 650/year, and nearly half of US hospitals (2845 of 5823) have never reported a single physician! The most extreme case is that of South Dakota, where three-quarters of the hospitals have never reported a single case to the NPDB. I’m sure South Dakota has some wonderful doctors, but the idea that the state’s 56 hospitals have not had a single physician who needed to be suspended for incompetence, substance abuse, sexual harassment, or disruptive behavior since the Reagan presidency is a bit of a stretch, don’t you think?
And on the merits of the matter, it’s hard to dispute that the NPDB has been an abject failure as far as its original goal went: it is not an effective data bank collecting data on suspect and problematic physicians. I think that Public Citizen and Dr Wachter transpose cause and effect, though, when they attribute the blame to the peer review process. The fault, I think lies in the NPBD itself.
The goal may have been laudable and simple — get in trouble, get a file, and keep bad doctors from hurting patients. Wow. Who could oppose something like that? But that’s not how it worked out in the real world. Perhaps it’s a consequence of the fact that it is so infrequently used, but the reality is that being in the NPDB is incredibly stigmatizing, which is not a matter limited to the ego of the reported physician, but also is an essential death sentence to his or her career. This is not a “Oh dear, now I’ll never be Chief of Staff,” sort of career disruption — being in the data bank makes a physician essentially unemployable.
And that’s why it’s shunned: it often seems unjust. There’s no proportionality, no way to indicate the gravity of the transgression, because the full details behind a report are screened from view. Molesting a patient and telling dirty jokes in the OR both show up as “sexual impropriety.” An isolated mistake or an episode of poor judgment is impossible to distinguish from incompetence, as both are filed as “quality of care deficiencies.” When the only punishment is the ultimate one, it’s no suprise that medical staffs are loathe to invoke it.
And it’s expensive. Since a physician at risk of a medical staff action usually knows how high the stakes are, they will commonly lawyer up and fight tooth and nail to prevent any blot on their record. The legal bills for these cases can run into the hundreds of thousands of dollars, and even if the hospital “wins,” all they’ve done is spend a ton of money to get rid of a problem. If they can get rid of him or her for free with a negotiated sham resolution, why would they go through all the expense to persecute the poor bastard as well?
Much of the same can be said for the state licensing boards, to which medical staff committees are also responsible for reporting of suspensions and revocations of privileges.
So, I think it should be noted that this is not a simple “docs are too softhearted to police themselves” issue. It’s that the legal and regulatory tools we have been given are too blunt and indiscriminate for those of us wielding them to feel that they are useful and fair in the vast majority of cases.
Because the true case of the dangerous/incompetent/morally unfit physician is relatively uncommon. Dr Wachter falls right into the false “Good doc/bad doc” dichotomy and buys into the assumption that there is a large cohort of “Bad Doctors” out there that we need to drum out of the profession. There are some, I am sure, but I’ve rarely seen one at our hospitals, and they’re actually quite easy to deal with when you come across them. It’s the gray cases, which comprise the majority of the head-scratchers that we have to deal with in the hospital. It’s the surgeon whose patients love him but just seem to have a lot of complications. It’s the doc who manages to pick a fight with every other member of the medical staff but never quite crosses any bright lines. It’s the creepy male doc who makes all the nurses uncomfortable but never really touches where he shouldn’t. The “incompetent” doc who you wouldn’t let care for your family member but seems to muddle by just well enough to keep from killing anyone.
You all know the one I’m talking about, right? But it can be tough to identify an incompetent doc. I’ve never yet met one whose ID badge or diploma listed them as “incompetent.” In many cases, there’s a legitimate defense to the care provided, even if it’s a weak defense. In many cases an error or errors may have been genuine and severe, but not characteristic of the doc’s general level of quality. The cut and dried “you suck” level of incompetence is rare and far overshadowed by the many cases of borderline physician skills.
The “Bad Doc” approach to this matter also makes the error of assuming that a problem doc is irredeemable and must be expelled from the order. I’ve seen docs who rose and fell and rose again over the long arcs of a career. Some of them needed to go through a formal, sanctioned process involving chemical dependency treatment, most often. Others, however, simply needed attention and managerial support: focused redirection, re-education, sensitivity training or the like, and with appropriate supervision they are able to continue practice. Reporting them to the NPDB is not a solution, at least not a defensible one in the “typical” borderline case. Sometimes you can counsel them or devise a practice plan that works to keep patients safe and the hospital harmonious. But the adversarial relationship makes this hard enough, and the need to carefully work around this death threat of the NPDB is a burden and an impediment to working collaboratively with the “challenged” physicians.
None of this is intended to be a defense for the truly impaired, incompetent, or sociopathic docs out there, or the medical staffs who have enabled them. I’m sure that the problem exists to some degree. But the idea that the NPDB is a valuable or even a positive tool in the vast majority of cases is itself laughable. It was a great idea but as implemented it has been an abject failure. The high-handed folks over at Public Citizen will never admit to it, will never modify it in ways that might make it more functional. They will, rather, rail against the scofflaw docs and hospitals who do not deign to use this blunt and ineffective instrument which has been thrust upon us. And we, working away on Medical Exec and Credentials Committees will be left with ad hoc and jury-rigged approaches to the borderline physicians who represent the more common and more challenging dilemmas in the industry.
*This blog post was originally published at Movin' Meat*
