Dear Doctor, Which one are you?- Patient, Physician, or Specialist?

We are all patients at some point.  Rich or poor, when sick we are worried and vulnerable. We’d all like a cure but at a minimum we want care, reassurance that all can be done, is being done.  Ideally we’d like to have confidence in the person watching over us. This can be a tall order.  As a senior physician, I remember the feeling of helplessness when my mother became a quadriplegic.  I became an increasingly passive participate as she went from hyper-acute ICU care, to inpatient care, to chronic care in a nursing home to home (http://alanpittmd.blogspot.com/2012/08/the-apex-of-care-i-am-successful.html).  Each step “forward” felt like a step back as her care became increasingly fragmented.

For some, healthcare experiences become a calling to serve.  They elect to become a physician, nurse or other healthcare professional.  Having interviewed many potential medical students, many have a naive, idealized view of the profession.  Now in mid life, with longer hours and a much less certain financial future than when I started, I had a somewhat jaded view until recently when my daughter Taylor elected to go into medicine. We had many discussions about a her choice.  Finally, she turned to me and asked what I recommended she pursue in these chaotic times- business, law, research? As a physician she was pursuing a worthy profession.  I couldn’t disagree.

After medical school most physicians specialize. In part, this is financial.  American specialists tend to make more than generalists.  However, this is also a result of the Darwinian selection process. Successful medical school candidates tend to be type “A.”  They want to be right.  Specialists train to know more about less (occasionally to the obscured) than their generalists counterparts.  However, over time, specialists are socialized to think of themselves as specialist first, then physician and then as a patient.  Some forget they were ever young doctors with calling.

The Accountable Care Act (aka..Obamacare) has come as a surprised.   Several provisions ask for coordinated care and a team approach, in essence asking for a cultural change for healthcare providers.  With a loss of income and control, many specialists are understandably frustrated, anxious and angry.   Although I don’t expected sympathy from many American’s for the plight of the specialist, earning less every year for the same (or more) work is never easy.  Although most in healthcare recognize the need for change, each group hoped the change would come from someone else’s piece of the pie. 

For many in my profession, Obamacare has become a rallying cry, representing of all that is bad with big government.   However, if you were President, what would you do?  The bills for decades of over utilization are coming due.  Although it remains to be seen whether care will improve for the average American, the current system is simply not sustainable.  Decisions have to be made in the best interest of the patient and the population, not the profession.   My daughter's choice has been a bit of a pause for me.  It has helped remind me healthcare is a noble pursuit, and that specialty care is a by-product of the business but not the purpose of the medicine.  Ultimately, we are all patients first. 

Just Do It! ...Works for Shoes, But for Healthcare, Not So Much… Have a Plan & Look Before You Leap

I am fortunate to not only practice medicine and train physicians for the future.  However, jobs in my field (radiology) have become scare.  One of my residents return from a trip after meeting with a group in his home state.  He mentioned to me the secret to the group’s success- Just Do It. Like billions of others, I’ve heard with Nike’s slogan. In the context of shoes, it’s a motivator to do the right thing, to get off the couch and get active.  However, for doctor’s, just do it may not be such a good mantra.  It is often the easy way out, better for the them, but potentially not for the patient.  

As radiologist. other physicians ask for things while caring for patients.  They might need anything from a chest X-ray up through a biopsy.  When another doctor asks for something, most radiologists learn to just do it.  They have learned that their customer, in this case the referring doctor, is always right.  

From personal experience I can tell you that to not just do it, but rather to engage in a conversation about the exam’s value may be …less than pleasant.  Often the patient sent for the exam is in front of me.  I can’t reach their doctor.  I have to explain why we might delay the test and go another way.  This discussion may take twice as long as the actually completing the exam, the patient’s confidence may be shaken and at times they’re upset.  However, I try to think what would I want for my family.   As a specialist, I may know more imaging options, the risks and benefits  and other options of the “ordered” procedure than the referring provider.  

This scenario is not limited to radiology.  The medical merry go round of pain has similarities.  The patient comes in to see the doctor expecting something to be done.  The simplest thing for the doctor is …just do it, write a prescription for narcotics, and get on to the next patient.   This starts a sad cascade of care often ending in addiction.

There are personal & financial incentives driving the just do it healthcare cultural.  Physicians would tell you they’ve never heard of someone getting sued for getting an imaging study or a biopsy- why should they take the personal risk of not just doing it?  And the reimbursement for just “not” doing- isn’t very good.  As eloquently illustrated in the Healing of America by TR Reid, healthcare around the world often reflects the countries cultural.  We see ourselves as doers.  Our incentives via reimbursement, are reflected in our care bias.

Can anything be done to combat the pressure to just do it?  I have a simple suggestion- have a plan. Every decision, every test in medicine, should have a next step.  Before anything is ordered, there should be a question..what next?  As a patient, ask what we (patient and provider as a team) will do next based on the result?  If the answer is nothing different, perhaps the first step should be skipped?  If you’re not going to have back surgery, regardless of the imaging, perhaps you shouldn’t be image.  If you start on narcotics for pain, when are you stopping? What else are is being done to diagnosis and treat the pain.  Even when the result is negative, this should be part of a plan. A negative test (eg…there is no evidence of cancer on your CT) can be the most liberating of all- what next?  Whenever possible, patients should ask for a plan- tell me the steps we are going to take.  Providers should have a plan- how does step 1 influence step 2?  And payers should require a plan before reimbursing.

For selling shoes, Just Do It offers encouragement.  For care, just do it seems more a cope out than good practice.

Death by Data- How Healthcare Providers Went from Historians to Librarians

Thirty years ago, in what might be referred to as BPC (before the personal computer), I took a class asking whether technology made our lives better or worse.  The topic seemed absurd, but it fulfilled a graduation requirement.  The professor from Bell Labs was part techie, part philosopher.  By the end of the semester I didn’t throw away my Walkman, but I also thought the question had merit.  Then I went off to med school and, for the most part, was able to forget about technology- everything was on paper. 

In medical school I learned to review the medical records (huge binders often marked by roman numerals designating volumes related to a patient) and to take a history.  Listen and the patient will tell you the answer was the mantra.  The patient’s problem was a narrative, a story of what happened to them in the past, and how it might have contributed to the present.  The treatment plan was the hoped for future.  Ideally, this all fit into a story that made sense.

Towards the end of my residency, electronic medical records(EMRs) began to appear.  This made sense.  Huge paper binders were difficult to review for a patient and essentially impossible for clinical studies.  However, EMRs were not built to tell a story but rather enter data.  The earliest EMRs were more for collections (revenue cycle) rather than care.  The narrative, the patient’s story was almost an afterthought.

Most of us are familiar with the clinical result.  Providers often has their eyes on the screen rather than on the patient.  Even if the right questions are asked, the information gathered fills tiny boxes, more like books in a library, rather than constructing a story.

Recently Melissa McCormack, a medical researcher at Software Advice, blogged (http://thehealthcareblog.com/blog/2014/01/06/actually-wed-all-be-better-off-with-our-health-records-on-facebook/) asking why medical records couldn’t be more like Facebook, an information timeline (note, she was not suggesting FB become a medical record, but rather EMRs borrow from the structure of FB).  I agree.  Current tools gather data with no real consideration of purpose, of constructing the patient’s narrative.  Stories can be told.  FB has shown it’s possible.  The medical community just needs to think different.

In Greek Mythology curiosity gets the better of Pandora. She opens a box she’s warned not to.  In doing so, bad things fly out- war, disease, envy, etc…She quickly closes it, but it’s too late.  When she opens it again, only thing left in the box is hope.  The question raised by my professor decades ago is truly academic. There is no going back.   We can’t live with technology.  However, technology needs a governor, a brake that ties it back to the problems it is designed to solve.  Data for data’s sake may not make our lives better.  Without constantly considering people and process, we run the risk of making things worse rather than better.  Nothing against librarians, but I would prefer to go back to being a historian.

Healthcare Technology Should Be about Enabling, Not Replacing, People- why it's less about the app and more about the process.

My friend Lisa Suennen recently wrote a thoughtful review of the Computer Electronic Show (#CES) http://www.venturevalkyrie.com/2014/01/11/people-who-need-people-a-ces-follow-up-report/5961.  For those of you unfamiliar with the event, there were more than 2 million square feet of exhibits and roughly 150,000 people last week in Las Vegas.  Digital Health is part of a broader offering covering all things tech.  Amongst all these glittering objects, the of envy for any true geek, Lisa had several interesting observations.  First, that many health entrepreneurs are (as she notes, wrongly) looking for ways technology can replace people, rather than enable people.  There is a general sense that scale (a magic word for the investment community) requires fewer bodies.  Second in her opinion, the ultimate goal should be a mash up, a convergence of IT, devices and services for true value.  I couldn’t agree more.

My efforts focus on collaboration.  Within health IT is what seems obsession with data, EMR’s and dashboards, but for me the future is about teams- getting the right people at the right time to come together.  Without this opportunity for timely expertise and collaboration, the value of data decays.  Information has trouble converting to knowledge.  However, collaboration is messy.  It requires thoughtful consider of how people and process interact with technology.

Replacing the Pager with a PDA.

For decades the pager has been the official form for medical communication.  It is safe and secure.  It is also limited, inflexible and a poor choice for collaboration.  In response, many physicians have adopted texting as an alternative method of communication.  However, as of September 2013, new federal mandates limit texting.  There is a potential 50,000 penalty for texting a single instance of patient information being exposed in an standard text.  The response by many vendors has been ….I have an app for that, to wrap messages in a secure technology.  However, an effective solution needs to be far more nuanced.

In the consumer space, apps can go viral.  However, the social fabric and supporting infrastructure for healthcare presents a number of obstacles.  There is an assumption that all providers will have a PDA.  However, PDAs at work are expressly forbidden by many nursing regulations.  This means messaging must be cross platform.  What if an individual doesn’t want their PDA to be leverage for work responsibilities; is the hospital required to provide a device?  Many hospitals do not have have the necessary wireless/cellular infrastructure to support PDAs.  Most hospitals do not have accurate information on their providers beyond pager numbers and an office address; snail mail remains the de facto form of communication.  

For their part, physicians often do not want to be reach directly.  In part this is a workflow issue.  Imagine a physician is in surgery and receives a call telling a patient needs their attention immediately.  Do they leave the surgery, or stop the surgery and call someone to cover?  There are reasons for call centers.  Practically, there needs to be permissions set by time of day, availability and role for the collaborative communication to be appropriately routed.  This requires high level enrollment into a “service” identifying roles and managing preferences.

The result has been islands of communication.  Groups have adopted apps for internal communication but no real holistic community of providers for collaboration. With the help of a vendor (disclosure- I have invested in the company, #Emerge.MD), St. Joseph’s has deployed a technology enabled service helping people to collaborate.  This service enables provider collaboration by name (eg...Dr. Jones) or by role (neurosurgeon on call).  It incorporates nursing requirements (for desktop messaging) as well as physician preferences.  Via this service teams of people can be brought together text, voice or video.  Importantly, there is sponsorship from a business owner, the hospital and more broadly the Accountable Care Organization.  The executives have something to gain- more cost effective care (throughput issues, access to specialists, etc…). This solution is now spreading through Dignity Healthcare. However, this was not plug and play.  It required extensive knowledge about the people and process rather than strictly technology.   

Even replacing an archaic device, the pager, with a PDA is not about technology but rather about understanding and management of a constellation of social processes. At the end of the day, health and healthcare are personal.  There are many processes that can be automated and improved upon via technology.  But for my money, I am with Lisa.  Transformation will be more about enabling rather than replacing people.   And people require services, not technology.

The Doctor is Always Right- Except When They're Not- Bias, Myth and Paternalism in Medical Decisions

A friend of mine was kind enough to drive his 85 yo mother to get a colonoscopy.  She had a normal study 18 months before.  There was some evidence of minor bleeding & her doctor just wanted to be sure.  This meant the "prep," with instructions to drink the last bit at 3 am, followed by a trip to the doctor's office at 530 am.  Another friend was told they had melanoma.  As you might imagine, this caused concern.  The doctor recommended a biopsy followed by 2 additional surgeries.  When I asked what stage melanoma, I was told it was stage zero; in terms of danger, this is just above freckle, the lowest potential for growth.

Both examples represent common medical experiences. In each case, there was an alternative- do nothing. For the older woman, it was reasonable to ask what the doctor expected to find and, if bad, what would be done about it.  I personally want to die with an undiagnosed cancer.  In the second example, surgery for the “near benign” required pain, risk and expense.  If removing the lesion via biopsy gave a 98.5% chance of not getting the disease, were the 2 surgeries worth the incremental improvements?

Each situation gets to the heart of "consent."  Ideally every procedure offers the patient a real choice.  After explaining the risks, benefits and alternatives, the patient chooses to proceed.  However this is rarely done.   Bias, myth and, on some level, well meaning paternalism all play a role.  

Bias- Mental tendency or inclination, especially an irrational preference or prejudice

Imagine spending 20 years learning a trade.  It is natural to believe you are helping, not hurting.  Physician's believe in their art. To expect all options are equally considered, goes against human nature.

Myth- a widely held but false belief or idea.

Although medicine is shrouded in science, we often do what we do because we do them. Practice is passed on from generation to generation. Many things are taken as "truths," without any real justification.  A recent Mayo Clinic Proceedings reviewed reversal of a 146 contradicted medical practice (MCP, August 2013). Medical knowledge is purported to be based in science but in actuality, this often not the case.

Paternalism- Though I walk through the shadow of death, ...thou art with me, thy rod and staff to comfort me. Psalm 23:4

Rod of a healer

It is difficult for both providers and patients to have a conversations as equals.  For the patient fear and anxiety go hand and hand with illness.   This is overlooked by those thinking computers will replace providers in the near future.  Most patients do not want to make life threatening decisions alone.

Providers may feel pressed for time and a responsibility to act as a filter for their patients, leading them to the right choice.  Unfortunately, well meaning desire can often result in an unbalanced discussion.  

In Seinfeld, Elaine was blacklisted as a bad patient.

I should note that most providers are not consciously motivated by financial gain.  Yes, treatment results in payment, but the vast majority of people believe that they are offering the best option.

What to do…Ask- what are you getting for the risk, what is the downside to waiting?

With all these well meaning forces, I would suggest a relatively simple approach of asking and when possible, consider watchful waiting.  For many patients, asking is intimidating.  There is a fear asking will degrade the relationship.  Most physicians are willing to explain there reasoning; and if they won’t, get a second opinion. Definitive answers are not always the best answers.  Finally, ask the harm in waiting.   Avoiding risk today may be better than possible risk tomorrow.

Congrats, You've won a shopping spree. Unfortunately, the stores are closing. Why you should worry about Medicare instead of Obamacare

After 30 years in healthcare, a someone finally explained Medicare to me.  Here is the short version. There are 4 parts (A,B,C, & D).  At 65 most Americans get parts A and B.  Part D is for drugs; the senior can be responsible for several thousand dollars/year.  Part C is the interesting one.  

"C" coverages lab, X-ray, hospitalizations, doctor visits, emergency transport- most things commonly thought of as healthcare.  You can choose to keep Part C which is free in most geographies or add a supplement reducing or eliminating co-pays.  Most seniors choose supplement plan "F."  For another $130/month (with the required $104 for Part B this brings the total to $235/month), the senior has access to any primary doctor or specialist, any hospital network accepting Medicare with no additional charges.  This is fantastic coverage.  I pay almost 10 times this amount and still have a deductible.  This is like a an unlimited shopping spree for a buck.  But unfortunately, many of the "healthcare" stores may be closing.

Here is the problem.  The healthcare costs a of money a lot more than $235/month.  The government has 2 choices.  Additional revenue could be raised, effectively charging seniors more for similar coverage.  This is DOA. Politicians like being politicians.  They, like most of us, think of themselves first.  Reducing entitlements, particularly Medicare, is suicide.  Alternatively, expenditures could be reduced.  This is what has been happening.  Hospitals, doctors, device manufacturers, labs, etc... are all being paid less.  

Although a popular public option, this may not be a good long term strategy.  Yes, the healthcare industry is bloated and mismanaged, but inefficiencies are not going to disappear easily.  As prices fall, businesses are going to fold- fewer hospitals, fewer doctors, less innovation.  I am not suggesting healthcare will disappear, but rather access will decline.  Like in any business without profit, store shelves become bare.  Politicians will keep their jobs.  Entitlements will be left untouched, but simply worth less. 

This has a ripple effect.  With all the dialogue around Obamacare (ACA as it is now again being called), it is easy forget the vast majority of expenditures are for the elderly.  Medicare is untouched.  If reimbursement for Medicare results in fewer choices and less access for the elderly, this will directly affect those participating in Obamacare; it's the same delivery system.

The ACA presumes all Americans need to pay for healthcare.  Although there is (bizarrely) not general agreement on this point, most believe a civilized society requires roads, schools and police, & care for the sick.  However, by segmenting the population into 2 groups (pay as you go for <65, and pay once for all you can eat for >65) seems destine to fail.  Ultimately every group must have some skin in the game when making medical decisions.  I am not suggesting the elderly should bear the full cost of their care but rather that price for care should be part of the decision.  When the doctor suggests a course of action, price should be at least part of the conversation.

Forget Obamacare.  It's a fly on the elephant's back.  American's have much bigger problems.  We need leaders who argue for what's right for the country, not for their careers.  We need lobbyists (yes, you AARP) who recognize that saving money for their members today may mean fewer services tomorrow.  People of all ages should pay something for more care.  This is the only way to actively engage the consumer in the decision process.

Do Patients Want To Be Customers?

A close friend of mine is unfortunately no stranger to healthcare.  A missed diagnosis was followed by a botched surgery leaving him with chronic pain.  He has sought help and largely been offered pills and more surgery.  Most recently, he had a cough and fever.  Going to his doctor he apologized, noting he did not have an appointment, but was worried. His doctors response- no problem, you’re a good “customer”, I’ll get you a script for some antibiotics.

For many of us in healthcare, this might have seemed a benign exchange.  After all, we are being asked to think about patients more as customers, to offer a higher level of service and follow up, and ultimately provide value around the the services we provide.  However, patients may view this differently.  In my friend’s case, this was an epiphany.  At that moment, he lost all faith in his physician and in fact began to generalize about providers generally.  If his doctor saw him as a source of revenue, someone who would be back for repeat business, what did that mean about all those appointments to follow?  Up till that point, my friend thought their relationship was based on mutual goals, working together to solve my his healthcare problem.  Disappointed and angered, he fired his doctor on the spot.

There seems to be a disconnect.  As providers, we'd like to think we are at Maslow's level 4 (self-actualization), or at least level 3 (psychological needs), but we are at level 1 (basic needs, survival mode). 21st century healthcare offers more than ever before, but in exchange for treatment options, the business of healthcare has now replaced what most of patients want- a partner to help them through some of life's greatest challenges.

I don't believe most providers consciously think of patients as opportunities for revenue.  However, I would be disingenuous to suggest that at time providers become overwhelmed and forget their work is their patients. Further, growth decisions, which lines of business to support and grow at a hospital system level, are in financial justifications.  And for their part, today’s healthcare environment requires patients must take a more active role in their health rather than expecting things to be done to them, magically making them well.  

Today we seem stuck at the lowest level of the hierarchy, what I'll call the impersonal "other" for lack of a better word.  The next level up would be customer, someone valued as an opportunity for a long term relationship rather than a one time transaction.  At this level, we would treat as if we want people to come back.  Currently, unlike most businesses, there is no follow up in healthcare.  We may not be able to get to the third level, where the goals of the doctor and patient align.  Perhaps someone can create a business model successfully executing on this vision.  If they do, they'll be very successful.