June 2015

June 25th, 2015

Let’s talk about patient satisfaction.

It matters from a reputation angle; Yelp reviews are endemic. It matters from a professional satisfaction angle; nobody likes to be disliked. And it matters from a systemic angle; patient satisfaction surveys are now tied to Medicare reimbursements. Moreover, we’ve seen employee-physicians with 20% of their compensation tied to the results of these surveys.

That can be problematic. Because medicine is not, nor should it be, a purely commercial affair driven by “customer,” ahem, “patient” satisfaction. As one wry physician noted: “Patient satisfaction, taken to the extreme, gives you Michael Jackson.”

Moreover, it doesn’t appear to make people healthier. To wit, the conclusion of a 2012 study in JAMA: The Journal of the American Medical Association:

Conclusion: In a nationally representative sample, higher patient satisfaction was associated with less emergency department use but with greater inpatient use, higher overall health care and prescription drug expenditures, and increased mortality. (emphasis added)

The mechanism seems to be straightforward, as captured in this study in the New England Journal of Medicine.

Many patients receiving chemotherapy for incurable cancers may not understand that chemotherapy is unlikely to be curative, which could compromise their ability to make informed treatment decisions that are consonant with their preferences. Physicians may be able to improve patients’ understanding, but this may come at the cost of patients’ satisfaction with them (emphasis added)

Maybe the New Yorker headline outlines the issue easily:

            When Doctors Tell Patients What They Don’t Want to Hear

You don’t have to be a rocket surgeon to know that it makes patients unhappy. We tend to, as people, shoot the messenger. And that’s a Catch-22. What’s a physician to do if the cost of creating informed patients is lower satisfaction? Conversely, what if the cost of creating satisfied patients (on surveys at least) is less informed decisions and higher morbidity?

And who’s at fault if all the higher morbidity folks team up and get nuclear-legalistic, anyway?

My guess, not Medicare.

Which brings us to a fundamental problem with patient satisfaction surveys. One patient = one vote. That means the patient who gives you one star, because he “liked the doctor who was here before, better” has the same impact as the patient who gives you five stars for saving her life.

xkcd picked up on this problem with consumer-driven democracy in a related comic on smartphone app ratings:


Of course, even the fact that we live in a world where there’s a meaningful parallel, in a satirical webcomic, between ratings of smartphone apps and ratings of physicians….

Well, maybe I should take a vacation…

I wonder what beaches are rated best...

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June 16th, 2015

Today I stumbled across this wonderful gallery of 45 medical paintings by Robert Thom.

The collection, entitled “Great Moments in Medicine,” was commissioned between 1948 and 1964 by the pharmaceutical firm Parke-Davis & Co. for its research headquarters in Ann Arbor. Parke-Davis was once the largest pharmaceutical company in America.

Now the collection lives at the University of Michigan, in their museum of art, a 2007 gift from Pfizer.

Even though many of the images are iconic—seen as posters in doctors’ offices around the country, and frequently used in medical texts—it’s rare to see them all in one place. (If you want posters, click here.) That’s because the work seldom tours, and Ann Arbor is less a tourist destination than a university town. (No slight to U-M, one of the top research universities in the world. Mostly it’s about geography. And weather.)

Of course, this is only one of Robert Thom’s series. He became well-known in his career as a prolific illustrator of professional arts, including the series “Great Moments in Pharmacy” housed with the American Pharmacists Association.

Before the internet, this particular collection was last anthologized in a 1961 art book, “Great Moments in Medicine.” Click here for the full gallery with descriptions and notes. It’s fascinating!

If you've read this far, don't miss Great Moments in Medicine, Part 2.

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June 11th, 2015

My last article led up to the question “How did physicians lose so much power in the medical economy?” So, it’s time for some speculation…they simply got outnumbered.

This per a recent review of Kenneth Ludmerer’s new book Let Me Heal: The Opportunity to Preserve Excellence in American Medicine, in The New York Review of Books. The whole review, by Lara Goitein, is worth a read—as I suspect is Ludmerer’s book, which discusses the history and future of the American residency system from its creation by William Osler in the 1890’s at Hopkins, through today.

Comparing teaching hospitals from the between-the-wars golden era, with modern institutions almost seems an exercise in nostalgia. To wit:

...Indeed, teaching hospitals deliberately limited their growth to maintain the ideal setting for teaching and research….With few exceptions, members of the faculty did not patent medical discoveries or accept gifts from industry…

So what changed after WWII? In a word: demographics. And with that, everything.

Here’s the U.S. birthrate for the last hundred years (courtesy Wikipedia):

The red parts are the baby boomers. With babies comes increased demand for medicine, or as Ludmerer calls it “throughput.” Or what has now been called the “medical-industrial complex.” After all, babies see a doctor nine times a year.

Of course, economic and technological changes accelerated the growth of medicine. There were more treatments available and new economic structures to pay for them. In this light, something had to give way—and it ended up being the personal relationships that physicians had both with themselves and between each other.

Of course, this systematization—while necessary to increase throughput, has not been without its costs. Per Goitein:

(Today)...many teaching hospitals provide their residents with “protocols” (often in the form of flow diagrams, or prewritten orders for tests and treatments) for common problems such as chest pain, pneumonia, heart failure, and stroke. While protocols may make residents more efficient and provide a basic safety check, they also devalue innovation and individual initiative, and discourage thoughtful consideration of unusual or unique features of individual patients. As Ludmerer points out, while standardization may impose a floor on performance, it may also impose a ceiling.

With so little time to think about patients, we would order batteries of tests roughly corresponding to whatever anatomic area was brought to our attention, sometimes before we’d even seen the patient. This was the only way to make sure (we hoped) that we wouldn’t “miss anything.” The tendency to overtest began as a survival technique, but by the end of residency it was ingrained as a style of practice—and this excessive use of tests is one driver of health costs.

As this style of practice has become ingrained, it has created a generational gulf between physicians. It’s one that we see every day.

…before World War II, house officers nearly universally described a “wonderful happiness at work”—despite their very long hours. Today, half of residents (and more in some specialties) experience “burnout,” a syndrome of emotional exhaustion with feelings of alienation from patients and low personal accomplishment. These young doctors look at older physicians—some of whom still carry the aura of a deep professional contentment—across a widening gulf.

Is it any wonder then that today’s physicians are increasingly opting for an entirely different economic model? The rise of the hospitalist, the decline of the private practice—perhaps all of these things can be traced to the one simple fact that physicians today are far less likely to develop deep, independent relationships with their their attendings than in generations past. Who can blame them for declining to take on the risk of setting up a practice when turnkey solutions and straightforward career paths are now on the table?

Okay. This one was long. Next time we’ll do something fun.

Question: As a new physician, would you consider setting up a private practice?

June 9th, 2015

I’ve been pondering two big-picture articles on the “cost curve” of medical delivery.

There’s a change in tone here that seems important, so we’ll tackle the first article today and the second one next time.

Let’s start with the New Yorker piece by surgeon and researcher Atul Gawande. It’s entitled Overkill, and follows-up on his influential 2009 article, The Cost Conundrum, in which Gawande studied Medicare delivery in McAllen, Texas. Long story short, high cost + low benefit. Twice as much as El Paso, yet similar populations and outcomes. The article was inflammatory enough to make Gawande an instant pariah in McAllen. Which is a shame because McAllen has excellent barbeque. (Uncle Roy’s and the Original Willie’s if you’re interested, right off I-2.)

Who can blame McAllen’s physicians? The leading tone in most recent articles on the topic matches Gawande’s original—blame the greedy physicians and crusade against “waste and abuse.” Many physicians we know interpret this as “you guys get paid too much,” to which many reply “Do you have any idea what medical school costs?” or “Not on an hourly basis!”

Or at least, they would reply, if they weren’t on call.

Changing the debate to lower medical costs

So it’s welcoming, to my cold economist’s heart, to see Gawande ask a new question. What’s the opportunity cost, within the medical system, of this “unnecessary care?” The money quote:

If an insurer had simply decreed Taylor’s back surgery to be unnecessary, and denied coverage, the Taylors would have been outraged. But the worst part is that he would not have got better. It isn’t enough to eliminate unnecessary care. It has to be replaced with necessary care. And that is the hidden harm: unnecessary care often crowds out necessary care...

In the article, Gawande discusses some of the new delivery systems that he thinks provide better incentives—notably packaged-price care and the centers-of-excellence approach. Yet, to me it’s the new framing of the cost debate that matters more.

What if we stop viewing the unnecessary care discussion as a proxy debate for medical vs. nonmedical economic resource allocation? Perhaps, instead, can we view the unnecessary care debate as fundamentally a misallocation within medical spending? In this light, the increase in spending is not just coincident with the decrease in physicians’ influence but perhaps caused by it. Which points to a way out that doesn’t necessarily come on the backs of physicians.

To wit, in McAllen since 2009:

The law allows any group of physicians with five thousand or more Medicare patients to contract directly with the government as an “accountable-care organization,” and to receive up to sixty per cent of any savings they produce. In McAllen, two primary-care groups, with a total of nearly thirteen thousand patients, formed to take advantage of the deal…

...the two McAllen accountable-care organizations together managed to save Medicare a total of twenty-six million dollars. About sixty per cent of that went back to the groups. It wasn’t all profit—achieving the results had meant installing expensive data-tracking systems and hiring extra staff. But even after overhead doctors in one group took home almost eight hundred thousand dollars each (some of which they shared with their mid-level staff). It was proving to be a very attractive way to practice.

Which starts to lead to the question “How did physicians lose so much control over the process in the first place?” And that’s a question we’ll turn to next time.

June 4th, 2015

TL:DR: Rote memorization has its downsides, and it’s hard. Yet, it does work, dependably, for making crucial knowledge a reflex and not a recall.

Recently, I visited an MD/PhD friend in Baltimore. She was busy Leaning-In before there was a book. Two kids, a husband on his own PhD journey, and (last I heard) a long-term goal of specialty research in pediatric oncology. We tend to meet up for coffee, instead of drinks.

So when I read articles like the one entitled Would Doctors Be Better If They Didn’t Have to Memorize?,” I think of the conversations with my friend. She knows all about workload and being tired.

Nor is this is a new debate. Rote memorization, almost by definition, is tedious and time-consuming. Even in my decidedly non-medical education, I’d go berserk in the face of mandatory memorization. There were key years of historic events (Battle of Hastings, 1066); arbitrary mathematical calculations (the eighth decimal of pi is 5); and esoteric grammar (an en dash is used to connect ranges, either factual or conceptual). None of that is fun.

Yet, despite my berserker rage, I remain more convinced by opinions like this one, (Thoughts on Residency--One Month After Graduation) posted recently on Mayo’s EmBlog. Key line:

You need to have enough medical knowledge so you can stay composed in the setting of multiple sick (and well patients) because people start looking at you now for answers.

There isn’t always time to look things up. Nor is there necessarily coordinated energy. Even Googling, while easy, isn’t effortless. One extra task in a busy system, just like one extra car at rush hour, can easily create gridlock. Sometimes “effortless” is exactly what’s required.

Those three memorized facts I mentioned came easily to mind. No need to double-check—even after fifteen years without touching a history, math, or grammar text. Is memorization crucial? I vote yes. It may, in fact, be so important a skill that it’s worth memorizing “useless facts” to keep the skill itself well-honed.

Sure, there’s a line somewhere. Force-feeding over-worked med students into fact-gluttony hardly serves any one. But let’s not be eager to discard memorization as a whole, even if you haven’t used the Krebs cycle since the biochem exam.