Sunday, July 29, 2012

Better Bedside Manners Heal Doctor-Patient Relationships

Would you rather your physician be an astute diagnostician or a compassionate and empathic practitioner? Of course, we want our physicians to be blends of these qualities. We want it all.  We want them to be chimeras of Drs. House and Welby. But, is this possible?

I can't say. I suspect that it is easier to cultivate soft bedside manners than it is to teach medical acumen, although the latter was the overriding priority when I was in medical training. No points were awarded in our morning reports with the chief of medicine for holding a patient's hand during the night. Big win, however, if the intern could recite 14 causes of hypercalcemia.  The message was that 'hard medicine' is what really matters.

Where's the bedside manners site?

The importance of bedside manners depends upon the specific medical circumstance at hand.  Good bedside manners may mean less if you are going to see a physician once for a procedure than it would if the doctor-patient relationship were to be ongoing.

There has been more emphasis on medical humanity in medical training in recent years, although the trajectory has not been a straight and steady incline. Resistance to reducing excessive and oppressive work schedules of interns and residents is still viable, but progress has been made. I'm not suggesting that medical interns work a 40 hour work week, but I do reject that exhausted and somnambulating house staff are a necessary feature of medical training and education. And, if medical 'reform' keeps progressing, how much dedication can we expect from house staff who will later join the ranks of employed physicians who are on a time clock?

Perhaps, shift work doctors will have meaningful doctor-patient relationships. Since these physicians will have more of a life, perhaps they will relate better to their patients as human beings. I'm not certain of this, but I offer it as a possibility.

Bedside Manners vs Brainpower

I have come to appreciate how important are the soft sides of medical practice. Of course, medical knowledge is critical, but medical judgment is paramount. We've all seen medical geniuses who wielded a clumsy clinical axe. Conversely, we've admired great healers who were not scholars. If I'm sick, I'll pass on the medical prodigy in favor of an excellent listener and judicious practitioner. Remember patients, no doctor has it all.

Here are a few clinical scenarios I've encountered recently that require a non-scholarly remedy.

  • A physician is interviewing a man with hepatitis C. His wife is at the bedside. Do you ask then about a history of intravenous drug use, which is an essential question in this circumstance?
  • A nurse gives a patient more sedation than the physician ordered. Should this be reported to her supervisor if no adverse consequence occurred?
  • A colleague requests that you do a procedure on an elderly patient that can be medically justified, but isn't truly necessary. What should the procedurist's next move be?
  • A patient is convinced that his complaints have a medical explanation, although the physician strongly suspects they are psychologically based. What's the doctor's game plan here? One false step and the doctor-patient relationship may be ruptured.
Physicians wrestle with these kinds of issues every day. Sometimes, we get them right and sometimes we misfire. We're not perfect, even though we often feel that this is the expectation. Not surprisingly, different physicians have their own individual approaches to medical and ethical issues.  Every physician is unique by virtue of different training, personality style and experience.  I wonder how the pay-for-performance panacea will measure all of this.
Doctoring is tricky business, and we don't know the specific ingredients and proportions that constitute a great physician. There is no recipe. It's an amorphous mixture of humanity, humility, medical knowledge, clinical experience, excellent communication skills, compassion and personal warmth.  And, of course, we're supposed to run on time.

As patients, which qualities in your physicians do you value most?

Sunday, July 22, 2012

Accountable Care Organizations (ACOs) and Physicians: Are We Partners or Prey?

During my college years, we loved the album Bat Out of Hell by Meat Loaf. We would wail along with Meat Loaf as he screamed out his passionate interpretation of Paradise by the Dashboard Lights. Another memorable song on that album was Two out of Three Ain’t Bad, which offers an important lesson to those of us interested in health care reform.

No, Meat Loaf was not a medical policy wonk who offered health care solutions via allegory in his ballads. It’s the song title that caught me as I read yet another article on accountable care organizations (ACOs). Take a look at this banal 3 word description.

Accountable Care Organization

These new organizations have much more to do with accountability and organization than they do with care. In other words, Two Out of Three Ain’t Bad.
ACOs are another coercive mechanism to track and compare physicians using quality metrics that are far removed from true medical quality measurements. As practicing physicians understand, and government reformers don’t, defining and measuring medical quality isn’t counting beans in a bottle. They claim they can count what can’t be easily counted. Conversely, just because something can be easily counted, doesn’t mean it really counts.

Of course, the ACO concept is attractive - more accountability, lower costs and higher medical quality. This 3-legged stool can stand only if all 3 of these legs are sturdy. I’m skeptical.

These ‘partnerships’ between hospitals/insurers and physician groups provide lump sum payments to doctors to care for a population of patients. If physicians spend less money on care than this sum, then they can retain the savings. This sounds quite reminiscent of the Health Maintenance Organization (HMO) era, where there was a conflict of interest that restricted patients’ medical care in order to save money. We recall how popular this model was for physicians and for our patients.

HMOs were soundly rejected. Are ACOs merely repackaged HMOs in new bottles?

Beware of any ACO that contains the word partnership, unless you consider a 95-5 split to be a partnership. A mouse captured in the talons of a raptor doesn’t feel that he and the bald eagle are partners.

For those who simply must know ACO details, I encourage you to peruse the 429 page proposal issued by the Center for Medicare & Medicaid Services (CMS) in March 2011. If any reader does so, kindly leave a comment below so we can arrange for an expeditious psychiatric referral for you.
Of course, ACOs are not really about quality, any more than pay-for-performance initiatives are. They are about cost control and reimbursement redistribution. Physicians sign up, not because we are smitten by ACOs promises, but because we don’t want to be excluded from the panels.

Will ACOs, in their ultimate form, be good for patients? This is unknown and unknowable at present. ACOs are swirling in the wind, and various constituencies are swatting at it. We don’t know what its final form will be or where it will land.

So, what’s the ACO score so far? 

  1. ACOs will employ thousands of bean-counting bureaucrats, which will reduce unemployment.
  2. ACOs will help to control medical costs.
  3. ACOs will be championed by physicians throughout the country.
Which of the above statements are true?  Meditate on the words of Meat Loaf, a prophet in his generation. Two Out of Three Ain’t Bad.

Sunday, July 15, 2012

Secret Shoppers in the Doctor's Waiting Room- A Twist on Pay for Perfomance

Image Depicts Doctor'sWaiting Room Flow Plan

On a prior posting, I opposed using secret shoppers to evaluation medical offices. I admit, however, that physicians’ office practices do need some healing. Patients who phone their doctor pray they will reach living breathing human beings, but often find themselves trapped in the expanding phone menu universe. Waiting room patient ‘flow’ can be stagnant. Getting medical records transferred, a reasonable and routine request, can test the mettle of even the most steeled and seasoned patients. Office staff, who are often multitasking machines, may be impatient with patients.

I don’t need a secret shopper to make these diagnoses in my practice. We already know them and struggle to improve them. We have made progress where we could and tried to mitigate the damage when we couldn’t remedy a particular situation.

Our most important resource of identifying our flaws is our patients. When they point out when we have missed the mark, they give us valuable quality improvement advice. They are exposed to aspects of our practice that we physicians, who are busy in our exam rooms, may not be aware of. Their suggestions improve our practices, and I am grateful when we receive them. I hope that they will continue to speak out.

Sometimes, these ‘recommendations’ are simply the gripings of a disgruntled patient. Often, however, they are constructive comments from patients who truly want to help us. We may know these patients for years and trust them. They are not hired hands on someone’s payroll who will never see us again. In general, our patients speak up because they care.

They don’t just address our waiting room and secretaries; sometimes they point the finger at me. When I fall short, and a patient calls me on it, I take it to heart and try to get back in gear. For me, these lessons from patients are my most potent and effective quality improvement program. For me, this is the right prescription for effective and honest quality review, not paid reports from sneaky and anonymous thespians.

This secret shopper strategy is a variant of the absurd pay for performance 'quality' scheme.  The impostors are paid to perform.  Let's bring the curtain down on this performance.

Sunday, July 8, 2012

Pay for Performance Attacks Medical Quality: Lincoln Lucks Out

Why does Pay for Performance (P4P) make most physicians reach for Maalox? I have devoted a good portion of this blog’s real estate to dismantling the fallacy that pay for performance improves medical quality. It’s easier to argue that this clumsy and robotic approach diminishes medical quality by incentivizing physicians and hospitals to game the system to maximize their quality scores.

When an irritating high school student raises his hand and annoys the teacher with the inquiry, ‘is this gonna be on the test?, it is a forerunner of the concept of pay for performance. The Ivy League seeking student won’t study material that he knows won’t appear on the exam. Similarly, physicians and medical institutions will focus their attentions on achieving those outcomes that will be measured and graded, which might be at the expense of patients who ‘are not on the exam’. For example, if irritable bowel syndrome isn’t being measured, but GERD is, then will these patients be treated the same? Beyond this, I reject the concept that medical quality can be reliably measured and quantified.

There’s a Renaissance painting hanging on a museum wall. Is it a masterpiece? Since it’s tough to measure and judge art, should we use a ruler to measure the perimeter of the frame and consider this to be a quality surrogate? Absurd, yes. But, if you buy into this fantasy, it makes it a lot easier to measure quality.

Why shouldn't we apply the P4P concept into other professions.  Not surprisingly, folks won't speak out against pay for performance until they are sagging under its yolk. Consider the following P4P extensions.

  • Teachers' quality is judged by students' attendence
  • Musicians' quality is graded by ticket sales
  • Congressmen's quality depends upon approval ratings
  • Meal quality depends upon weight
  • Book quality depends upon # pages
This is the same silliness that is being imposed on the medical profession. Sure, they can present P4P to the public as rational policy, but no slogan can sanitize the scheme. Of course, serious reforms in the health care system are needed, including a hard look at how physicians and hospitals are reimbursed. Too often, the interests of the medical community and those we serve are misaligned. However, to force P4P on us and then use the results to reward or punish us financially is capricious, unreasonable and fallacious.  Perhaps, even the goverment knows this is not a true quality initiative, but a poorly disguised cost control cudgel.

Is this blog post any good? How can we grade it? By the number of comments? Number of retweets? Why agonize. Let’s all agree that a blog post’s quality can be measured by the word count. Here’s my suggested metric.

          # Words               Quality

               1 - 100                                    Poor

               101- 199                               Mediocre

               200 – 300                            Lousy

               301-400                                Below average

               >400                                      Superb

If the Gettysburg Address is graded using the above schema, we would see how overrated this speech is. The reason we have elevated this speech into the pantheon of American rhetoric is because we didn't have an available grading tool that would have shown us that Lincoln's remarks were ordinary political drivel.  Some presidents have all the luck. 

Let us hope that Pay for Performance shall perish from the earth. It is altogether fitting and proper that we do this.

Sunday, July 1, 2012

Supreme Court Upholds Obamacare: There's Order in the Court

President Obama enjoyed a towering victory days ago that I feel leaves the GOP reeling, although they are spinning the Supreme Court’s validation of Obamacare as a great gust of wind at their backs. While I would not have expected a different response from them, I fear that there is a developing wind that may blow them away in November. I offer this analysis as a tepid Romney supporter who will be voting more against Obama than I will be voting to support Romney.

The phrase Obamacare is peppered throughout this blog. I was recently chastised by an unabashed whale-saving tree hugger that I should abandon this derisive term which detracts from my otherwise unvarnished objectivity. On the evening that the Supreme Court's decision was announced, I was watching CNN and its pontificating pundits. Various panelists were spewing forth verbal pabulum telling us benighted listeners what we were supposed to think. John King, the moderator, and many members of the spin squad all used the term Obamacare freely and repeatedly. If CNN, the apotheosis of journalistic excellence, permits this term to be aired, then surely the Whistleblower is entitled to a free pass on this. For those who seek validation of why CNN is the ‘most trusted name in news’, simply zap this link for amusement. Because I am unfailingly fair and balanced, I disclose that Fox News was also eating crow.

We now know that Obamacare is constitutional which offers no support for the merits of the Affordable Care Act. While there are elements of the plan that I do support, I am deeply skeptical that the plan will control costs and increase medical quality. My fear is that medical costs will continue to escalate and that medical quality will suffer as physicians and hospitals compete in the Pay for Performance Follies where medical documentation and check mark medicine, not medical quality, is rewarded. Is the price for increased access to medical care for the uninsured medical mediocrity for all?

Here are just a few aspects of medical practice that won’t be counted but really counts.

  • Can the physician take an accurate medical history?
  • Can the physician skillfully examine patients? I’m a gastroenterologist. I’m supposed to know how to palpate the liver and perform other diagnostic tasks with my hands, eyes and ears. These skills will never be assessed by the government or insurance companies. Does that  that they don’t matter?
  • Does the physician know when a diagnostic test is not needed? (Tell me how you would test for this?)
  • Does a physician know when an incidental ‘abnormality’ on a CAT scan can be ignored?
  • Does a physician know how to deliver bad news to patients?
  • Does a physician know when watchful waiting is the right prescription?
  • Does the physician know how to manage medical issues on the phone at night when he does not know the patient? Which of them should be sent to the emergency room?  Why not send them all just to be safe? 
  • Does the physician know when to consult a specialist? Is sending every patient with chest pain to a cardiologist good medicine even if patients and specialists encourage this practice.
  • Is this physician compassionate?
A majority of Americans oppose Obamacare in whole or in part. This opposition has developed even before the plan’s bitter medicine has been swallowed. Can the administration continue to spin this by suggesting that the public doesn't yet grasp the plan?  Are we really that dumb?
Chief Justice John Roberts has pulverized the liberal argument that the Court is an arm of the Republican Party, as was bitterly alleged in Bush v Gore in 2000. While public support of the Court has been gradually ebbing, I have not personally believed that the justices pass their decisions through a political prism. Of course, they have different judicial philosophies, which is quite different from acting as a political partisan. Not only did the Chief Justice validate Obamacare, but he did so by joining the Court’s 4 liberal members to do so. I would have never predicted this and I doubt that many readers what have either. Chief Justice Roberts has the long view, and sees the Affordable Care Act as a speed bump. His overriding priority is to protect and defend the integrity of his institution. I feel that he deserves praise and respect for his decision, even though I was hoping for a different outcome. Had he joined with the Court’s conservative members and overturned Obamacare, he would have been lambasted by the political left. Why aren’t they praising him now? Wouldn’t such a response from them be' fair and balanced'?

Fairness means applying the same standard in all circumstances.  Reminds me of the the iconic four word phrase carved into the facade of the Supreme Court.  Equal Justice Under Law.