Sunday, August 26, 2012

Improving Patient Satisfaction: Lessons from 18,000 Feet

First Customer Service Representative?

Your call is important to us.  Please listen carefully because our options have changed.

Reader query: During your current or any prior lifetime, has any phone menu option ever changed?

I have more than once experienced an option not offered on the robotic phone menu option choices - a dead phone line after a 30 minute wait.

Have you tried this customer plea as I have?  Could you pretty-please jot down my cell phone number in the event that we are disconnected?  Here are some of the responses one might expect from such in insolent request.

• Are you joking?
• I would but I think it's illegal.
• Sorry, our phone bank only receives incoming calls.
• No, but if you prefer, I can transfer your call to our grievance hotline. Just click on option #17.
• Uproarious laughter from the entire phone bank who heard my request on speaker.

As I write this, I am at 18,000 feet in a propeller plane that I trust will land safely in Cleveland.  Hopefully, the air traffic controllers are all awake and alert. I'm flying in from Canada where my mom and I observed how indifferent the airline and customs personnel were to the plights of the passengers.  Regrettably, this level of  'customer service' isn't restricted to our neighbor to the north.  Air travel isn't much fun these days for anyone anywhere.

I'm sure the airline folks are as hassled as we travelers are.  Would you want to face angry and frustrated passengers each day when you are powerless to remediate their complaints?  At times, the lines of happy travelers at the customer service desk in the airport for lucky folks who have missed flights or lost luggage reminds me of the lines I endured at Disney World.  This analogy is apt since both sets of lines lead to adventure!

Here are my observations as an airline customer.

• I do not feel that my business is appreciated.
• Reaching a living, breathing human being on the phone should only be attempted if a physician has cleared you for this activity. Cardiac patients need not apply.
• Flexibility to adapt to customers' needs or to changes in circumstances have been left out of the playbook.
• Fees charged to make even the most trivial change in ticket reservations are unconscionable.
• No obvious regard for the value of customers' time with regard to flight delays.
• Service on board?  Now we passengers can ask, 'are you joking?'
• Dissatisfied customers have no recourse.  In other spheres of the marketplace, if we are not treated well, we dump them and walk down the street to a competitor.

There are lessons here for the medical profession and for our patients.  Fortunately, patients and physicians enjoy much better partnerships than do airline industry have with its customers.  But, our relationships with patients have been challenged from many internal and external forces. How are we doing in with regard to patient satisfaction?   What do our patients say?  While there are many legitimate reasons why high levels of patient satisfaction are more diffiicult to achieve today, patients still deserve our best effort and outcome.  I am skeptical that pay-for-performance and similar efforts are the right tools to get this job done.  When your only tool is a hammer, than physicians start to look a lot like nails.  Haven't we been hammered enough?

While it is a generalization, I believe that private practice medicine - like any private business - has stronger incentives to provide high levels of patient satisfaction.  Employed physicians, the emerging dominant model for doctors, may not be as vested in catering to their customers, although I know there will be disagreement here.  For employed physicians, their sense of patient satisfaction may be feedback survey results from patients, which will be reviewed by their supervisors and placed in their personnel files.  Private practitioners, in contrast, may be more concerned with pleasing the patient directly than in pleasing the survey. This difference may appear subtle, but I believe it is substantive.  In the same way that teachers are criticized for teaching to the test, physicians who must answer to bean counters may be practicing medicine with an eye toward the survey.  This can lead to gaming the system. 

As I noted on a prior post, the airline industry has taught the medical profession important lessons on medical check lists.  I don't think, however, they have much to teach us about customer service.  If you disagree, give them a call for some pointers on how to soothe seething passengers.  Remember, your call is important to them.

Sunday, August 19, 2012

Unnecessary Antibiotics in Livestock: What's My Beef?

I’ve already written about the overuse of antibiotics in this country. This overutilization costs money and causes medical complications. It also is believed to be the cause of a new generation of superbugs, that can attack us with impunity as we may have no effective antibiotic to defend ourselves with.


As an aside, I remember when I first learned the meaning of the word impunity. Here’s the opening paragraph from the short story written by a nineteenth century master.

THE thousand injuries of Fortunato I had borne as I best could, but when he ventured upon insult, I vowed revenge. You, who so well know the nature of my soul, will not suppose, however, that I gave utterance to a threat. AT LENGTH I would be avenged; this was a point definitively settled -- but the very definitiveness with which it was resolved precluded the idea of risk. I must not only punish, but punish with impunity.

Without resorting to Google, can any readers name the work and the author?

Digression over. Antibiotic (ATB) overutilization is not just an issue that affects man; it affects beasts also. Farmers have been prescribing antibiotics to fowl and cattle for years to make their animals heartier. This issue falls under the jurisdiction of the Food and Drug Administration (FDA), who have imposed restrictions on ATB use in livestock over the years. There is tension between those who feel that ATB should be banned and those who favor a more permissive policy.

Surprisingly, more antibiotics are prescribed to animals than to humans in this country.

Farmers and veterinarians feel they should be free to prescribe ATBs to keep their animals in good health. Antagonists claim that ATBs should not be allowed simply to prevent infections that result from unsanitary conditions. Moreover, there is a widespread view that overutilization of ATBs in cattle creates superbugs that can threaten humans. Farmers counter that these fears are hyped.

These are real issues that need real science to separate facts from politically correct arguments.

(1) It’s true that ATB use in cattle and livestock have increased.

(2) It’s true that superbugs are on the rise.

(3) This does not mean that (1) has caused (2).

The FDA has tightened the rule requiring now that farmers will need veterinarians' prescriptions for antibiotics, a requirement that is expected to substantially decrease their use. 

I’m inclined to agree that both animals and humans receive more ATBs than they need. But, I wouldn’t want to create new mandates based on a hunch or even a logical belief. Before we adopt policies that affect industries, livelihoods and jobs, let’s ask ‘where’s the beef?’

Sunday, August 12, 2012

How Much Does A Colonoscopy Cost?


One would think that a physician who earns his living billing patients would be conversant with the prices of his services. Not this doctor. I am queried periodically by patients asking how much I charge for a colonoscopy. Of course, every physician recognizes that this question is not phrased properly. It doesn’t matter what we charge; it’s what an insurance company determines we will be paid. I might believe that your colonoscopy was worth a thousand bucks, but those who pay the bill have a different sense of its value. Many ordinary folks think that we doctors can simply raise our prices to enrich ourselves. Physicians cannot do this. The hardware store and the supermarket can raise prices in response to rising overhead and market forces, but we physicians cannot. While I realize that the public does not sympathize with physicians who are lumped in with the 1%, a pejorative term popularized by the Occupy movement.

The reality is that many private medical practices are struggling financially and have closed. Many of these practitioners have retired and others have become physician employees. Our practice in the Cleveland suburbs is feeling the squeeze and I cannot estimate how long we will remain viable. Personally, I believe that private medicine is being targeted by design, and when it becomes extinct, the public will lose an important health care resource. While I am not opining that private practice is the only model that can offer high quality medical care, I maintain that when the physician is also a business owner, that he has a strong incentive to satisfy his patients and his referring physicians. Employed physicians are given incentives, which are metrics that reward or punish them depending upon how the measure up on various ‘quality’ schema. Throughout this blog, I have railed against pay-for-performance and its cousins which claim to measure medical quality, but will fail in the mission. It’s like assessing the quality of a chef’s culinary creation by weighing the plate of food. Get the point?

Pay-for-Performance is in the lowest tier of the bottom 99% of quality control measurment. It was not designed to increase medical quality, but to control costs, which is a legitimate goal. At least have the guts to say so out loud.

I don’t have a clue what a colonoscopy costs. This is partially because I have never been interested in the business of medicine. However, colonoscopies are like airline tickets; no two passengers pay the same fare. Insurance companies have different rates. If we obtain biopsies or use a nurse anesthetist to administer the Michael Jackson juice before colonoscopic take-off, then there will be additional charges that cannot be firmly stated in advance.

When I do see what we are paid for a colonoscopy, it certainly doesn’t seem exorbitant considering the years of physician training and experience we have, the outstanding nursing care we provide, the immaculate and modern facility and equipment we use and our devotion to providing the highest quality service possible.

Who can put a price on an experience like this? Not us.

Sunday, August 5, 2012

The Plague of Unnecessary Antibiotics

With regard to antibiotics, physicians and the public have each been enablers of the other. Patients want them and we doctors supply them. There’s nothing evil about this arrangement. Antibiotics are one of medicine’s towering achievements and have saved millions of lives. Shouldn’t we prescribe them to patients who need them? Of course we should. But why do we prescribe them to patients who don’t?


Before you race to the comment section to accuse me of being a self-righteous preacher, realize that throughout this blog, I have confessed my own mistakes and shortcomings, and will continue to do so. (Yes, many commenters have enthusiastically assisted me in this effort.) So, when I throw a stone at the medical profession, I am also in the line of fire.

I have since the heady days of medical internship, been a conservative practitioner, preserving my soul even after completing training where medical overtreatment was worshiped. In medicine, less is so much more. I wish that more patients and more of us subscribed to the philosophy of medical parsimony.

Why would a physician prescribe an antibiotic (ATB) that is not needed?

First, there are times when the medical situation is murky, and the physician may be unsure if an ATB is truly needed. If there is concern about this patient, then the doctor may understandably prescribe the ATB, just in case the illness is a bacterial infection. (ATBs are effective against bacterial infections, but are not effective against more common viral infections including common colds.) Doctors often must make recommendations and decisions based on incomplete information. Wouldn’t it be nice if we knew with 100% certainty if a sick patient needed surgery, as many medical malpractice attorneys believe?

However, I am not referring to prescribing ATBs when the clinical situation is unclear. I refer to situations where they are clearly not indicated, and should not have been prescribed.

Over the years, I have seen numerous cases of ‘diverticulitis’, ‘sinusitis’, ‘touches of pneumonias’, upper respiratory infections, coughs, colds and various sore throats all treated with ATBs. Many of these patients received a 2nd course of ATBs when the condition persisted or recurred. In many of them, these drugs were simply not needed. Don’t think that ATBs were mere placebos. Unlike true placebos, ATB have real medical risks and can cause harm.

Of course, it’s possible that my medical judgment is flawed and that these patients truly needed ATBs, and it was lucky these folks had sharper physicians who recognized this. However, ask any doctor – including yours – if the ATB trigger is pulled too quickly. If the doctor says no, then get a second opinion.

So, why does this happen?

  • Patients demand it, convinced that they need it. This belief is strengthened if prior physicians have provided them with ATB ‘Kool Aide’ for the same viral symptoms.
  • Patients who are told only to rest and drink fluids may not believe they received sufficient medical care. “He did nothing for me. Who needed this appointment? For this I took off work?”
  • It may take 15 minutes to convince a patient that ATB are not needed, and only 10 seconds to prescribe one. Additionally, some patients can’t be convinced by any argument.
  • Physicians want to keep their patients satisfied. This will become more relevant when patient satisfaction reporting will be tied to physician reimbursement. Won’t that be ironic if lower quality care that patients approve of will reward doctors?
  • Physicians may falsely believe that prescribing an ATB reduces their legal vulnerability, arguing that the ATB is evidence of active treatment against the condition. For some reason, physicians don’t fear being sued if an unnecessary ATB causes a medical complication or a serious side-effect.
Overutilization of ATBs costs money and exposes patients to unnecessary risks. I’m also philosophically hostile to any treatment or medical test that is not needed. Additionally, medical experts have warned us for a few decades that the tsunami of ATBs that are prescribed so casually is breeding out superbugs that resist our available ATBs. It is tragic when a patient is severely ill from a true bacterial infection, and the necessary ATBs won’t work because the germ overpowers it.

So, the next time you have the sniffles and you’re in your doctor’s office, make sure you demand the right treatment. And, if you leave without a prescription, don’t feel that the doctor did nothing for you. He may have done quite a lot for you. And, that's nothing to sneeze at.

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.