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Friday, November 26, 2010

Donald Berwick and the office visit

I have included a series of links below, which I came upon after reading Dr. RW's blog -

Dr. RW's blog as well as the post in First Things expressed complete dismay regarding Berwick's comments relating to the need for office visits. The Berwick comments originated from a piece he wrote in 2002 entitled "Escape Fire", which described events in the 1949 tragedy in Mann Gulch which took the life of a number of smoke jumpers. He elegantly identified parallels between the dogma of the smoke jumper training at that time and the role in guaranteeing the tragedy and the present state of health care in the US.

It is an interesting piece and quite independent of hearing Berwick's story and reasoning, I find I share his sentiments regarding office visits. I also suspect that I am true to my contrarian roots in that the idea that delivering value to patients may not require face to face visits to the degree which we have previously believed is an idea that does not appear to be widely embraced within MD professional circles... as least not yet. The arguments to the contrary are somewhat telling and appear to supported by belief and declaration as opposed to actual data.

I toggle between the world of MD's and the world of non-health care folks. I am consistently struck by the perceived value of face to face visits within the MD world and how that contrasts with the annoyance this seen as within the world of those who are the seekers as opposed to the deliverers of care. When I see patients which I do primarily in the ambulatory setting, I always look at the visits asking one question. What specific piece(s) of information did I garner from this encounter which informed me in such a way to alter the management of the patient's condition and could that information have been garnered in such a way which would be more efficient in terms of everyone's time and money?  I generally conclude that much of the activity associated with the visits could have been done better outside of the context of a visit that was very time consuming and wasteful to my patients.

Others argue to the contrary. For example, one of the comments on the First Things piece was:
In order to make an accurate diagnosis, doctors MUST have, in person, interaction. The diagnostic process, requires the doctor to assimilate all of the physical findings, such as skin color, and texture, heart, breath, and bowel sounds, and the nuances, of these that can only be detected with stethoscopes, pulse, alterations, detected by palpation, of the various organs. They take this information, combine it with their vast (hopefully!) knowledge of anatomy, physiology, biochemistry, pathology, and clinical experience, to formulate a diagnosis, and subsequent treatment plan. This can only be accomplished, the “old fashioned” way, by personally examining the patient. Indeed, all large part of the diagnostic process, is done, as a result of the physical examination, and the history, provided by the patient.

I agree that diagnostic work is incredibly important and requires the assimilation of lots of information. However, what worse context to do this than in a hurried face to face encounter where the collection and inputing of information is rushed and the formulation of a DDx and treatment plan occurs under time pressured conditions. It only makes sense that moving as much of this outside the time constraints of the face to face encounter will limit errors which occur more frequently when we are pushed for time.

What information can be collected at a face to face encounter? This author suggests that it is information derived the "old fashion way" from the physical exam. However, all tests need to be validated in some fashion to determine whether they provide information which is reproducible and predictive of some outcome. My own experience with elements of the PE show that whenever new technology comes along which allows elements of the physical exam to be tested with additional rigor, the value of the exam ends up being much less than initially suspected. The bedside neuro exam was almost immediately found to be suspect when the CAT scan became available. The ability of clinicians to listen to the heart and predict anatomy was found to be sorely lacking when cardiac echo was available. How many phantom spleen tips have been identified on the abdominal exam? Who ever sees anything actionable looking into the ears of someone with no ear complaints. For the vast numbers of asymptomatic people who come for regular checkups, the physical exam is likely worse than worthless.  What is the predictive value of the physical exam in someone who has no complaints? I can not know for sure but I suspect it never been tested. However, the more bullets checked, the more you get paid.

The only thing I can state with certainty is the face to face exam is most consistently of  value to the health care system and provider that drops the bill.  Many visits may bring value to the patient but the persistence of this encounter structure rests upon the value brought to the provider. Changing the payment system to encourage alternative compensation arrangements would redoubtably release a  wave a welcome change.

Monday, November 22, 2010

Where will change in health care come from?

It has been a long time coming and it will likely be still a while before change fully plays out in the health care arena. There is a consensus that our economy cannot accommodate sustained growth of the health care economy which is well above both the growth rate of the overall economy and greater than inflation. The possible scenarios for the end game are too numerous to count and can range from enlightened change and adaption to a Mad Max post apocalyptic hell. I suggest that something entirely different will happen.

Our medical model is based upon a training and credentialing model which may not be the best fit for a rapidly changing world. It is increasingly incapable of change. Rather than provide improved and more efficient approaches to training a health care workforce which can re-invent themselves on a recurring basis and better serve the public, it is better suited to protect itself. Undesirable outcomes trumpeted in the press serve as justifications to reinforce a regulatory framework which does more to serve the interests of those regulated than serve the public at large. No better examples of regulatory capture can be found in health care than anyone else. Whether one deals with state licensing, hospital credentialing, or residency oversight, each additional layer of regulatory hoops creates barriers to entry and brakes on innovation. While the initial motivation and justifications are to protect the public, the ultimate winners are the regulated.

No lesser developed country can afford to duplicate such a wasteful  and dysfunctional system. Much the same as when the US military found it could train highly skilled corpsman to deal with complicated health issues during the Vietnam war and this spawned the development of the PA profession, new models of health care delivery will come from developing countries. It is only a matter of time before rules based management and electronic decision support tools will allow for better and less costly management of the vast majority of common conditions. While resistance to these changes will be difficult barriers to deployment in the US and other western countries, I suspect that this will not be the case elsewhere.

Over time, data will become available which will demonstrate whether more expensive models retained in places like the US are actually superior in outcomes over less restrictive approaches that will be deployed elsewhere. I suspect it will be like any other model in history where high cost activities move offshore to find lower cost alternatives. There might be some modest quality decrement but the cost differences will dwarf any quality loss. The guilds will put a valiant fight but like the Luddites who fought mechanical looms, they will be relegated to the category of a curiosity of history.