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Sunday, June 24, 2012

All conflict is based upon religious differences

I read a great piece by Connie Cass, AP reporter, entitled " Parties are worlds apart on how to fix the economy". The gist of the article is is summarized by the opening paragraph...
Millions of Americans are desperate for work, runaway government spending clouds the future and Democratic and Republican candidates are busy making one thing clear: They're light years apart on what to do about it.
 She goes on the described the different world views...
On planet Republican: The economy is backsliding, and the president is to blame. His stimulus spending did more harm than good, and his big-government rules are strangling businesses. The answer is repealing health care, energy and financial regulations and cutting taxes. That should spark investment and create jobs. Tackling the deficit requires huge spending cuts, just not at the Pentagon. The unsustainable guarantee of Medicare and Medicaid must change.
In the Democratic universe: The economy's slowly improving, thanks to government spending that helped fend off a depression. Another dose of targeted spending will help. Republican policies in the Bush administration — cutting taxes and eliminating rules — brought on the financial crisis and budget deficits. The rich should help dig us out by paying higher taxes. The Pentagon's budget must be cut, but entitlement spending can be controlled without drastically altering the social safety net.
 Neither world view is provable or disprovable. They represent belief systems, like belief systems more typically linked to religious sects or groups. They are secular religions. There may be some empiric evidence which may ostensibly support one view or another, but not to the point where one belief system becomes unquestionably more plausible than its competition.

Each set of believers tries to seize the intellectual high ground by enlisting the support of public "experts" who attempt to speak with authority. Paul Krugman writes columns for the New York Times zealously excoriating those who push for spending cuts and austerity Rheinhart and Rogoff in their book "This time is different: Eight Centuries of Financial Folly" provide data to support their contrary position. However, data to support either side has inherent flaws: it is always retrospective and correlative. While the work they do are adequate to receive accolades and academic recognition, the work is not capable of bridging the gap between moving what is believed into the domain of what is known and fact.

I have to appreciate the perspective of Ariel Rubinstein in his book "Economic Fables"
This is how I usually begin lectures on economics and social issues:   I would like to start with what I believe every academic should do when appearing in public, especially when speaking about political and controversial issues – to clarify the extent to which he is incorporating his professional knowledge in his remarks, whether he is expressing views with the authority supported by academic findings, and what part of his comments are nothing more than his personal thoughts and opinions. And so, I would like to declare unequivocally, without hesitation and even with a bit of pride, that my words here have absolutely nothing to do with my academic knowledge. Everything I say here is personal, based upon the entire range of my life experience, which also includes the fact that professionally I engage in economic theory. However, to the best of my understanding, economic theory has nothing to say about the heart of the issue under discussion here. I am not sure that I know what an option is; I am not attempting to predict the rate of inflation tomorrow nor the productivity index in manufacturing the day after tomorrow. Of course, I am aware of the fact that you have invited me here to speak because I am a professor of economics who is supposed to know all this, and my ignorance definitely embarrasses me. So you ask why I have come here? Because as an economic theorist, I would like to state that economic theory is exploited in discussions about current economic issues, and I don’t like it…, to put it mildly.
I have blogged on a similar topic, identifying the dangers of scientists moving from the realm of science into the realm of advocacy (

What this boils down to are belief systems.  I must admit that my belief system encompasses a belief that complex economic systems are most durable when they are controlled by market forces. There are lots of articles and books both supporting and contesting my belief system.  I realize that I may be able to find empiric evidence to support my beliefs, but I will never be able to prove that my beliefs are "right". Neither will Krugman or Rheihart and Rogoff. Each will sway some very smart and well meaning people. Each will be used to drive particular political agendas. One side may dominate for a period of time and partially implement portions of their agenda and some outcome will come about. 

Social selection pressures play out over periods of time well beyond the life expectancy of anyone who might be able to appreciate fully the impact of any single decision or belief sets. I believe that my belief system is correct (in that adoption of such will mean more will benefit in the long run)  but understand that it is simply a belief system, supported by the evidence that I believe is most important, and that I will not be alive long enough to see an unambiguous answer to the question of whether my beliefs are basically on target or flawed.

Health care systems review

In my browsing, I cam across a review of health care finance systems:

It was published on the Cato Institute Website in 2008 making it a little bit dated. However, in my experience, it is the best summary which focuses on comparisons of organizational structure, funding sources, and challenges. For those of you who are skeptical of the Cato conservative market-based orientation, get past the Executive summary and dive into the meat of the report. There are many nuanced differences in how systems are organized, many of which I was completely unaware of. For this reason alone, this report is worth reading.

I believe the author's conclusions are supported by the data in the report:
•Health insurance does not mean universalaccess to health care. In practice, many countries
promise universal coverage but ration care or have long waiting lists for treatment.
• Rising health care costs are not a uniquely American phenomenon. Although other countries spend considerably less than the United States on health care, both as a percentage of GDP and per capita, costs are rising almost everywhere, leading to budget deficits, tax increases, and benefit reductions.
• In countries weighted heavily toward government control, people are most likely to face waiting lists, rationing, restrictions on physician choice, and other obstacles to care.
• Countries with more effective national health care systems are successful to the degree that they incorporate market mechanisms such as competition, cost sharing, market prices, and consumer choice, and eschew centralized government control.

Sunday, June 17, 2012

Cloud computing, EHRs, and other disruptive innovations

Jim Manzi has written an interesting piece in the Atlantic Monthly regarding the history and development of cloud computing:
When some friends and I started a software company in 1999, we used current software development languages and tools that were designed to allow access via the Internet. This was entirely incidental to us, since we assumed that we would ultimately install our software in the traditional manner. When we delivered a prototype to an early customer, they didn't have IT people to install it, so we allowed our customer temporary access to our software via the Internet -- that is, they could simply access it much as they would access any web site.
As they used it, two things became increasingly clear. First, this software made their company a lot of money. Second, despite this, the IT group had its own priorities, and it would be very difficult to get sufficient attention to install our software any time soon. 
I look at my own institution (which shall remain unnamed) and review all its attempts to deploy software in an enterprise fashion, including its EHR. We have very smart people at multiple levels, all working diligently to accomplish their respective tasks. These are not stupid or incompetent  people..far from it. However, almost every attempt to deploy software systems in an enterprise fashion has been fraught with major problems. These challenges were highlighted by Mandl, et al this week in the NEJM in a piece entitled "Escaping the EHR Trap - The Future of Health IT" . In this piece the authors note:
Early health IT offerings were cutting-edge,1  but contemporary EHRs distinctly lag behind systems used in other fields. In 1966, members of Octo Barnett's laboratory at Massachusetts General Hospital invented a highly efficient programming language for the earliest EHRs; the Massachusetts General Hospital Utility Multi-Programming System (MUMPS) partitioned precious computer memory so parsimoniously that with only 16 kilobytes, the earliest personal computers could run an EHR supporting multiple users. But nearly a half-century later, most EHR vendors not only have failed to innovate but don't even embrace existing modular architectures with interfaces that allow extension of product capabilities, innovative uses of data, and interoperation with other software.
Loss of technological leadership reflects apathy and even opposition by EHR vendors to promoting liquidity of the data they collect. This attitude has thwarted medicine's decades-long quest for an electronic information infrastructure capable of providing a dynamic and longitudinal view of the health care of individuals and populations. EHR companies have followed a business model whereby they control all data, rather than liberating the data for use in innovative applications in clinical care.
The authors go on to identify specific areas which EHR vendors fall short - the inability to work with other systems, private storage, fostering communications between providers and between providers and patients, documentation tools, analytic tools, and decision support. Why does this persist? One of my colleagues made the observation that in the present environment the deployment of an EHR is like drug development. It involves huge costs and risks and is constrained by all sorts of regulatory issues. I think a flawed payment system coupled with a constraining regulatory environment is the cause. 

It does not and should have to have this structure. EHR's have evolved primarily in response to a series of regulatory mandates, not in response to the needs to patients or health care providers. Furthermore, where IT has impacted other industries (retail, banking, travel, entertainment), it has created whole new series of products unimaginable before IT tools could be deployed. These products ended up being deployed because smart people created business plans where these new ideas and products could me monetized. Thus the public was served, new products were created, and entities that took the risks became wealth creating engines. 

The payment systems linked to health care are much less capable of adapting to such new products. Thus, we have failed to create pathways whereby new products, which could be created by novel IT tools, can be monetized. The payment system makes such activities not into risky business ventures; it is business suicide to make investments in new systems and approaches which cannot be monetized readily and paid for. 

We are left with large organizations health care organizations, attempting to deploy EHRs primarily to collect meaningful use monies, pushing basically dysfunctional systems on providers. They call upon us to become expensive data entry clerks using work processors which no clerk would put up with (NO SPELL CHECK!).  We would not be in the quandary and the industry would be developing modular and light weight applications to meet many more real needs of patients and providers if the payment system allowed us to create new products and use creative approaches to monetize them. 

 The culture within organized medicine has been hostile to financial innovation in general. For example, people and entities that bypass the usual payment system such as those who develop concierge practices are often viewed a unethical. Legal constraints also make it very difficult to experiment with innovative approaches to care delivery, that might come as a consequence of using new technology. And we wonder why everything except health care gets cheaper and better. 

In some sense by focusing on what what we call the EHR, we miss a bigger picture, that being that health IT is not limited to EHRs. It is about how technology will change how we interface with patients, collect and analyze information, and make decisions. Here again, the payment system (and licensing system) by and large prevents healthy innovation and development of software tools that will allow us to do what is essential to caring for more people for much less money. We know we are not incentivized to that now and we anticipate that we may be provided with the incentives at some point in the future. We just have no real idea of when that future will be upon us. 

For the small and lightweight medical applications and EHR world to thrive, it needs a different business model, one that allows new products and care practices to evolve and support themselves. 

The End Is Near - Chicken Little meets high impact journal

The Mayan Calendar identified this year as the year of the apocalypse. However, my retirement planning is based upon having sufficient money to live beyond December 21, 2012. I can discount the predictions of ancient Mayan texts reinterpreted by New Age "Scholars", carrying on a traditions of many who preceded them predicting "The End is Near".

However, new players have now entered the game, supported by what is perceived as cutting edge science, similarly predicting that the end is near. What near means is an open question. Last week in the journal Nature (impact factor 36.1 - #1 for all general scientific journals), an apocalypse predicting article was published (behind the fire wall) entitled "Approaching a Stage Shift in Earth's biosphere". The authors were careful not to violate the a famous dictum of professional economics, that being never provide both a specific prediction or number and a date in the same prediction.
"Humans now dominate Earth, changing it in ways that threaten its ability to sustain us and other species. This realization has led to a growing interest in forecasting biological responses on all scales from local to global
However, most biological forecasting now depends on projecting recent trends into the future assuming various environmental pressures, or on using species distribution models to predict how climatic changes may alter presently observed geographic ranges. Present work recognizes that relying solely on such approaches will be insufficient to characterize fully the range of likely biological changes in the future, especially because complex interactions, feedbacks and their hard-to-predict effects are not taken into account."
Here we have it in the introduction to the article. The tools used to make predictions are insufficient to characterize "fully" the range of changes in the future. I am reminded of the Nicholas Taleb book "The Black Swan" and the chapter entitled "we just can't predict". In this chapter he explains the simple problem of predicting the speed and direction of billiard balls. After 40+ collisions one needs to account for every particle of the universe in order to predict the speed and direction of the last ball struck. We are talking about predicting events minutes into the future and a limited number of interactions of well defined objects and we need to account for every particle in the universe! Tell me again how we can reliably predict and control stage shifts involving the entire Earth?
The introduction of the Nature article goes on to state:
"Particularly important are recent demonstrations that ‘critical transitions’ caused by threshold effects are likely12."
What do they mean by likely??? Can they provide us with some modest quantitation here? Perhaps likely means a one in 10 chance or a 1 in a 100 or perhaps 1 in a 100 million. What time frame are they suggesting? Next week? Next year? Next century or millennium? Next million years? I do not need the mantle of science to make such predictions. The reference for this particular statement was also published in Nature in 2009 in an article entitled "Early-warning signals for critical transitions". (
Notable in the introduction of this article is the statement:
"It is notably hard to predict such critical transitions, because the state of the system may show little change before the tipping point is reached. Also, models of complex systems are usually not accurate enough to predict reliably where critical thresholds may occur."
I wonder if they are ever accurate enough, particularly when the model they are dealing with is the entire earth. In any case,  I fail to see where the "likely" claim is supported, whatever the authors mean by likely. Such predictions can never be falsifiable and if they are can not be falsifiable, they cannot be science.

The authors go on the state:
"Critical transitions lead to state shifts, which abruptly override trends and produce unanticipated biotic effects. Although most previous work on threshold-induced state shifts has been theoretical or concerned with critical transitions in localized ecological systems over short time spans, planetary-scale critical transitions that operate over centuries or millennia have also been postulated. Here we summarize evidence that such planetary-scale critical transitions have occurred previously in the biosphere, albeit rarely, and that humans are now forcing another such transition, with the potential to transform Earth rapidly and irreversibly into a state unknown in human experience."
Within the article they identify previous phase shifts which include glacial–interglacial transition,
‘Big Five’ mass extinctions,.and the Cambrian explosion. Unless I am horribly mistaken all these events occurred independent of human activity. The authors imply that humans are now taking on God like characteristics and whatever the next transition may be and whenever it might happen, it will be due to human activity. I would call that a stretch. They go on to conclude:
Two conclusions emerge. First, to minimize biological surprises that would adversely impact humanity, it is essential to improve biological forecasting by anticipating critical transitions that can emerge on a planetary scale and understanding how such global forcings cause local changes. Second, as was also concluded in previous work, to prevent a global-scale state shift, or at least to guide it as best we can, it will be necessary to address the root causes of human-driven global change and to improve our management of biodiversity and ecosystem services.
Humans have engaged in all types of activities throughout history to predict and control future events ranging ranging from use of oracle bones by the ancient Chinese, astrology, water divining, dream interpretation, and other forms of magic. For much of the past two millennium the source of "truth" and tool for divination in the western world were holy scriptures and educated classes were in general agreement that the Bible held all of the information needed to divine the future and guide human decisions.   All of these approaches seemed to make sense at the time they were used and their deployment and were supported by the best evidence that these particular cultures had at the time. Some still believe this to be the case.

I too do not like surprises, particularly the types which adversely affect humanity. However, I am also distressed when the most prestigious scientific begins to sound like a press release from the Millerites. The Millerites were not quite as clever in that they provided specific dates and when the apocalypse failed to materialize, their followers lost interest. Our modern day Millerites are clever enough to cover themselves in the veil of science and use vague terms such as likely and avoid any specific time frame whatsoever.

I believe that we humans are pretty much just passengers on this planet and we have little or not real lasting impact on the course of the planet. Furthermore, we are simply delusional if believe humans are capable of predicting future courses of events and the effects of specific human actions on broad ecosystems. We may believe we can manage the earth but I believe that is a mistaken belief. We simply will never be able to muster that type of control and any attempts to develop such control mechanisms will likely have terrible unintended consequences.

Wednesday, June 13, 2012

Can healthcare be a right if it contains both needs and wants?

The argument goes something like this. Markets have been shown to be the mechanism by which scarce resources are allocated most efficiently and the way to solve the health care scarcity, allocation and cost problems is better use of market mechanisms. The counterpoint is that health care is different. It is so important and so central to human existence that it cannot be trusted to the market. It reminds me of that deep philosophical discourse of my young adulthood:
Taste great! Less filling!

I must admit that I am a free market guy. I will admit this but I am also willing to listen to the contention that there is something fundamentally different about health care which might require that we generate some sort of market carve out.  The statement that health care is different is used as a discussion stopper, requiring no further justification or data to support it, something on the order of the belief that mothers, children, and apple pie and inherently good.

I suspect that this contentious issue may not be fully resolved by deeper discussion, but it sure could be fleshed out more substantially.  Such a discussion might allow us to define where legitimate grounds for disagreement might exist, which assumptions are behind each position, and what the downstream consequences are for embracing particularly stances.

Because of this belief that health care is different, many contend that health care is a basic human right. Whether you believe that any human rights can and should be defined as positive rights, that is rights to some good or service created by another human being is the larger question. If I were to embrace the concept that health care is different from the remainder of things delivered by market forces, there must be defined in some way which these specific differences can be defined.  What this means is health care goods, services, and activities can defined  as distinct from everything else and that classified as lying within the health care domain exhibit some specific criteria which distinguish them from non-health care. We can call this a definition of scope.

Once we have made the leap to create a legal entitlement, definition of scope becomes essential to define. Within the world of voluntary exchange, what is exchanged and how has infinite possibilities. Once exchange becomes mandated by law, the flexibility all but disappears. To define what the scope of the health care entitlement is no minor task, but the justification for such an ambitious undertaking is simple; health care is different.

This leads us to the obvious question. How is health care different and what is it different from? It is remarkable how often this claim is made and how little has been written to critically address the assumptions underlying this assumption. It is reasonable to assume that health care could be viewed as a right if the following conditions were met;

1. Access was required for near term survival or functioning
2. Those requiring access are not in a position to negotiate for their immediate needs

I believe the key word in this analysis is need. One can perhaps justify legal entitlement status for essential human needs. However, how do you define human needs and distinguish them from human wants? Humans cannot survive without food, water, and protection from the elements. These are unquestionable human needs. However, our wants relating to these domains extend well beyond what we need. We can survive and actually do reasonably well physically on a simple diet and basic shelter. Most everyone strives for more. It is what we do.

We have no defined universal minimum standards in the US for food and shelter. For the most part, the resources required to feed people and protect them from the elements can and are met in the US. Food is plentiful and cheap and our major concerns revolve around obesity and not hunger. There is huge variation in the quality of housing in the US, but the poorest of US housing still vastly surpasses a minimum standard to protect occupants from the elements. It may not be optimal but we are able to provide a minimum standard for nearly all US residents.

Health care provides problems that food and shelter do not. At the extremes it is relatively easy to distinguish between health care wants which do not qualify as health care needs. Few would argue that plastic surgery in normal teenage girls is a health care need. However, it quickly gets more difficult. The original Oregon Health Plan quickly discovered this quandary.  This controversy reached national attention when (from Wikipedia):

“During 2008 and 2009, the Oregon Health Plan stirred up controversy when enforcing 1994 guidelines to only cover comfort care, and not to cover cancer treatment such as chemotherapy, surgery and radiotherapy for patients with less than a 5% chance of survival over five years.
Springfield resident Barbara Wagner said her oncologist prescribed the chemotherapy drug Tarceva for her lung cancer, but that Oregon Health Plan officials sent her a letter declining coverage for the drug, and informing her that they will only pay for palliative care and physician-assisted suicide. She appealed the denial twice, but lost both times. Tarceva drugmaker Genentech agreed to supply her the $4000-a-month drug for free. Wagner's plight garnered a flurry of attention from the media, the blogosphere, and triggered protest from religious groups. Wagner died in October 2008. “ 

 If we could define basic health care needs, we could perhaps reach an agreement regarding should be part of the entitlement. However, this is simply not possible. Was Wagner's desire to be treated for cancer a need or a want? This will not be an isolated extraordinary circumstance. Decisions like these will need to be made every day in places all across the country.  Who could be charged with making such decisions? If you think these are handled clumsily by the private sector now, just wait until the state becomes the dominant player. Richard Epstein warned of this in his book Simple Rules for a Complex World:

“This conception of individual welfare rights survives on the naïve belief that government can continue to fund the right without dictating the plan of service. Yet protection of these newly minted positive rights invests government at all levels with vast powers to tax, to regulate, and to hire the very individuals whose rights it is duty bound to protect. “

 This has all been seen and discussed before. The needs and wants dilemma was eloquently summarized by  Eva Ryten in the 1998 Journal of the Medical Association of Canada (156: 650) when she wrote a response to a critique of an article on projecting future physician manpower needs in the Canadian health care system.  
“I have always steered clear of discussing health care “needs” and “wants” because in the context of a fully publicly funded health care systemthis is a sterile debate. Almost the first lesson of economics is that if price is reduced, demand increases. Although all publicly provided health care must eventually be paid for through taxation, to the consumer of health care the price at the point of consumption is essentially zero.

When the price of a good is zero, demand will be unconstrained. No wonder health care budgets are regularly exceeded, and how easy it is to blame this on physicians for inducing demand merely to meet their income targets. Where there are no prices, any distinction between needs and wants is meaningless. That economists should advocate that the health care system be funded in such a way as to eliminate any incentives for sensible use of resources strikes me as bizarre. Rosenquist should ask the economists how they are going to ensure that, in the absence of price mechanisms of any kind, only health care “needs” are going to be met.”

I again am reminded the of Albert Einstein Einstein who said:

“If I had an hour to solve a problem and my life depended on it, I would use the first 55 minutes to formulate the right question because as soon as I have identified the right question, I can solve the problem in less than five minute.”

We have invested huge amounts of time to solve a problem we do not understand. We have made assumptions that health care is different without doing the hard to work to define how of if it is different. Ultimately it all comes back to age old problems with human wants and desires. This is not where policy wonks excel.

Sunday, June 10, 2012

A history of physician assistants

As the delivery of health care becomes more team based and collaborative, we are experiencing a shuffling of roles and responsibilities. I did a literature review and found an interesting draft manuscript

This manuscript referenced a paper published almost 15 years ago in the Bulletin of the History of Medicine. This paper is behind the pay wall, but I was able to access it thorough my access to Project Muse.

The focus of these papers is on the history of the physician assistant training in the United States. It is both fascinating and timely. It is timely because the same thorny turf issues which are raised now had their origins in the past. Dr. Gene Stead, the famous Chair of Medicine at Duke University was a driver of the PA concept. It apparently developed as a consequence of a number of influences on Dr. Stead's career with a share of serendipity. Natalie Holt describes this her "Confusion Masterpiece" article from 1998:
Stead's first effort toward this goal began fortuitously in 1957 and was shared with the supervisor of medical and surgical nursing at the Duke Nursing School, Thelma Ingles. As Stead tells it, the setting of an administrative meeting brought the two together. They had assumed their places before the meeting, and in the style of a "Southern gentleman," Stead 
had to make conversation of some kind, so I said, "What are you going to do next year? Are you going to continue doing what you are doing?" She said, "No, I'm going to have a sabbatical year." And I said, "Well, I think you're going to waste that year." She perked up a little and said what did I know about it. I said, "Well, I've been watching people take sabbatical years and they will take psychology or they will take sociology or they will take administration, but [when] they would come back to the nursing school, they wouldn't be any better as far as what nurses do than they were if they'd never done it. I think you're just going to waste that particular year." 27
Ingles agreed that she wanted a program that would enhance her capabilities as a nurse, yet few such opportunities existed. In 1957, the "nurse-clinician" or "nurse practitioner" role had not developed. (In 1970, for that matter, there were few organized clinical nursing programs in the country, and the ANA had not expended much effort to publicize those that existed.) 28 Small barriers, however, did not usually stop Stead--particularly when he had the authority to eliminate them. "Well," he proposed to Ingles, "why don't we break the mold and you take a sabbatical year in the medical school? I don't think any nurse has ever done that." 29
Thelma Ingles became the first (at least at Duke Medical Center) to do just that. She operated much as a medical student in a clinical clerkship, using patients as the springboards for seminars on specific topics in clinical care. She selected patients in the hospital in whom she had taken an interest, investigated their conditions, and met with Stead daily to determine what instruction she needed. If Stead was not prepared to provide her with instruction in a particular area of biology or pathology, he "would collect some green stamps from somebody" who owed him a favor, and Ingles would receive instruction with the willing or begrudging assistance of other Duke medical professors. 30
 When Ingles attempted to deploy similar training within the nursing education establishment, she was stymied: Holt went on to describe:
After her sabbatical year, Thelma Ingles returned to the Duke Nursing School to create a Master of Science in Nursing program modeled on her experience with Stead. The program included clinical rotations for the nurses, taught with the assistance of the Department of Medicine staff. The University approved the program and, in the words of Stead, trained "some extraordinarily competent nurses." 33 But administrators at the National League for Nursing (NLN), the accrediting body for nurse training programs, did not approve of Duke's clinical nursing specialization program and withheld their accreditation. They complained that the program lacked structure. In addition, they criticized the use of physicians as instructors. 34 While the master's degree program continued to exist without accreditation, in Stead's mind the NLN's action squelched the excitement and opportunity offered by a nursing program jointly run by both medical and nursing professionals.
 Fear of change on the part of nursing administrators stifled more than one attempt to expand nursing responsibilities at Duke. The next major incident occurred in the Class of 1961 of Duke's baccalaureate nursing program. Shortly before graduation, the classmates approached the supervisor of the senior year nursing program, Ruby Wilson. The students wanted more authority and responsibility than they saw possible in the typical nursing role. As Wilson recalls, they said: "We don't want to become like all the rest, . . . and in talking about it, Thelma [Ingles] came up with the idea that maybe this group of graduating seniors might become the staff for a particular unit." 35
Only after development of an expanded nurse clinician role was stymied by organized nursing did the PA program develop as a separate entity under the direction of  physicians. There was substantial contention within the house of medicine, but the PA concept garnered sufficient support of major physicians groups early on which ultimately ensured its survival.

The turf battles still persist and in some respects are more complex. The parties involved, physicians and nurses, are perhaps even more interdependent. There are more parties added to the mix; NP's,Doctors of Nursing, Physical therapists, clinical psychologists, optometrists,  to name but a few. Each may have clinical responsibilities associated with complex reporting authority. At this point in time, leaders of teams which deliver care tend to be physicians. However, that may change.

Is training to be a physician any more or less preparatory to lead teams of people all involved in health care delivery? Is the curriculum of medical school essential or even relevant to leading health care teams? Is so,  how many physicians who are leaders now could muster a passing grade on the USMLE? One could argue that it is their broad experience which equips them for such a role but if it is experience that counts, what about the experience of others who have taken a different pathway and have also garnered experience?

It has been 100 years since the Flexner Report was published. This report revolutionized the training of physicians and put in place a model of training that remains in place today. It made allopathic medical training preeminent. In the big picture, 100 years is not such a long time. For physicians to continue to claim the leadership role in health care, we need to be more than point of service clinicians. The Flexner Report was innovative and disruptive and it, along with scientific based medicine, permitted the dominance of  physicians in health care for the next 100 years.

The next sets of disruptive innovations will be like Dr. Stead's creation of PA's, creation of other non-physician clinicians who can provide value to patients, likely at lower costs. Where physicians end up in this mix is an open question.

Sunday, June 3, 2012

Limits of looking

From the Gladwell archives - almost 10 years old but still worth reading.

Another non-insured option for delivery of health care

Yet another indicator of the revolution ongoing in health care:

Punishing Doctors Who Make You Wait

One Medical Group in New York and San Francisco promises on-time appointments and no waits in its waiting rooms.One Medical GroupOne Medical Group in New York and San Francisco promises on-time appointments and no waits in its waiting rooms.
There’s nothing worse than showing up on time for a doctor’s appointment and then having to wait because the physician is running late.
Because insurers tend to pay a certain amount for each patient doctors see and each procedure they perform rather than for the time spent with a patient, doctors have an incentive to see as many patients as they can and often double-book patients for 10-to-15-minute appointment time slots.
Still, why should you suffer for a flawed business model? And how best to punish doctors who make you wait?
One option is to switch to a doctor who values your time. Patient dissatisfaction with long waits is not lost on physicians, and new practice models are popping up around the country partly in response.
On its Web site, One Medical Group, a practice with five offices in San Francisco and a newly opened one in New York City, promises “same-day appointments and longer, more personalized visits that start on time.”
How does the medical group guarantee on-time appointments? The practice, which charges patients a $199 annual membership fee to join and uses information technology to help manage costs, doesn’t require that patients come in for routine ailments like urinary tract infections. Instead, the medical professionals treat them by e-mail or phone, similar to a new service in Minnesota we wrote about earlier this year. Refills are also done online. Such policies help limit the number of patients coming into the office.

We have met the enemy and he is us

I read the reviews of Dan Ariely's new book "Why we lie"  in the WSJ last week. I have read and enjoyed "Predictably irrational" and "The upside of irrationality". I find Ariely is a provocative thinker and good writer. It is a good combination. I have yet to read his new work, not having access to it before the June 5th release date. What was described in the review I found tantalizing. In my humble opinion I believe that Ariely is a very clever experimentalist.  
Granted, having not read the book, it is not possible to judge the book critically. However, that does not appear to stop hundreds of WSJ readers from rendering a judgment, some of them very harsh. For those of you who have neither read the review of the book, the gist of the book is that given the opportunity, many people will lie and/or cheat, particularly if they see others lying and/or cheating. It is not a particularly flattering picture of human nature. I look forward to digesting the entire package.

The comments run the gamut from finding the conclusions unrepresentative of people to being nothing more than common sense. Are humans basically honest? In our own minds we are, meaning that when we operate at the edges of "honesty" we rarely cross the boundaries where we feel uncomfortable with what we do. However, what each of us is comfortable with may vary tremendously. Furthermore, without consistent feedback from our environment we will become more and more comfortable with more pushing the limits of stretching the truth and gaming to our advantage.  I suspect there is a spectrum of how aggressively individuals will look for their limits ranging from the absolute Goody Two-Shoes to Hannibal Lecter.  Most of us are somewhere in between.

One needs only to look as far as billing in health care to see this in action. When I was in training, manipulating the coding system to maximize your billings was viewed as highly unethical. One did not bill for everything one did and those who did so were viewed with great prejudice. Now those same maximizers are invited to medical conferences where the audiences now pay to hear them and collect CME. Are they dishonest? Depends on how you look at this. If your perspective is whether their billing practices follow the intentions of those who contrived the system, coding optimizers are clearly gaming and looking to push their actions to the edges of acceptable practice. The more that some agents push their limits means that others will find those practices acceptable. 
Further evidence of the human tendency to play fast and loose with the truth can be found at the PolitFact site ( The vast majority of claims investigated are not completely true and many (most?) are rated as untrue. I had a hard time find analytics on this site that give a breakdown of what they found. At the least we can conclude that within a very public realm people are fast and loose with the truth. It only makes sense that within more private realms it only gets worse.

In writing this post I remembered a draft post that I started almost two years ago but did not finish based upon a WSJ story by Eric Felton about cheating. ( In this story Felton wrote:

Europe was in a tizzy this past week. The ruckus involved the finale to last week's World Cup qualifying soccer match between Ireland and France. In the concluding moments of the game, French team captain Thierry Henry rescued a ball that was going out of bounds by grabbing it with his hand. (For some reason known only to the inventors of soccer, this is a no-no.) Shuttling the ball deftly to his foot, Mr. Henry set up the decisive goal. The referee failed to catch the French footballer's cheating, and after the game Mr. Henry proclaimed that the ref's error absolved him of responsibility: "I will be honest, it was a handball. But I'm not the referee. I played it, the referee allowed it. That's a question you should ask him."Mr. Henry's attitude is shared by athletes in just about every American sport. They believe anything the ref doesn't call is OK. With the burden of maintaining integrity entirely on officials, cheating is encouraged. Players hide behind a petty legalism that liberates them to cozen and counterfeit—or worse.

And how can I forget the cheating scandal that rocked the Atlanta Public Schools. The follow up from the Atlanta Journal Constitution  Follow up from the AJC suggested that similar cheating was ongoing basically everywhere they looked. I guess they bought into the Vince Lombardi dictum "If you ain't cheating, your ain't trying"

How do we deal with this apparent fact that most of those who we deal with cannot be trusted? It fits with what most of us know, that being trust may take years to create and can disappear in an instant. We need to understand when we are in situations where our trust can be backed by knowledge and when it cannot. Human nature is what it is and it is not likely to change, at least not in the near term. The world is navigable given the right combination of law, personal vigilence, and tools that promote transparency. No single tool will ever be sufficient and the best world requires every improving use of all three.