Musing on July 1 transitions

Tomorrow is housestaff transition day. Those who are completing their training are board eligible and transitioning into practice independence. An entire new crop of medical graduates of residency graduates transitioning into fellowship positions starts tomorrow.

I will generally provide a brief welcome to our program and I am slated to do so tomorrow. In giving this some thought, I recall my transition, first as an intern and then as a fellow in sub-specialty training. As an intern, I showed up on July 1. There was no orientation before July. I simply showed up and they gave me white coats and pants. We were not issued picture ID's, only a name badge which pinned on to my coat.

Upon arriving, we were directed to our teams consisting of junior and senior residents who took their new interns under their wings to their respective wards. I started in the ICU. It was a mixed medical and surgical unit with nursing staff taking direction from both surgical and medical teams. They liked the surgical patients better.

There were three new interns on my team and we were supervised by a senior resident and a recently graduated intern who was now considered the junior resident. We were briefly welcomed to our new home. We then drew straws for the first night of call. I drew the short straw and had the privilege of being on call the first night of internship. Not much else to know. There were no call quarters for sleeping. You did not expect to sleep.

All the key information on the cadre of patients under care were incorporated on to 3x5 index cards with one patient per cared. All the cards were combined and shuffled like a poker deck and dealt to the new interns. We were handed our stack and started walking rounds. When we reached the first ICU bed, a name was called and the intern who was dealt the card acknowledged their new charge.

Technology was crude. We had paper and pen. We had no pagers. All calls were send via overhead page. There were not many places to hide. Senior residents, nurses, and ward clerks knew how the hospital worked. From my recollection, they were very good at what they did but we were limited in what we could do. It was a not so complex world. We examined patients. We drew blood, We ordered simple tests, we started IV's. We administered drugs from a limited formulary, not because our hospital was poor but because there we a limited number of drugs at our disposal.

Yes in the ICU and CCU we had a few more tricks at our disposal. I put in a lot of Swan-Ganz catheters. That was before it was discovered these are generally pretty useless. We placed chest tubes and central lines. We had no ancillary teams doing that for us. Interventional Radiology did not really exist except in a few places were radiologists were toying with placing catheters where catheters had never been before.

Not so different with the transition to fellowship. I remember we had the transition from dial phones to push button. We were issued long distance codes. No longer did we require the assistance of telephone operators to call long distance. Little did I realize this was a harbinger of the transfer of tasks from support personnel to me. I did not concern myself with process. I simply saw the patient, made an assessment and wrote my thoughts on paper.  I wrote orders and assumed they were done. They were not so complex. Procedures meant I was called upon to undertake some task. I announced what I wanted to do and magically things were set up.  I did not trouble myself with how this happened.

My training happened in a Mayberry world. It was not comlpex. No one wore name tags because people don't wear name tags in Mayberry. Everyone knows who lives in Mayberry and everyone know their place.

Tomorrow, the new housestaff formally start. However, they have been around for more than a week. They have undergone a rigorous orientation at multiple sites. They have been vetted for practice at multiple sites in multiple hospitals and have been issued multiple name badges. Each hospital requires training on different computer systems, each requiring a unique set on logins; for the network, for the application, for remote access, each expiring after some period of time (usually three months), and each with a different set of stringency (at least 6-8 characters, mixture of upper and lower case with symbols, but excluding certain ones like \). Strangely enough we still have long distance codes even when the concept of what represents long distance is nearing extinction.

There are countless regulations not to fall afoul of. There is a constantly evolving set of competencies to measure up against, most of which are either irrelevant or un-measurable. The practice environments have become dizzyingly complex. The diagnostic and therapeutic options are orders of magnitude greater than anything I was offered as a resident or fellow. However, with that complexity comes the need for people and processes to deploy these options. At each step, the number of things done to of for patients has grown geometrically. They are hospitalized for shorter times where more things must be done.

It is very different. In some respects it is very different and good since we have options to save and improve lives which simply did not exist. In many respects this changed environment brings major challenges. We must face these challenges because we have no other choice. It is as much a part of the training environment than what learning the tasks I was called upon to learn as a house office 30 years ago. Hopefully the parts that bring little or no value to trainees or patients will disappear over time.

It is no longer Mayberry. It is not informal and for the most part it is not like family. It is business, complex, and behavior dictated by formal rules.

Ambulatory Surgery Centers, Regulations, and Access to Abortions

It has been an interesting news week, with all sorts of intriguing stories from the Supreme Court, stock market frothiness as a consequence of Fed whispering, the expanding civil war in Syria which threatens to to broader into a broader Sunni/ Shiite regional war, as well as the Paula Deen pile-on.

However, the story I found most intriguing was the story out of Texas where Senator Wendy Davis successfully filibustered proposed legislation. I have not blogged on anything related to abortion because I am basically hopelessly confused and conflicted. The issue can best be characterized as an impossible moral issue which will only become more difficult to address as technology pushes the bounds of what is medically possible. Who knows how we will handle the inevitable issues which will arise when we can really make test tube babies without the need for a human carrier. Anything that pulls the public away from the polar regions in this debate will be useful. The abortion issue is not going to be settled by anything as cut and dry as Roe vs. Wade this time. The science and medical advances have made this increasingly difficult.

This blog is not about such issues but instead I wish to look at on part of the Texas bill which applies regulatory standards on the centers which offer abortions in Texas. I need to ask what are the criteria we apply to require specific procedures to be done in an ambulatory surgery center and what are the benefits which accrue to patients by invoking such a requirement?

Not so long ago there was a piece written in the New York Times which highlighted the cost differential for procedures done is the US vs. elsewhere in the world (NYT). One such procedure was colonoscopy where much of this work is now done in ACS's. While ACS's are touted as lower cost environments when compared to hospitals, US ACS's are much more expensive than similar environments in Europe where colonoscopies are done. The US ACS's may offer higher level of service but the outcomes are virtually identical to what is seen in Europe where such procedures are done at substantially lower cost.

One of the issues raised by the Texas bill is the cost of moving the abortions done after 16 weeks to ASC certified facilities is that this is projected by some to essentially decimate the pool of available facilities which provide abortion services. Proponents of the bill say this is essential for patient safety, an argument made by multiple parties when arguing for this same requirement when applied to other procedures. In those cases the argument is potentially riddled with conflicts of interest because more expensive approaches to interventions may also be associated with higher fees and better margins. In the case of abortions that does not appear to be the case.

The key point here is whether the call for movement of this procedure to higher cost environment is likely to be associated with better patient outcomes. Data from a survey looking at abortions identified that there were 12 maternal deaths associated with the almost 800K abortions reported in the most recent year surveyed (2008 -CDC). Depending on how one looks at this it can either be viewed as the horrific death of 12 women in facilities that did not meet the standards set for ACS's which is UNACCEPTABLE or it could be spun as the services are offered in an environment which is marked by a remarkable safety record.

Taking all the moral baggage aside, one should ask why should procedures performed in abortion clinics be viewed any differently than procedures performed in other medical facilities.  This is really no different from how we look at statistics relating to certification of other medical facilities and their outcomes. We get alarmed by specific egregious examples where medical or dental offices are found to fall far outside acceptable practices and in response to these outliers, we push for onerous standards which are unlikely to affect the very outliers who prompted action in the first place.  We end up with procedures, which could be deployed safety at reasonable cost, which then are deployed at markedly higher cost with little of no additional benefit to those they are applied to.

Yes, we can rally for a safer environment for patients to have their procedures done in but we need to ask the question as to who this actually delivers value to? Does certification translate into anything useful? The anti-abortion forces can use the patient safety dodge and it puts the pro-abortion camp in a difficult t argue position unless they come to realize that this issue must be addressed as part of a much larger question; do more expensive and complex care environments lead to better outcomes and is any amount of money spent to save one life always justified?

It is probably a bad idea to attache this specific debate to the abortion issue. What can be guaranteed is that the likelihood for rational discourse approaches zero when abortion enters into the debate. Still, the question remains; why compel care move into higher cost environments when there is likely no benefit to those receiving the care? Just claiming one's intent is to create a better care environment should not be enough.

The IPAB: Doubling down on administrative payment systems

While various elements of the Affordable Care Act are slowly being deployed, one huge piece looms six months in the future. The first IPAB recommendations were originally slated to be released by January of 2014. However, this body still has no members. Some of the pressure to constitute this body has been dissipated since the chief actuary of CMMS reported a substantially lower growth rate project for Medicare spending for 2011-15 at 1.15% annually. I have my doubts that this medical inflation rate will continue. When the ACA really kicks in and more money floods into the health care economy, the medical inflation rate will be off to the races again.

I cannot begin to conceive how this entity will work to set the prices over what may amount to close to 20% of the economy. How will fifteen wise (or perhaps not so wise)  individuals be able to know when they have set the prices for particular services too high or too low? While much has been made about the claims that the IPAB cannot explicitly ration care, by setting payments low enough they can guarantee that undervalued services will be is short supply.

The only metrics they are charged with overseeing are total dollars spent. Not surprising since the main job of the IPAB is cost control.  Never (and I mean NEVER) in the history of mankind has such an entity every succeeded in setting prices or controlling costs. There are two possibilities. We could be smarter than everyone previously or we will meet the same fate. I have NO reason to believe we are smarter.

Rethinking Thin - A Contrarian view of weight loss

Th just finished reading Gina Kolata's book "Rethinking Thin". I have always enjoyed her columns and now after reading this book, I realize that she has a significant contrarian streak. This book calls into question a number of assumptions widely held about weight loss, ideal weights, and the health benefits of weight loss. A major portion of the book tracks subjects in a University of Pennsylvania weight loss study. Their stories are very touching and they serve as a backdrop to educate readers on dismal science of weight loss. 

I was not aware of the substantial evidence supporting the genetic basis of weight ranges, including multiple twin studies. It seems that with few and rare exceptions, our weight ranges are predetermined. While it has been postulated that appetite control circuits of the brain may be influenced at key points in human development, there is little evidence that any dietary interventions can make much of an enduring difference for a given individual. Diets come and go and weight comes off only to be put back on. It appears to be one of the only universal findings in medicine.

There is no question that we now live in a world where food is much more abundant than any time in history. While there are places on the earth where hunger exists, even pockets in wealth countries, for the overwhelming majority of Americans, we do not spend our time being hungry because we cannot get enough calories. It is hard for us to understand the the words of the Lord's Prayer..."give us this day our daily bread". At the time this prayer was first uttered, most of humanity had great fears regarding the source of their next meal. That these concerns are no longer primary is not such a bad thing. However, the anxieties associated with an abundance of food and its ramifications has replaced the anxieties generated by concerns about where our next meal will come from.

I think few would desire to move back to an earlier state of scarcity. The question is what is the impact of the  change in weight distribution toward being heavier in the US population? Gina Kolata's book raises substantial concerns that there is conflicting evidence supporting a negative health effect on those arbitrarily defined as being overweight and even those who are classified as stage I obese. In fact, recent studies (JAMA article) supported a lower mortality for those classified as overweight.

Our biases which lead to our visions of idea weight are based upon limited science and evolving perceptions of beauty and health. The recent history of this evolution is nicely described in Gina Kolata's book. It is not rare that people admit to being offended by site of obese people,  and such strongly held beliefs bring to mind religious beliefs. As Jonathan Haidt describes in his book "The Righteous Mind", many of us are influenced by concepts of sanctity and we may be offended by behaviors or appearances which violate things we view as being holy. How can people violate the temple that is their body?

I could not help to draw parallels between those who appear to be predestined to weigh more than others and those who appear to be predestined to be attracted to the same sex. This week Exodus International issues an amazing apology for trying to "cure" homosexual individuals. While this ministry was active for almost 40 years, the leaders of this organization have recently come to an epiphany: Alan Chambers noted in the  LA Times:

"I am sorry that some of you spent years working through the shame and guilt you felt when

your attractions didn't change," Chambers wrote in a statement on his website. "I am sorry that I ... failed to share publicly that the gay and lesbian people I know were every bit as capable of being amazing parents as the straight people that I know. I am sorry that I have communicated that you and your families are less than me and mine."
Chambers, who is married to a woman and has two adopted children, told The Times he is still attracted to men and comfortably lives with that tension, but that others may be unable to do so. He said that 99% of people who went through gay-conversion therapy did not lose their same-sex desires.

You can't remake people into what they are not. It is not a matter of willpower or self control.  I can imagine that after this obesity madness runs its course a similar apology may be forthcoming.

Blurring the distinctions between normal variation and disease

The newly released DSM 5 has created another round of controversy. Over the years, the DSM has grown in size and complexity and the latest version, with almost 950 pages. This latest version has been accompanied by issues of inadequate validity studies, even prompting the NIMH to work on its own study. In his book "Saving Normal", Dr. Allen Frances explains that a crux of the problem is that it is impossible to define normal or mental disorder.

This problem is not exclusive to psychiatry. In a world where we are tempted to medicalize everything, any variation ends up becoming some variant of pathology. What is normal and what is disease? This ends up having huge ramifications. If every undesirable human state is redefined as some variant of human disease, than everything becomes part of health care.

Are you shorter than you desire? That is verticality deficiency disorder which can be addressed. Are you emotionally disturbed by your body habitus? Might you want improved muscle tone or exercise tolerance? Difficulty with concentration or attention span? Peculiar pigmentation? Disturbed by the effects of aging on your appearance? All these states may be amenable to medical intervention.

In a world where we use our individual resources to address these issues, we make decisions as to our own priorities. However, it the brave new world where resources are commonized first and then allocated by all knowing central bureaucracies, the legally mandated one size fits all of entitlements forces us to decide what is normal and what is sufficiently pathological to warrant interventions. It is an impossible task.

Phasing out Fee for service

The NEJM published yet another piece addressing the payment system in health care. It is based upon a report issued by the "The National Commission on Physician Payment Reform", which  was created by the Society of General Internal Medicine (SGIM) to assess how physicians are paid, and how pay incentives are linked to patient care.Their summary recommendations were the following:

1. Over time, payers should largely eliminate stand-alone fee-for-service payment to medical practices because of its inherent inefficiencies and problematic financial incentives.

2. The transition to an approach based on quality and value should start with the testing of new models of care over a 5-year time period, incorporating them into increasing numbers of practices, with the goal of broad adoption by the end of the decade.

3. Because fee-for-service will remain an important mode of payment into the future, even as the nation shifts toward fixed-payment models, it will be necessary to continue recalibrating fee-for-service payments to encourage behavior that improves quality and cost-effectiveness and penalize behavior that misuses or overuses care.

4. For both Medicare and private insurers, annual updates should be increased for evaluation and management codes, which are currently undervalued. Updates for procedural diagnosis codes should be frozen for a period of three years, except for those that are demonstrated to be currently undervalued.

5. Higher payment for facility-based services that can be performed in a lower-cost setting should be eliminated.

6. Fee-for-service contracts should always incorporate quality metrics into the negotiated reimbursement rates.

7. Fee-for-service reimbursement should encourage small practices (those having fewer than five providers) to form virtual relationships and thereby share resources to achieve higher quality care.

8. Fixed payments should initially focus on areas where significant potential exists for cost savings and higher quality, such as care for people with multiple chronic conditions and in-hospital procedures and their follow-up.

9. Measures to safeguard access to high quality care, assess the adequacy of risk-adjustment indicators, and promote strong physician commitment to patients should be put into place for fixed payment models.

10. The Sustainable Growth Rate (SGR) should be eliminated. Repeal of the SGR should be paid for with cost-savings from the Medicare program as a whole, including both cuts to physician payments and reductions in inappropriate utilization of Medicare services.

11. The Relative Value Scale Update Committee (RUC) should make decision-making more transparent and diversify its membership so that it is more representative of the medical profession as a whole. At the same time, CMS should develop alternative open, evidence-based, and expert processes to validate the data and methods it uses to establish and update relative values.

Don't get me wrong. The way we pay for medical services has created all sorts of problems and deformations in the health care markets. However, these recommendations simply invite a different set of top down perversions.   Whether services are paid piecemeal or bundled is best decided by those at the point of service. At this point one of the biggest problems for someone who in entrepreneurial is that participation in Medicare simply gives one little or no leeway in terms of redefining and rebundling of services.

Recalibrating fees from the top down is simply a form of perpetuating the same administrative pricing boondoggles we now suffer from. Using political processes to define prices never works. What is being entertained is simply changing who will hold the political cards.

There are two reforms which are essential. The first is to move as much of the payments away from third party mechanisms as possible. Until there is a realization that third party payment is the central problem we are no going to make much headway into fixing the worsening mess.Catastrophic health issues should be backstopped with insurance. However, much of medicine does not happen in this realm.

Second, the regulatory environment needs to be changed. To get to where people have access to what enhances their health, we need to broaden our view of who can deliver services and how they can be delivered .We need to move away from an archaic encounter based model and deploy new technologies to allow for asynchronous encounters and exchanges which empower patients to receive value at steeply lower costs.

None of this is captured by the SGIM document.