Today I read in the LA Times and the Washington Post that the poster child for integrative health care, the Mayo Clinic, is making moves to limit access to patients who have certain forms of Medicare and Medicaid. It is pretty obvious that they are making those decisions since their margins on those patients are less advantageous than patients covered under other insurers or those who pay cash. If the truth be told, they are likely pursuing a strategy publicly that virtually all other health systems are doing privately if they can.
What does it mean when major health systems limit access to insured patients. Obviously it means they will have a hard time getting what they want when they want it. The implications in a world post health care reform will very much depend upon how health care reform is structured. There will likely be outlets for que jumping for those who have means, although there is no guarantee this will be the case given our experience with Medicare. What sort of enhancements will be available to those who have means?
It may be that the Mayo model is dependent upon extracting higher rents from private insurance models and being geographically placed to avoid specific high cost, lower margin patient populations. If health care reform closes the avenues for patients to pay premium prices, either indirectly through their insurance or directly through their own pocketbooks, what happens to the Mayo model? Does their model have sufficient margins to continue with only the geography piece to exploit?
In contrast to the Mayo refusal to accept selected patients covered by Medicaid and Medicare, most public hospitals are happy when they can receive any payment for much they end up providing for free, but they do not represent the model for sustainable health care of the future. I suspect they may fare even worse under health care reform. The first thing to go will be their local subsidies. Taxpayers will not believe there is any reason for their tax dollars should go to pay for both underwriting a national health plan and their local public hospitals.
One thing that we should all expect is that things that our actions will always generate a combination of intentional AND unintentional consequences. The unintentional consequences which will unquestionably occur is that the only viable health care entities which will survive in the future are ones that can avoid spending more money than they take in. Virtuous, non-profit seeking organizations will do fine as long as their non-profit seeking behaviors result in consistently positive cash flows. That is not likely in the long run (or even in the short run).
In a world where prices for services float and multiple levels of service are priced through market measures, there are all types of opportunities for for health care organizations and providers to fill the almost infinite numbers of niches which ultimately serve human needs. However, the direction we are moving will result continuation of the status quo; financial survival of organizations that can figure out how to avoid the terrible trifecta: poor payers, bad geography, and poorly paying health care activities.
Sunday, October 11, 2009
Thursday, October 8, 2009
Close but no cigar
I saw the article link on Greg Mankiw's Blog to Martin Feldstein's piece in the Washington Post (http://www.washingtonpost.com/wp-dyn/content/article/2009/10/07/AR2009100703048.html). It is an interesting idea which proposes to use a a government issued health insurance voucher to underwrite the private purchase of high deductible policies which feature a sliding scale deductible based upon a fixed percentage of gross income. He also advocates the voluntary use of a government issued credit card to cover the deductible if individuals or families do not have cash flow to cover expenses.
The upside is that this approach would create some pricing discipline in medicine, since people would be less insulated from the actual cost of much of medicine. It would be worth testing in a demonstration project. However, I see at least two major problems. First, I cannot see the Federal Government as an effective agent in terms of running a credit card company. How exactly would this work? Would this simply be farmed out to MasterCard of Discover? Would individual states handle this?
I have a hard time imagining Uncle Sam playing the role of loan collector. Granted, the Feds know a lot about our individual financial circumstances but I fear that political fallout would preclude aggressive collection of health care debts. A program like this would also be very prone to massive fraud.
It is great that the proposed program builds such an effective safety net. That is the very reason that I fear it has such a potential for similar or worse moral hazards than our present system. Ultimately, the only effective curb on ridiculous pricing of health care services is when the public in general feels their sting. Insurance insulates the public to a sufficient degree to insulate medical pricing from consistent downward pressures. This is not to say that lots of people don't get hurt by health care expenses. However, enough are protected to allow for the system to continue, for now.
This approach still does not explicitly address the problem with pricing in health care. Presumably since most of ambulatory care would occur below the deductible, how will prices for non-insured services be determined? While virtually all providers now participants in insurance plan, a move to high deductibles would prompt many to move to a non-insurance model. While I believe this would ultimately create a more rational pricing structure, the transition could be very disruptive. Would Medicare be part of this voucher program?
The upside is that this approach would create some pricing discipline in medicine, since people would be less insulated from the actual cost of much of medicine. It would be worth testing in a demonstration project. However, I see at least two major problems. First, I cannot see the Federal Government as an effective agent in terms of running a credit card company. How exactly would this work? Would this simply be farmed out to MasterCard of Discover? Would individual states handle this?
I have a hard time imagining Uncle Sam playing the role of loan collector. Granted, the Feds know a lot about our individual financial circumstances but I fear that political fallout would preclude aggressive collection of health care debts. A program like this would also be very prone to massive fraud.
It is great that the proposed program builds such an effective safety net. That is the very reason that I fear it has such a potential for similar or worse moral hazards than our present system. Ultimately, the only effective curb on ridiculous pricing of health care services is when the public in general feels their sting. Insurance insulates the public to a sufficient degree to insulate medical pricing from consistent downward pressures. This is not to say that lots of people don't get hurt by health care expenses. However, enough are protected to allow for the system to continue, for now.
This approach still does not explicitly address the problem with pricing in health care. Presumably since most of ambulatory care would occur below the deductible, how will prices for non-insured services be determined? While virtually all providers now participants in insurance plan, a move to high deductibles would prompt many to move to a non-insurance model. While I believe this would ultimately create a more rational pricing structure, the transition could be very disruptive. Would Medicare be part of this voucher program?
Sunday, October 4, 2009
Location, location, location
I am amazed that the longer I practice medicine, the more it looks like real estate. I know that sounds bizarre, but allow me to elaborate. There is a dictum in real estate which says something to the effect that the most important determinant of value is location, location, and location. Ostensibly what this means is the actual structure is really of secondary importance, no matter what anyone has put into it. What is most important is where the structure happens to be placed.
The practice of medicine follows the same rules. Instead of location we deal with context. Information in medicine is critical but information without context is difficult to interpret and potentially dangerous. When I was in training, we still checked serologic tests for syphilis on every patient who was admitted to the hospital. While this practice was perhaps useful at a time where the prevalence of syphilis exposure and occult carriage was significant in the patients who were being admitted, by the time I came along most of the positive blood test that came along were false positives. The screening test was a good test within a certain context but its application needed to remain within that context for it to be useful.
The utility of both diagnostic and therapeutic interventions need to be understood within the context they are validated. In fact, the entire practice of medicine needs to be examined within the context of who we see and why we see them. During the past century, there has been a fundamental change in the types of patients we see and why we see them. We have moved from a model of seeing patients when they clearly identifiable present problems to a model where we see them when they are feeling fine in the hopes that we can keep it that way. Unfortunately, I do not believe we have adequately modified our thinking to account for this dramatic change in context.
There was a time where most patients seen were actually sick. Our physical exam tools were validated (at least to some degree) within those contexts. Similarly, most of our diagnostic tests were validated within specific well defined disease contexts. Rales detected on chest exam within the context of fever and a cough points to pneumonia. A positive RPR within the context of a young sexually active man with a palmar plantar rash is meaningful.
Despite moving to a well patient model, we still do many of the same things to our patients, using tools that have been validated in patients with illness. What is the utility of listening to the chest of an asymptomatic 20 year old? What is the utility of examining every square centimeter of skin in a young, dark-skinned patient with no personal or family history of skin disease? What is the hit rate for relevant findings for any of these routine exams or labs in asymptomatic individuals?
Like real estate and location, the first thing to always consider in medicine is our location equivalent, context. We should not even begin to consider how many baths or how big the yard is until we have clearly defined location, location, location.
The practice of medicine follows the same rules. Instead of location we deal with context. Information in medicine is critical but information without context is difficult to interpret and potentially dangerous. When I was in training, we still checked serologic tests for syphilis on every patient who was admitted to the hospital. While this practice was perhaps useful at a time where the prevalence of syphilis exposure and occult carriage was significant in the patients who were being admitted, by the time I came along most of the positive blood test that came along were false positives. The screening test was a good test within a certain context but its application needed to remain within that context for it to be useful.
The utility of both diagnostic and therapeutic interventions need to be understood within the context they are validated. In fact, the entire practice of medicine needs to be examined within the context of who we see and why we see them. During the past century, there has been a fundamental change in the types of patients we see and why we see them. We have moved from a model of seeing patients when they clearly identifiable present problems to a model where we see them when they are feeling fine in the hopes that we can keep it that way. Unfortunately, I do not believe we have adequately modified our thinking to account for this dramatic change in context.
There was a time where most patients seen were actually sick. Our physical exam tools were validated (at least to some degree) within those contexts. Similarly, most of our diagnostic tests were validated within specific well defined disease contexts. Rales detected on chest exam within the context of fever and a cough points to pneumonia. A positive RPR within the context of a young sexually active man with a palmar plantar rash is meaningful.
Despite moving to a well patient model, we still do many of the same things to our patients, using tools that have been validated in patients with illness. What is the utility of listening to the chest of an asymptomatic 20 year old? What is the utility of examining every square centimeter of skin in a young, dark-skinned patient with no personal or family history of skin disease? What is the hit rate for relevant findings for any of these routine exams or labs in asymptomatic individuals?
Like real estate and location, the first thing to always consider in medicine is our location equivalent, context. We should not even begin to consider how many baths or how big the yard is until we have clearly defined location, location, location.
Informing and consenting
I read a piece on Medscape summarizing the findings from a recent Archives of Internal Medicine article (Hoffman - Arch Intern Med. 2009;169:1557-1559, 1611-1618.). In this study they found that fully one third of men who underwent PSA testing where not counseled ahead of time regarding the purpose, implications, and limitations of the screening test.
I can't say this was surprising. From first hand experience I can attest to the fact that we medical training focuses on wrote memorization of vast amounts of trivia, development of specific technical skills, and a culture of testing which relies on multiple choice tests which substitutes forced selection of the "right" answer for any actual appreciation of nuance and uncertainty. How can a physician present choices when this discussion has rarely been entertained in their training environment.
There are so many structural and cultural problems which influence this outcome that it is hard to begin to look where to make changes. I believe there are two principles which should guide us with our encounters with patients. First,after we have intervened we should be relatively confident that the patient is better off than before we intervened. Second, the principle of patient autonomy is (or at least should be) central to everything we do. Basically, adherence to these two principles will result in no intervention unless we believe the patient is better off AND we can convince the patient of this.
With this as a starting point, perhaps we should consider changing some terminology. We now engage in a process which is termed informed consent. Just the way the wording is set up places the emphasis on the consent, informing being just a modifier of the consent process. I propose we change this to informing and consenting. This places equal weight on both processes since the consent is actually meaningless without the informed piece.
There is an organization called the Foundation for Informed Medical Decision Making which is developing educational tools for patients to make such decisions (http://www.fimdm.org/about_hd.php). This has tremendous potential but has a number of potential unintended consequences. It will be a source of pressure on physicians to remain informed. I have no doubt of the ability of information systems to outstrip the knowledge base of even well read providers. It will also provide a challenge in terms of who can and will vet the information. Perhaps a "Wikopedia" like model will develop with multiple editors. I am sure that will serve as a challenge to the keepers of the temple of knowledge. What is sure is physicians will be challenged in terms of being the sole source of proprietary knowledge. The asymmetry of information noted by Kenneth Arrow 50 years ago may have been a temporary state.
I can't say this was surprising. From first hand experience I can attest to the fact that we medical training focuses on wrote memorization of vast amounts of trivia, development of specific technical skills, and a culture of testing which relies on multiple choice tests which substitutes forced selection of the "right" answer for any actual appreciation of nuance and uncertainty. How can a physician present choices when this discussion has rarely been entertained in their training environment.
There are so many structural and cultural problems which influence this outcome that it is hard to begin to look where to make changes. I believe there are two principles which should guide us with our encounters with patients. First,after we have intervened we should be relatively confident that the patient is better off than before we intervened. Second, the principle of patient autonomy is (or at least should be) central to everything we do. Basically, adherence to these two principles will result in no intervention unless we believe the patient is better off AND we can convince the patient of this.
With this as a starting point, perhaps we should consider changing some terminology. We now engage in a process which is termed informed consent. Just the way the wording is set up places the emphasis on the consent, informing being just a modifier of the consent process. I propose we change this to informing and consenting. This places equal weight on both processes since the consent is actually meaningless without the informed piece.
There is an organization called the Foundation for Informed Medical Decision Making which is developing educational tools for patients to make such decisions (http://www.fimdm.org/about_hd.php). This has tremendous potential but has a number of potential unintended consequences. It will be a source of pressure on physicians to remain informed. I have no doubt of the ability of information systems to outstrip the knowledge base of even well read providers. It will also provide a challenge in terms of who can and will vet the information. Perhaps a "Wikopedia" like model will develop with multiple editors. I am sure that will serve as a challenge to the keepers of the temple of knowledge. What is sure is physicians will be challenged in terms of being the sole source of proprietary knowledge. The asymmetry of information noted by Kenneth Arrow 50 years ago may have been a temporary state.
The great screening disappointment
There were two stories which hit the lay press this week which dealt with related issues, prostate cancer and melanoma. The NY Times article - Melanoma on the Rise, or Is It Just Diagnoses? By NICHOLAS BAKALAR September 28, 2009 ) is in fact one of series articles in the NYT dating back over 10 years which have raised similar questions after prompting from articles published in the peer-reviewed medical literature.
http://www.nytimes.com/2009/09/29/health/29mela.html
This article, reporting on a study published in the September issue of The British Journal of Dermatology, raised the question whether early screening using skin exams actually results in any patient benefit. The usual actors weigh in, stating the usual justifications for their positions, an exercise which I think is the equivalent of what we used to observe in our very small children when they engaged in "parallel play". They were in the same room and using the same toys, but they displayed little actual substantial interactions or exchange.
The realization that what appeared to be such a simple concept, that is screening for cancer, turns out to be so devilishly difficult is slowly playing out in the peer reviewed realm and inexorably spilling into the lay press. The history of the screening paradigm is wonderfully reviewed by Dr. Barnett Kramer (Editor of the JCNI) in a great video on the Research Channel.
http://www.researchchannel.org/prog/displayevent.aspx?fID=567&rID=29066
It can be accessed via Google video. The take home message is it is easy to discover what can be diagnosed as early cancer. Whether what is discovered is actually biologically malignant and whether intervention prolongs lives is uncertain.
There are some very interesting parallels to earlier events in human history outside of medicine. Many has always had a desire to predict and control future events. Throughout much of history, these efforts have focused on supernatural deities and magical thinking. For over 1000 years the Oracle at Delphi held sway over critical decision making in the western world. The same origins of hard science in astronomy are intermixed with the magical thinking in astrology. The revolution of science and Newtonian mechanics led earlier generations of scientists to believe in determinism; that with enough information regarding our current state we could predict the future.
The quantum revolution of the early 20th century put an end to such thinking in the world of physics and the impact of this is still diffusing out, slowly influencing thinking in other predictive realms. It is unquestionably painful to the luminaries of both physical biological sciences, creating and understanding of the uncertainty which is inherent in any predictive activity. The hard lesson was that one can never be sufficiently informed about the present state to reliably predict the future state. Determinism is dead and this should be recognized as being true within medical sciences as any other branch of science.
Predictive health initiatives and screening activities to prevent future events are wonderful marketing tools. We all want them to be true, they attract idea patients (who are not sick), and they validate our own desires to have predictive powers. Like other fields (e.g - finance, meteorology, business) the value of health professionals is still linked to our ability to look into the future and we are understandably reticent to admit the limits of our prognisticatory capabilities. If we can't provide such information, where is our worth?
The problem with the predicting the future is that it has not happened yet. Where the stakes are high enough, prediction will always result in action which always has the potential to alter the outcomes. Whether the intervention made a difference is not discernible. It is Schrodinger's cat all over again.
http://www.nytimes.com/2009/09/29/health/29mela.html
This article, reporting on a study published in the September issue of The British Journal of Dermatology, raised the question whether early screening using skin exams actually results in any patient benefit. The usual actors weigh in, stating the usual justifications for their positions, an exercise which I think is the equivalent of what we used to observe in our very small children when they engaged in "parallel play". They were in the same room and using the same toys, but they displayed little actual substantial interactions or exchange.
The realization that what appeared to be such a simple concept, that is screening for cancer, turns out to be so devilishly difficult is slowly playing out in the peer reviewed realm and inexorably spilling into the lay press. The history of the screening paradigm is wonderfully reviewed by Dr. Barnett Kramer (Editor of the JCNI) in a great video on the Research Channel.
http://www.researchchannel.org/prog/displayevent.aspx?fID=567&rID=29066
It can be accessed via Google video. The take home message is it is easy to discover what can be diagnosed as early cancer. Whether what is discovered is actually biologically malignant and whether intervention prolongs lives is uncertain.
There are some very interesting parallels to earlier events in human history outside of medicine. Many has always had a desire to predict and control future events. Throughout much of history, these efforts have focused on supernatural deities and magical thinking. For over 1000 years the Oracle at Delphi held sway over critical decision making in the western world. The same origins of hard science in astronomy are intermixed with the magical thinking in astrology. The revolution of science and Newtonian mechanics led earlier generations of scientists to believe in determinism; that with enough information regarding our current state we could predict the future.
The quantum revolution of the early 20th century put an end to such thinking in the world of physics and the impact of this is still diffusing out, slowly influencing thinking in other predictive realms. It is unquestionably painful to the luminaries of both physical biological sciences, creating and understanding of the uncertainty which is inherent in any predictive activity. The hard lesson was that one can never be sufficiently informed about the present state to reliably predict the future state. Determinism is dead and this should be recognized as being true within medical sciences as any other branch of science.
Predictive health initiatives and screening activities to prevent future events are wonderful marketing tools. We all want them to be true, they attract idea patients (who are not sick), and they validate our own desires to have predictive powers. Like other fields (e.g - finance, meteorology, business) the value of health professionals is still linked to our ability to look into the future and we are understandably reticent to admit the limits of our prognisticatory capabilities. If we can't provide such information, where is our worth?
The problem with the predicting the future is that it has not happened yet. Where the stakes are high enough, prediction will always result in action which always has the potential to alter the outcomes. Whether the intervention made a difference is not discernible. It is Schrodinger's cat all over again.
Monday, September 28, 2009
What's the point?
The piece by Jamie Heywood: Forget Medical Privacy in Wired Magazine last week (http://www.wired.com/techbiz/people/magazine/17-10/ff_smartlist_heywood) regarding patient access to medical records makes perfect sense..at first. However it raises a number of questions. Why have we not shared such records in the first place? What is the historical background regarding information conveyed from physicians to patients? What exactly is the contractual relationship between doctor and patient? Who hires the doctor? What is the specific agreement between patient and physician in terms of deliverables? What is the purpose of the medical records? Are all the purposes of the medical record the same for all parties who may need access to the record?
When you start to think about the medical record in this light, it appears that many elements and aspects of the medical record have never really been defined. For the physician, the record developed as a tool which allowed him (or her) to recall key elements of the patient’s history at subsequent visits. It was primarily a tool which allowed future care to be done with sufficient information about the past. The patient had little interest in these notes since they did not contain information which could be interpreted by the patient. There was generally no agreement that the physician would create any sort product such as a written document relating to the patient’s care. The physician’s job was to diagnose and treat.
At some point, the medical record developed additional purposes. It took on legal importance, perhaps sometime in the 19th century during the nation’s first “malpractice crisis”. In the 20th century it became an essential piece in justification of billings. In order to get bills paid, both physician and patient acquiesced to having a third party be privy to the physician notes. One of the third parties was the State since state payers became dominant players in the game. Furthermore, the medical record took on legal importance in that it took on specific and perhaps onerous legal protections in the form of HIPPA.
While the ambiguity regarding ownership and purpose of the medical record was not critical in an earlier era, it creates problems in the present environment. It represents only a piece of the ambiguity inherent in the entire structure of the medical encounter as currently structured. There is a contractual relationship between physician and patient and perhaps it is desirable to better define the nature of the deliverables. When I go to an attorney to deal with a specific legal issue, I generally have a defined expectation as to what I will have when the encounter is completed. Similarly, I have comparable expectations when I see my accountant or other financial advisors. These are fellow professionals who have created a much less ambiguous relationship with their clients.
The ambiguity theme permeates medical encounters. Our present encounter structure harkens back to an earlier era where the doctor patient relationship bore scant resemblance to our current times. We (as clients) now schedule meetings with a host of professionals in the hope that we derive some benefit. For anyone who has any concept of time management, an agenda-less meeting is an anathema. Yet, we actively discourage patients from bringing an actual agenda. Bringing a list is generally evokes outright hostility but why is this? Shouldn’t patients and physicians welcome transparency in regards to actual goals and objectives?
As it stands, some vague rationale for a visit may be understood. It may be represented by some brief and often misspelled reason for a visit typed into the schedule by by some call center employee who might as well reside in Banglore. It may be as nebulous as here for a “check up”. Ultimately what is the product of a specific visit? Would it not be reasonable for both patient and doctor to have defined the anticipated deliverables before the visit?
At least one of the deliverables might be a summary report which is geared to the patient. It should be structured is such a way that the conclusions of the provided are obvious as is the rationale for any specific interventions and tests. The report need not be available immediately after the encounter since not all conclusions and plans can be formulated in real time. This report unquestionably would belong to the patient. Whether all notes and information collected as part of the visit would belong to the patient could be open to debate. However, the simplest approach to this problem is to define the deliverables as everything the patient paid for; all tests billed to the patient as well as a summary report which contained defined elements. These elements would include the diagnosis, a modifier which could convey the degree of certainty (unquestionable, likely, possible, atypical), prognosis, reasons for treatment, and recommended interventions.
Instead, we engage in factory medicine, encouraged by payment schemes which were openly designed to encourage volume. Patients of earlier generations raised in a culture of deference to physicians and general stoicism tolerated the movement toward cattle call medicine, occasionally erupting in sporadic annoyance but more commonly responded with bewilderment. The newer Gen X and Yer’s failed to understand why, in a world increasingly engineered to cater to their individual needs, medicine was so unresponsive. Not surprisingly no one has a good answer other than this is how we have always done things.
When you start to think about the medical record in this light, it appears that many elements and aspects of the medical record have never really been defined. For the physician, the record developed as a tool which allowed him (or her) to recall key elements of the patient’s history at subsequent visits. It was primarily a tool which allowed future care to be done with sufficient information about the past. The patient had little interest in these notes since they did not contain information which could be interpreted by the patient. There was generally no agreement that the physician would create any sort product such as a written document relating to the patient’s care. The physician’s job was to diagnose and treat.
At some point, the medical record developed additional purposes. It took on legal importance, perhaps sometime in the 19th century during the nation’s first “malpractice crisis”. In the 20th century it became an essential piece in justification of billings. In order to get bills paid, both physician and patient acquiesced to having a third party be privy to the physician notes. One of the third parties was the State since state payers became dominant players in the game. Furthermore, the medical record took on legal importance in that it took on specific and perhaps onerous legal protections in the form of HIPPA.
While the ambiguity regarding ownership and purpose of the medical record was not critical in an earlier era, it creates problems in the present environment. It represents only a piece of the ambiguity inherent in the entire structure of the medical encounter as currently structured. There is a contractual relationship between physician and patient and perhaps it is desirable to better define the nature of the deliverables. When I go to an attorney to deal with a specific legal issue, I generally have a defined expectation as to what I will have when the encounter is completed. Similarly, I have comparable expectations when I see my accountant or other financial advisors. These are fellow professionals who have created a much less ambiguous relationship with their clients.
The ambiguity theme permeates medical encounters. Our present encounter structure harkens back to an earlier era where the doctor patient relationship bore scant resemblance to our current times. We (as clients) now schedule meetings with a host of professionals in the hope that we derive some benefit. For anyone who has any concept of time management, an agenda-less meeting is an anathema. Yet, we actively discourage patients from bringing an actual agenda. Bringing a list is generally evokes outright hostility but why is this? Shouldn’t patients and physicians welcome transparency in regards to actual goals and objectives?
As it stands, some vague rationale for a visit may be understood. It may be represented by some brief and often misspelled reason for a visit typed into the schedule by by some call center employee who might as well reside in Banglore. It may be as nebulous as here for a “check up”. Ultimately what is the product of a specific visit? Would it not be reasonable for both patient and doctor to have defined the anticipated deliverables before the visit?
At least one of the deliverables might be a summary report which is geared to the patient. It should be structured is such a way that the conclusions of the provided are obvious as is the rationale for any specific interventions and tests. The report need not be available immediately after the encounter since not all conclusions and plans can be formulated in real time. This report unquestionably would belong to the patient. Whether all notes and information collected as part of the visit would belong to the patient could be open to debate. However, the simplest approach to this problem is to define the deliverables as everything the patient paid for; all tests billed to the patient as well as a summary report which contained defined elements. These elements would include the diagnosis, a modifier which could convey the degree of certainty (unquestionable, likely, possible, atypical), prognosis, reasons for treatment, and recommended interventions.
Instead, we engage in factory medicine, encouraged by payment schemes which were openly designed to encourage volume. Patients of earlier generations raised in a culture of deference to physicians and general stoicism tolerated the movement toward cattle call medicine, occasionally erupting in sporadic annoyance but more commonly responded with bewilderment. The newer Gen X and Yer’s failed to understand why, in a world increasingly engineered to cater to their individual needs, medicine was so unresponsive. Not surprisingly no one has a good answer other than this is how we have always done things.
Tuesday, September 22, 2009
The inherent dependence of specialists on generalists
I had some recent surgery to repair an orthopedic issue. The surgeon is extremely good at what he does. He benefits from being very focused on a defined skill set and he does what he does repeatedly and often. Practice does make near perfect.
For the model of physician care which requires defined and discrete tasks whose execution requires little knowledge beyond the specific organ-limited pathology, this approach works fine. The orthopedist may repair my knee, the gastroenterologist may peer into their periscope, the dermatologist excise the skin cancer, or the cardiologist may place their stent. Assuming the patient survives the immediate post procedural period and the repair holds, any other problem the patient may have is someone else's concern.
This whole model is predicated on the assumption that problems can be treated discretely. Many problems can be approached this way and there are substantial incentives to stake out your claim as a physician in an arena where problems can be managed with such distinct beginnings and ends. However, one of the problems with this approach is a product of hyper-specialization; the loss of the ability to do much of anything else.
Who in this model sees the big picture? I believe in the ideal world, from the perspective of a patient, the most valued healer is someone who cares for them, not someone who can do something to them. Interventions may be a piece of the care package, but as those whose professional activities become more and more focused on a limited number of things they do and think about, they become less valuable in terms of integrating care. There may even be a point where their skill sets render them incapable of this. When a physician has done nothing but robotic prostatectomies, or ERCPs, or Mohs surgery, or cataract surgeries, or knee replacements for countless years, they likely are not able to keep sufficiently up to date to perform any function which requires them to have a broad medical knowledge base outside of their narrow focus of expertise.
There may be financial advantages to individual physicians who can claim to be incapable to having the understanding which would allow them to care for many facets of their patient's needs. From the standpoint of controlling one's time and being paid optimally for acquired skills, the ideal scenario is assume responsibility for only a very defined period of time and to be paid as handsomely as possible for a defined intervention. However, I think virtually anyone would be hard pressed to see this as a model which would be highly desired by patients under any circumstances.
In virtually all other realms of human interactions the person who is most highly valued is the one who is in charge. We value those who can coordinate human activity, identify where activity has created real value, and see where other activities represent only Brownian movement. In medicine, assuming long term broad responsibility is like holding the "old Maid" in cards. It means making difficult decisions, open ended commitments, dealing with lots of uncertainty, being responsive to all types of patient needs and getting paid badly. If the building trade were like medicine, the most poorly paid schmucks would be the general contractors.
We still have cadres of generalists and specialists who maintain a generalist knowledge base. These docs often find themselves fielding calls from patients on a broad variety of topics, even outside their realms of expertise. Patients are good at detecting physicians who have a modest knowledge base and exhibit the slightest proclivity toward problem solving. Why any physician would persist in this type of behavior in the current climate may be hard to fathom. To some it is a higher calling. To others perhaps it is reflective of some sort of personality disorder, trying to gain stature by demonstrating competence beyond their peers. Given the present incentive structure, it is not unreasonable to predict the behavior will become increasingly less common at a very time where it is needed more than ever.
The trend toward hyper-specialization is not going away. Perhaps it is accelerating. When do we reach a tipping point? If 10% of the physician workforce is completely incapable of understanding anything outside of their narrow focus of technical expertise, is that a problem? What about 50%? 80%? Should someone else fill that void?
For the model of physician care which requires defined and discrete tasks whose execution requires little knowledge beyond the specific organ-limited pathology, this approach works fine. The orthopedist may repair my knee, the gastroenterologist may peer into their periscope, the dermatologist excise the skin cancer, or the cardiologist may place their stent. Assuming the patient survives the immediate post procedural period and the repair holds, any other problem the patient may have is someone else's concern.
This whole model is predicated on the assumption that problems can be treated discretely. Many problems can be approached this way and there are substantial incentives to stake out your claim as a physician in an arena where problems can be managed with such distinct beginnings and ends. However, one of the problems with this approach is a product of hyper-specialization; the loss of the ability to do much of anything else.
Who in this model sees the big picture? I believe in the ideal world, from the perspective of a patient, the most valued healer is someone who cares for them, not someone who can do something to them. Interventions may be a piece of the care package, but as those whose professional activities become more and more focused on a limited number of things they do and think about, they become less valuable in terms of integrating care. There may even be a point where their skill sets render them incapable of this. When a physician has done nothing but robotic prostatectomies, or ERCPs, or Mohs surgery, or cataract surgeries, or knee replacements for countless years, they likely are not able to keep sufficiently up to date to perform any function which requires them to have a broad medical knowledge base outside of their narrow focus of expertise.
There may be financial advantages to individual physicians who can claim to be incapable to having the understanding which would allow them to care for many facets of their patient's needs. From the standpoint of controlling one's time and being paid optimally for acquired skills, the ideal scenario is assume responsibility for only a very defined period of time and to be paid as handsomely as possible for a defined intervention. However, I think virtually anyone would be hard pressed to see this as a model which would be highly desired by patients under any circumstances.
In virtually all other realms of human interactions the person who is most highly valued is the one who is in charge. We value those who can coordinate human activity, identify where activity has created real value, and see where other activities represent only Brownian movement. In medicine, assuming long term broad responsibility is like holding the "old Maid" in cards. It means making difficult decisions, open ended commitments, dealing with lots of uncertainty, being responsive to all types of patient needs and getting paid badly. If the building trade were like medicine, the most poorly paid schmucks would be the general contractors.
We still have cadres of generalists and specialists who maintain a generalist knowledge base. These docs often find themselves fielding calls from patients on a broad variety of topics, even outside their realms of expertise. Patients are good at detecting physicians who have a modest knowledge base and exhibit the slightest proclivity toward problem solving. Why any physician would persist in this type of behavior in the current climate may be hard to fathom. To some it is a higher calling. To others perhaps it is reflective of some sort of personality disorder, trying to gain stature by demonstrating competence beyond their peers. Given the present incentive structure, it is not unreasonable to predict the behavior will become increasingly less common at a very time where it is needed more than ever.
The trend toward hyper-specialization is not going away. Perhaps it is accelerating. When do we reach a tipping point? If 10% of the physician workforce is completely incapable of understanding anything outside of their narrow focus of technical expertise, is that a problem? What about 50%? 80%? Should someone else fill that void?
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