By Ilana Yurkiewicz

My preceptor would call this a “Pandora’s Box” case. Do not open the conversation if you are not prepared to grapple with all of its consequences. This is what I am thinking as I interview Ms. L.

I have a standard set of social history questions. Ms. L screens positive for nearly all of them. Victim of domestic violence. Victim of sexual violence. Poverty. Addiction. Depression. Thoughts of self-harm.

I try not to cringe as she pulls down her gown to show me scars on her chest where an ex-boyfriend burned her with cigarettes. I am looking at deep bruises, not at the hands of some common enemy we call illness, but at the hands of another human being. What compels someone to do that? We are in a hospital, but this is far from strictly a medical problem. Continue reading “When Practicing on Patients Can Have Real Consequences”

By Richard Reece, MD

The National Journal has released a Special Report. The Report features a series of  four articles: Restoration Calls – Fixing America’s Crumbling Foundation. Among these articles is: “Why Do We Trust Doctors?”  It contains results of a Gallup poll, showing trust in doctors is at all-time high of 70% over the last ten years.

This is intriguing considering numerous media articles on physician personal profiteering and physician partnerships in technologies such as imaging equipment  for financial gain.

The article begins, ”We’re cynics about insurance companies and critics of big health companies.  So why do we still believe in physicians?”

Why indeed?  The author of the April 26 piece, Margot Sanger-Katz, tells the story of 60 year old Mary Morse-Dwelley of Maine who has undergone 22 operations to close an abdominal incision and who has had her gallbladder, uterus, and 2 feet of intestine removed.  She has spent two years in bed. Despite this long surgical ordeal, she implicitly trusts her surgeon. So does the American public, if you believe Gallup.

When patients are asked why they trust doctors, patients say they see doctors as someone who is trying their best to help them. They do not see them as agents of government, insurance companies, or institutions. They trust the interpersonal face-to-face relationship and the motives of their doctors.

Continue reading “Why Do We Trust Doctors?”

By H. Gilbert Welch

In case you missed it, a recommendation came out last month that physicians cut back on using 45 common tests and treatments. In addition, patients were advised to question doctors who recommend such things as antibiotics for mild sinusitis, CT scans for an uncomplicated headache or a repeat colonoscopy within 10 years of a normal exam.

The general idea wasn’t all that new — my colleagues and I have been questioning many of the same tests and treatments for years. What was different this time was the source of the recommendations. They came from the heart of the medical profession: the medical specialty boards and societies representing cardiologists, radiologists, gastroenterologists and other doctors. In other words, they came from the very groups that stand to benefit from doing more, not less.

Nine specialty societies contributed five recommendations each to the list (others are expected to contribute in the future). The recommendations each started with the word “don’t” — as in “don’t perform,” “don’t order,” “don’t recommend.”

Could American medicine be changing?

For years, medical organizations have been developing recommendations and guidelines focused on things doctors should do. The specialty societies have been focused on protecting the financial interests of their most profligate members and have been reluctant to acknowledge the problem of overuse. Maybe they are now owning up to the problem.

Continue reading “The Testing Glut”

By John R. Graham

Well, the future of American health care is now controlled by lawyers. That may not be news – doctors, drug makers, and medical-device makers have long complained about the cost of lawsuits. But this different: The future of PPACA is in the hands of the Supreme Court. Hundreds of lawyers billed thousands of hours analyzing and preparing briefs for the case. And that’s after countless hours spent by Congressional staff lawyers putting the bill together in 2009 and 2010. The result? A “law” so confusing that even the legislators – themselves mostly lawyers – could not bother to even try to read it.

It makes one think: If the lawyers are designing the health-care system, shouldn’t they be forced to operate under regulations similar to those they’re imposing? How, for example, do lawyers get paid? Today, they negotiate fees with clients. That hardly seems fair. In health care, doctors don’t negotiate fees with patients, they get paid according to an opaque schedule determined by health plans. Lawyers should do the same. The solution is “legal insurance”. After all, who amongst us knows when we’ll need a lawyer? It is often an unpredictable expense, and yet the “market” seems to have failed to provide such insurance. Government must intervene.

Continue reading “What if We Regulated Legal Services Like Health Care?”

By Jim deMaine

I felt sad when I went to make rounds in the hospital.

One of my patients, a colleague, had been readmitted in poor condition for recurrence of a primary lung sarcoma.

I spent a few minutes examining Dennis and chatting.  He then, with a quizzical look, said, “Jim, I’m going to have to sue you.  I know I’m dying.  My wife Alice and the kids are still pretty young.”  He saw my look of surprise and added, “You know, I don’t have much life insurance or other very significant funds for them to live on.  It’s nothing personal.  I know you’ve given me good care, but my wife is upset and tends to blame you for the outcome.  I guess the hospital and others will be named.”

There wasn’t much more for me to say at the time except, “Dennis I can find another attending for you if you’d like.”  He replied, “No, I want to stay with you.”

Dennis was a well liked family doctor.  About five years earlier a “coin lesion” was discovered on a chest X-Ray.  This 2cm spot in the right upper lobe had a smooth rounded border and didn’t contain calcium.  A CT scan showed no enlarged lymph nodes and no other spots elsewhere.  A needle biopsy of the spot was not diagnostic.  We knew the spot was new because an X-Ray five years earlier was normal.  He hadn’t traveled to an area where Valley Fever or other fungal infections were common.

Continue reading “Doctor Versus Doctor”

By Ilana Yurkiewicz

What does it take to get into medical school today?

High MCAT scores. Pre-requisites galore, coupled with a stellar GPA. Research experience. Clinical experience. Volunteering.

It has become a series of check-boxes, many going through the process gripe. Worse, it’s an exercise in conformity.

Last week at TEDMED, Dr. Jacob Scott shone the spotlight on this system as a root cause of the lack of creativity among people going into medicine.

“You can’t take any risks, or you won’t get in [to medical school] – you won’t get into the club,” he told the audience. But, he continued, that means weeding out creativity. Future doctors are being trained to “memorize certainty,” rather than think imaginatively.

Having gone through the admissions process recently, I could relate to many of Dr. Scott’s sentiments. It’s true: preparing to get into medical school does little to encourage risk-taking. Admission criteria are rigid. And you know if you don’t do what they ask, there is no shortage of others who will.

Want to become a doctor? You can’t slip up, or you’ll fall behind. You can’t rock the boat, or you won’t get admitted.

This critique is not unique to medical education. Scott’s talk reminded me of a speech by former Yale English professor William Deresiewicz to the 2009 plebe class of the United States Military Academy at West Point. Skeptical of modern benchmarks of success, Deresiewicz told the young cadets:

“It’s an endless series of hoops that you have to jump through [to get into college], starting from way back… What I saw around me were great kids who had been trained to be world-class hoop jumpers. Any goal you set them, they could achieve. Any test you gave them, they could pass with flying colors…. I had no doubt that they would continue to jump through hoops and ace tests and go on to Harvard Business School, or Michigan Law School, or Johns Hopkins Medical School, or Goldman Sachs, or McKinsey consulting, or whatever. And this approach would indeed take them far in life.”

Continue reading “Is Medical School Admission Squashing Creativity?”

By Aaron Carroll, MD

Whenever I post about the malpractice system, I try to make it clear that while I don’t consider it to be the cause, nor the cure, for the problems in our health care system, that doesn’t mean that the system isn’t broken in many ways. Nuisance cases do exist; cases that have real merit never see the light of day. One additional side effect of portraying the malpractice system as the boogeyman of the entire system is that we lose sight of the fact that it really does impact physicians. Take defense costs.

There’s a new paper in the Journal of Law, Medicine, and Ethics by yours truly and co-authors that looks at this in detail:

The objective of this study was to take a closer look at defense-related expenses for medical malpractice cases over time. We conducted a retrospective review of medical malpractice claims reported to the Physician Insurers Association of America’s Data Sharing Project with a closing date between January 1, 1985 and December 31, 2008. On average a medical malpractice claim costs more than $27,000 to defend. Claims that go to trial are much more costly to defend than are those that are dropped, withdrawn, or dismissed.

Continue reading “Malpractice Defense Costs Are Real”

By Steven Schroeder, MD

How physicians are paid and what services they choose to recommend are key drivers of today’s escalating health care costs. The Society for General Internal Medicine (SGIM) has convened an independent commission to assess physician payment and physician-influenced expenses as well as issue recommendations on how to reform physician payment to restrain health care costs while at the same time optimizing patient outcomes. The 13-member National Commission on Physician Payment Reform will work together over the upcoming year, with a final report expected in early 2013.

Payment incentives and systems directly impact medical services that physicians provide as well as the overall approach to their patients. For example, the current fee-for-service system aligns payment with services provided rather than overall care outcomes. While the Commission will examine existing formulas that determine physician payment, such as the Resource-Based Relative Value Scale (RBRVS), we will also investigate promising payment methods that could lead to higher quality of care and better patient outcomes. More specifically, the Commission will evaluate optimal incentives and safeguards surrounding the three principal forms of physician payment: fee-for-service, capitation, and salary, as well as variations of these forms such as episode-based payments, global payments, pay-for-performance and partial capitation that attempt to incorporate quality into the equation.

The Commission appreciates that many have already put considerable effort into payment reform.  We would like to complement, not duplicate, these efforts.  We will review new approaches in the Affordable Care Act designed to constrain costs, including bundled payments and Accountable Care Organizations, as well as disincentive payment strategies that penalize providers for avoidable costs. We will also draw on the factual findings of The Medicare Payment Advisory Commission.  A key difference is that the National Commission on Physician Payment Reform will look at the entire physician payment system, including both public and private payers.

Continue reading “Commission Tackles Physician Payment Reform”

The Permanente Federation is the national organization for Kaiser Permanente’s doctors. In this interview taken at HIMSS12, Executive Director of the Federation Jack Cochran gives an overview of transitions physicians are undergoing in the workplace. He also debunks what he says is the biggest myth about patient to doctor emails.

By DINOSAUR MD

Medicine is simple and straightforward; except when it’s complex and nuanced.

Medical diagnosis is a simple matter of taking a history, performing an examination, and reviewing the results of ancillary testing; except when it’s a complicated case of eliciting subtle nuances from the patient in both the interview and the exam, and interpreting multiple pieces of conflicting data.

Medical treatment is a straightforward affair of providing appropriate treatment; except when there are multiple treatment options with unclear risks and benefits, technically challenging surgical or other procedures to perform, not to mention fully informing the patient and family about all of those treatment options, risks, and benefits, plus eliciting and answering all their questions.

Nothing to it.

Notice, though, that the key ingredient here is DIAGNOSIS. Performing a flawless appendectomy won’t do a thing for an ovarian cyst, nor will a PPI prescription do much for an acute coronary syndrome. Performance measures that look at treatment without addressing diagnosis are somewhere between misguided and ludicrous.

Why does American medicine have this so bass-ackwards? Follow the money. Thanks to the specialty-heavy RUC, the commission that sets fees for various procedures, doing something — anything — is paid far more handsomely than thinking (even thinking about what to do).

Continue reading “Pay for the “A””