This letter from residents appears in Academic Medicine – Unintended Consequences of Duty Hours Regulation
Prior to this year, 30-hour call shifts were the norm for many residents in our hospital and nationally. The rigor of these shifts taught us to maintain professionalism and compassion amidst life-and-death stakes. Overnight calls, despite the unavoidable fatigue, were training grounds for independent decision making and some of the most exhilarating times of residency. These shifts were often the best opportunities to watch the evolution of disease away from the pages of a textbook and to experience the transition from trainee to doctor under appropriate supervision. Most important, the extended hospital shifts were the time for residents and patients to bond—developing the critical doctor–patient relationship and designing a collaborative plan of care.
No amount of shift-design or fatigue-mitigation strategies can replace such important experiences—from a medical and humanistic standpoint. The decrease in daily continuity has whittled away the interactions on which the patient–doctor relationship depends. Electronic cross-cover lists have replaced personal interactions as residents’ primary source of information. On the whole, the changes have established a norm of perpetual patient transfers from one team to the next, with diminished opportunities for any one team to develop responsibility for a patient. As a result, we residents are losing “our” patients.
While I empathize with these residents, I will argue that we can provide excellent training. Our family medicine residency in Huntsville, Alabama developed a call schedule that minimizes the negatives and maximizes the positives. The key is responsibility. All interns and residents work a maximum of 14 hour shifts. When you admit a patient, you “own” that patient. They emphasize continuity. Hand-offs occur during rounds with the night and day residents rounding together first thing in the morning with the attending physician.
While I do believe that the old schedule made great physicians, perhaps we can still succeed, if we do design our call systems around principles rather than hours. When we emphasize the patient and the physician patient relationship, then we may even do better.
But then everyone knows that I am a life long optimist.
Colonoscopy costs skyrocket
I just heard about this a few months ago. Apparently the latest trend in colonoscopy is the use of propofol rather than conscious sedation with Versed (Midazolam) plus an opiate. The problem comes from the cost.
The NY Times highlighted this trend yesterday – Waking up to major colonoscopy bills.
As I write repeatedly, the ACP is championing high value, cost conscious care. The ABIM Foundation has put forth the Choosing Wisely campaign. Where does this fit?
I have had gastroenterologists tell me that this is unnecessary and just increased expense.
Are there any defenders out there? Any critics?
Sherlock on diagnostic errors
Masterpiece Theatre has just run the second 3 episode series of Sherlock – a modern retelling of Sherlock Holmes. These show originate in Great Britain and are simply brilliant. While watching an episode yesterday Sherlock said this to a detective:
You have a solution that you like, but you are choosing ignore anything that you see that doesn’t comply with it. – from the Blind Banker – Sherlock Season 1 Episode 2
Too often physicians jump to a diagnosis despite strong clues that they should consider other diagnoses. They should fear Sherlock’s admonishment.
Why do we expect productivity from physicians
When I first joined the faculty in 1980, no one used the terms productivity. The concept of RVUs had not yet arrived. I believe it was a better time.
Productivity does not just plague physicians. Tim Jackson has authored a brilliant piece about productivity.
At first, this may sound crazy; we’ve become so conditioned by the language of efficiency. But there are sectors of the economy where chasing productivity growth doesn’t make sense at all. Certain kinds of tasks rely inherently on the allocation of people’s time and attention. The caring professions are a good example: medicine, social work, education. Expanding our economies in these directions has all sorts of advantages.
In the first place, the time spent by these professions directly improves the quality of our lives. Making them more and more efficient is not, after a certain point, actually desirable. What sense does it make to ask our teachers to teach ever bigger classes? Our doctors to treat more and more patients per hour? The Royal College of Nursing in Britain warned recently that front-line staff members in the National Health Service are now being “stretched to breaking point,” in the wake of staffing cuts, while a study earlier this year in the Journal of Professional Nursing revealed a worrying decline in empathy among student nurses coping with time targets and efficiency pressures. Instead of imposing meaningless productivity targets, we should be aiming to enhance and protect not only the value of the care but also the experience of the caregiver.
The care and concern of one human being for another is a peculiar “commodity.” It can’t be stockpiled. It becomes degraded through trade. It isn’t delivered by machines. Its quality rests entirely on the attention paid by one person to another. Even to speak of reducing the time involved is to misunderstand its value.
What unintended consequences have productivity and RVUs wrought? We have encouraged physicians to spend less time with patients, do procedures more quickly, avoid telephone calls and emails (no RVU points here) and generally worry more about volumes than individual patients. Now I know that I use hyperbole in these statements, but while we rarely are as cold as the previous sentence, the concepts do influence us. Anyone who can remember medical practice prior to these concepts can explain how practice has changed because of these phrases.
Patient visits are not widgets. Patients expect and deserve our full attention without concern for the clock. Patients have questions that we need to answer. History and physical examinations take time. Considering multiple diagnoses takes time. Sometimes we need to stop and read while the patient is in the room. We need time to do our job properly.
I hope others will take up the call. We should banish productivity as a descriptor. The concept has diminished our profession and thus we should reject it.
Does a service history predict physician behavior?
What follows is meant to be highly provocative. I have used some hyperbole. I hope some readers will agree and some readers will consider this screed inane and dumb. Please comment and criticize my hypotheses. If this makes you think critically, then I have succeeded.
HIghly valuing service behavior has become a major plus in choosing medical students. This fashion has great face validity, but we should always ask tough questions about any new fad.
Yesterday on Twitter I saw this wonderful quote:
“The more logical a solution to a complex problem sounds, the more strongly it deserves to be challenged.” Ackoff
Of course pre-med students now pad their resumes with service work, checking off another box.
The idea that service predicts seems a bit too simple. Do we necessarily want our physicians to all value service? A wonderful NY Times column should make one think – The Service Patch
I am not against “service”, but I will take the position that admissions committees overvalue the concept. I think David Brooks would agree.
The student discussion was smart, civil and illuminating. But I was struck by the unspoken assumptions. Many of these students seem to have a blinkered view of their options. There’s crass but affluent investment banking. There’s the poor but noble nonprofit world. And then there is the world of high-tech start-ups, which magically provides money and coolness simultaneously. But there was little interest in or awareness of the ministry, the military, the academy, government service or the zillion other sectors.
Furthermore, few students showed any interest in working for a company that actually makes products. It sometimes seems that good students at schools in blue states go into service capitalism (consulting and finance) while good students in red states go into production capitalism (Procter & Gamble, John Deere, AutoZone).
The discussion also reinforced a thought I’ve had in many other contexts: that community service has become a patch for morality. Many people today have not been given vocabularies to talk about what virtue is, what character consists of, and in which way excellence lies, so they just talk about community service, figuring that if you are doing the sort of work that Bono celebrates then you must be a good person.
Let’s put it differently. Many people today find it easy to use the vocabulary of entrepreneurialism, whether they are in business or social entrepreneurs. This is a utilitarian vocabulary. How can I serve the greatest number? How can I most productively apply my talents to the problems of the world? It’s about resource allocation.
People are less good at using the vocabulary of moral evaluation, which is less about what sort of career path you choose than what sort of person you are.
In whatever field you go into, you will face greed, frustration and failure. You may find your life challenged by depression, alcoholism, infidelity, your own stupidity and self-indulgence. So how should you structure your soul to prepare for this? Simply working at Amnesty International instead of McKinsey is not necessarily going to help you with these primal character tests.
We should not assume that doing service predicts anything. Using a service history as a proxy for character fails the smell test. Pre-med students are smart, and they can figure out what they need to do and say to bolster their applications.
We should not over value service. Rather we should provide medical school environments that provide appropriate role models.
Many medical students enter school for the “right reasons”, and somehow we change them. We change them with exorbitant tuitions, too many teachers who would rather be doing research or caring for patients, and too few role models. We have a testing system that, in my opinion, rewards test taking and memorization. We test for knowledge but we need physicians who have wisdom. Not all physicians have to be service minded. Some great physicians believe that they provide “service” every day through compassionate care of their patients. For many that is enough.
It is broken and needs fixing
Large Swathe of Physicians Shun Medicaid, Medicare Patients
Many physicians find the hassles of CMS no longer worthwhile. Everyone can imagine why physicians no longer accept new Medicare patients, but what are the answers?
The specialists least inclined to see new Medicare patients are adult psychiatrists (57%), plastic surgeons (68%), general internists (73%), family physicians (75%), and obstetricians-gynecologists (76%). In contrast, rates of accepting new Medicare patients top 90% among cardiologists, hematologists/oncologists, general surgeons, anesthesiologists, and neurologists.
Know that the following speculation represents my opinion, not based on any data or inside information.
Medicare billing is painful and compensation is inadequate for general internists and family physicians. A practice manager can add all the expenses and divide time into those expenses. This exercise gives a daily or hourly cost of practice. Too often Medicare payment does not cover the cost of practice.
Medicare requirements also increased the cost of practice.
Medicare helps most seniors afford medical care, but finding a physician is becoming more and more difficult. Medicare is the problem and part of the solution.
CMS should rethink documentation requirements. They should figure out how to include time as a major factor. A 10 min level 4 visit differs greatly from a 30 min level 4 visit. Phone calls, emails and forms take time. Pay the physicians for their time, and we will have enough physicians available.
I fear that we soon will not have sufficient numbers of physicians accepting Medicare, and that is sad. Only Medicare can solve this problem.
The value of optimism
Jane Brody, health reporter for the NY Times, has a wonderful piece today – A richer life by seeing the glass half full
As an optimist, of course I love this article. The points that she makes are very interesting.
Murphy’s Law — “Anything that can go wrong will go wrong” — is the antithesis of optimism. In a book called “Breaking Murphy’s Law,” Suzanne C. Segerstrom, a professor of psychology at the University of Kentucky, explained that optimism is not about being positive so much as it is about being motivated and persistent.
Dr. Segerstrom and other researchers have found that rather than giving up and walking away from difficult situations, optimists attack problems head-on. They plan a course of action, getting advice from others and staying focused on solutions. Whenever my husband, a dyed-in-the-wool pessimist, said, “It can’t be done,” I would seek a different approach and try harder — although I occasionally had to admit he was right.
Dr. Segerstrom wrote that when faced with uncontrollable stressors, optimists tend to react by building “existential resources” — for example, by looking for something good to come out of the situation or using the event to grow as a person in a positive way.
The question for you is this: am I just fortunate to have optimism genes? Have I just been rewarded with good luck and does that good luck lead to optimism? How can pessimists change? In my experience pessimists view me (and other optimists) as having a serious DSM-IV diagnosis.
As I read the article, the value of optimism comes from looking a potential obstacles and see them as hurdles to leap, rather than quagmires.
What the critics of concierge medicine did not understand
We need to define terms:
- Concierge medicine – paying a large (>$3000/yr) fee to contract with a physician (usually an internist) to provide same day appointments, phone access, email access, comprehensive and continuous care
- Retainer medicine – paying any fee to receive the same access as concierge medicine. Generally concierge practices have smaller panels, i.e., the more you pay, the less patients the physician has to follow
- Direct primary care – retainer medicine for a lower fee
These definitions are arbitrary and mine only. Here is the big point:
These patient care strategies are growing rapidly, because patients and physicians do not like our current payment system. As I have written for 10 years, if we do not carefully understand the success of these relationships, then we cannot learn from them.
The development of the various retainer relationships shows that patients find the current state of outpatient medicine unacceptable. Patients only pay because otherwise their primary care access (here I use the expansive definition of primary care, comprehensive, continuous, complex, caring, etc.) has major flaws.
Folks, this is 2012! Patients expect to communicate with us through a variety of strategies. They would like to text us, email us or talk on the phone. They want to come at their convenience, not our convenience. They want one excellent physician to coordinate their entire care.
Our current payment system discourages physicians from providing excellent service to patients, because the payment system only recognizes the office visit. This payment system has unintended negative consequences.
Today’s NY Times has a wonderful article about one such arrangement that I have previously featured in this blog. More Care Up Front For $54 A Month
Policy wonks have ignored this movement for too long. Retainer medicine is a fast growing start-up industry. It grows because it fills an unfilled niche.
We ignore its growth at our own disadvantage. We must consider whether this is a better way to provide complex, comprehensive, continuous care.
Call it concierge medicine for the masses. The idea is that routine, mundane primary care should not require expensive insurance and can be cheaper without it. Direct primary care practices charge $50 to $60 a month for adults, with lower fees for children. Depending on the practice, the monthly fee also may cover certain lab tests, basic X-rays and stitches for cuts.
But the fee does not cover anything beyond primary care. Typically employers combine direct primary care with high-deductible insurance plans, needed to cover hospitalizations and visits to specialists.
“Health insurance is supposed to protect you against risk, like car insurance does,” said Dr. Bliss. “We don’t insure our cars for tire changes and tune-ups.”
Even though Becker pays Qliance for primary care and pays half of each worker’s $5,000 annual deductible for insurance, the company’s costs dropped 11 percent in 2010. Costs had been rising about 14 percent annually, Mr. Riordan said.
This emperor is fully dressed.
I became a bobble head
At our regional medical campus graduation, the graduating students gave me this present. So now I am a Bobble Head. What an honor!
Happy 10th blogiversary to me #10yrsblog
Ten years, even though I have been typing this blog for the entire time, it really seems incredible. I did not imagine 10 years ago that I would still be ranting and people would be reading. My counter tells me that I have had 2.8 million visitors. This does not include those who follow on twitter – 1626 followers and 2576 tweets – or read the blog on facebook.
I do plan to continue for now as I still find blogging fun, intellectually stimulating, and a great hobby.
Thanks for reading all these years. I hope to continue making this a worthwhile read.
