Three Health Care Trends Patients Will Notice in the New Year

As we enter the New Year, I like to reflect on where we've been and where we're heading in medicine. By far and away, this is the most tumultuous time I have ever experienced in health care.  Doctors and nurses appear stressed and downtrodden, administrators are running scared, desperate to seem "value-added," and patients are scrambling to get seen in these last two days of 2013.

It's strange really.

I thought I'd try to make some realistic predictions of what patients should expect in the year ahead now that the "Patient Protection and Affordable Care Act" (PPACA) begins to sink it's tap root into the American medical system.

Triage

With the sudden expansion of the patient pool without a relative expansion of the physician pool, patients can expect a greater degree of triage to occur in medicine when they need to see a doctor. Triage will occur in many ways, but will fall along two lines: (1) treat the most urgent then (2) the most lucrative. Like it or not, these priorities will drive care for most medical facilities, especially our newly minted Accountable Care Organizations (aka, large hospital systems and care networks).  Specialists will become purely  proceduralists, internists and family practice doctors will see specialty follow-up and manage a team of nurse practitioners and "physician extenders," and these care extenders will become the front line care team for the more common ailments. In effect, follow-up specialty care will shift down the health care "food chain" to those less specialized in the name of improving "efficiencies" in health care. Some will argue this is cherry- picking lucrative patients and procedures, others will see this as a survival necessity for health care systems squeezed for revenue. Call it what you will, but realize it's another unintended consequence of the changes taking place in our health care market today.

Costs

There is no question that out-of-pocket costs (both direct and hidden) for health care will continue to rise for patients.  Given the recent holiday season, most Americans are strapped for cash at the beginning of the year.  But insurer's want their first installment for coverage as early as 10 January 2014.  Hidden in their premium will be a 2% tax added to the every insurance plan's premiums, plus a $2 fee that goes to the Patient Centered Outcomes Research Institute (PCORI) created by our new health care law.  As I've previously pointed out, the costly PCORI replicates functions already performed by the Agency for Health Care Quality and Research (AHRQ). The PCORI's budget is also scheduled to mushroom from $350 million to over $500 million annually in the years 2014-2019 with patients paying directly for this government agency thanks to this added fee.  And what do they get in return from the PCORI?  A wealth redistribution scheme to pay for even more "patient-centered" research redundancy.

Patient's take-home pay will also be reduced for middle-class individual tax filers earning more than $200,000 and families earning more than $250,000.  This is because they will pay an added 0.9 percent Medicare surtax on top of the existing 1.45 percent Medicare payroll tax. They’ll also pay an extra 3.8 percent Medicare tax on unearned income, such as investment dividends, rental income and capital gains.

Finally, patients will quickly begin to understand what the terms "deducitible," "co-pay," and "co-insurance" mean when it hits their pocketbooks.  My bet: they won't be happy about it.

Finally there's the issue of health insurance subsidies actually being tax credits.  As reported in the Wall Street Journal:

The federal subsidies that will help many people pay for their coverage are actually tax credits tied to their income. They will go to people making as much as 400% of the federal poverty rate—in most states, $94,200 for a family of four in 2013. The more you make, the smaller your subsidy. The subsidy process "will all be part of the tax computation," says Judy Solomon, of the Center on Budget and Policy Priorities.

People can choose to receive these credits as monthly payments that flow to their insurers over the course of the year. But if they do this, and the subsidies turn out to be too large—if the consumer's income was higher than expected and she should have received a smaller subsidy than was dispersed—the recipient may need to repay at least part of the overshoot.

To avoid this situation, people should report major changes in income to their exchange website when they occur. Consumers who know in advance that their income may fluctuate can also take "less financial support," meaning a smaller subsidy upfront, or opt for a lump sum at year's end, says Cheryl Fish-Parcham, of the consumer group Families USA. 

The government giveth and the government taketh away.   Hey, someone has to pay for all of this bureaucracy.

Confusion

The difficulties experienced with the government's HealthCare.gov website will have their trickle-down effects felt in 2014.  Given the number of vendors involved in development of the site, and their unwillingness to claim responsibility for the site's shortcomings, patients who registered on the site are likely to have little recourse for their difficulties readily apparent.  Social workers will be saddled with helping these patients, along with their other duties.  As if they don't have enough to do already.

Doctors will be introduced (perhaps "force-fed" is a better verb) to the "new and improved" ICD-10 coding scheme in 2014.  With bureaucracy run amok in medicine, this is another hassle foisted upon physicians and care-givers.  Compliance with the scheme is now a pre-requisite for physicians to be paid properly.  Expect more screen time, cursing,  and less patient-care time from your doctor as a result.

Insurers will be even more aggressive with denials based on insurance industry-developed "coverage decisions."  Doctors and patients alike will continue to find this frustrating as insurers must assure their profit margins.

So as we begin the New Year, strap in, and get ready for Health Care 2014.

We're all going to be taken for quite a ride by the changes ahead.  Rest assured, though, that there are still many doctors and nurses out there who will try to help ease their patients' burdens in such a stressful time for everyone.

-Wes



  

Mission Impossible V: The MOC Exam

"Place the palm of your hand on the palm scanner," she said.

 He complied and watched the computer screen in front of her read "Verified" in bold green letters.

With that, she looked up at him, shrugging her shoulders.  "In my time here at the testing center, I'm still waiting for someone's identity to change between where you scanned your hand around the corner to here, just 10 yards away!" He smiled and she chuckled to herself.  "Now pull out those pockets and let's seem 'em."

He complied.

"And the back pockets."

He turned. "Nothing.  See?" he said.

"Now roll up your sleeves..."

Secretly at this moment, he was hoping a rabbit would appear, but complied again.

She handed him back his driver's license, rose from her computer, and said, "Follow me."

She led the way through a high security door toward a testing cubicle and quietly sat him at a screen that contained an image of his face shot earlier during his check-in process.  She logged him in and there before him was a computer screen with a large American Board of Internal Medicine logo on it.  She pointed out the silver headphones for to the left of the screen.

"Those are for audio, in case there's any of that on your test.  And these to the right are noise-cancelling headphones if you prefer to wear them.  Here's a white board for your use.  Remember we are audio and videotaping everything.  Whatever you do, don't raise your hand at any time unless you need us.  Got that?  We will come get you.  Don't raise your hand otherwise.   Any questions?  Good luck..."

With that the escort left the room.  He sat before the screen and placed the noise headphones on his head.  The screen asked if he wanted to take a tour to familiarize himself with the features available on the software before starting his test.  He clicked the "Yes, tour" button.

With that, the screen flickered and went black. He could hear the noise cancelling headphone suddenly begin to make sounds.

"Good morning, Dr. Phleps."

A picture appeared on the screen as the mysterious voice continued: "This is Dr. Richard J. Baron, the mastermind and ring-leader of the American Board of Internal Medicine that supports the security and secrecy procedures that you have just endured.  He and his many well-paid collaborators have conspired to create a series of time-consuming and anxiety-producing tests and questionnaires designed to frustrate and instill fear in their professional membership. It has become clear that their processes are being promoted as a measure of physician excellence, when in fact, it sets a floor of performance standards for physicians while assuring the continuation of their administrative positions. Your mission, should you decide to accept it, is to pass your test so you can continue to demand accountability for the high salaries of these physician admistrators and the expense of this process that are soon to be imposed on physicians every two years. ... But remember, if you fail to pass, the Secretary will disavow and knowledge of your actions and perhaps your ability to practice medicine...  Good luck.  (This program will self-destruct in five seconds)..... * bbbbzzzzaaaaaaaappppppp *"

And with that, a small puff of smoke arose from computer and the screen went black briefly before it returned to the ABIM logo screen. The menu there again asked if he wanted to start the test.  He clicked the "Yes, start the test" button on the screen. A contract screen appeared reminding him that he'd only be able to take the test if he agreed to be disavowed and reported to credentialling agencies if he divulged any test content or materials to anyone at anytime.

Realizing his wife would kill him for wasting thousands of dollars if he refused, he clicked "I Agree."

The first question appaered while the clock in the upper right corner of the screen began counting down. (A familiar theme song began playing in the background)

-Wes

(Epilogue: Yes, dear reader, Dr. Phelps recently learned that he accomplished the impossible.)

You Are Christmas

To all of the first responders
Laboring in the icy night in an hour of unexpected need
While their children get tucked into bed
In the blanket sleepers...

You are Christmas.

To all the caregivers
Who make Christmas happen
Even when their hearts are heavy and
Moments of rest too few…

You are Christmas.

To all the suffering
Who rise to the occasion
With a smile or a simple gift
Or permission for others 
To celebrate without them…

You are Christmas.

To all the doctors, nurses and hospice workers
Whose own trees go undecorated and gifts go unsent
Because it seems every year
The hospitals are full at holiday time...

You are Christmas.

To all the parents
Who recapture the innocence of the season
For the sake of their children
With a song, a story, a silly ritual…

You are Christmas.

After all, it was never about the strong, the powerful, the rich,
The proud,
It was always about the humble, the faithful, the courageous,
The quiet, hopeful ones.
The scared young family standing in wonder at the manger,
Trusting, holding faith, believing in good,

Believing in love.

From both of us – Merry Christmas,

Diane and Wes Fisher

This Christmas, Look Up

I sit before the computer screen this morning, wondering "What should I write?"  Yet as I thought about this, I realized I should really write about why I'm thinking about this.

My journey in this space of social media has been a bumpy one, full of ups and downs, ins and outs, obsession and indifference, all rolled up into one.   Yeah, this sums up health care social media now, at least for me.

I began writing here in November 2005, not really knowing what I was doing.  I thought of this space as a marketing space, then an information-to-patient space, then a social space ("gee, so many interesting people here!) and even an "inside view of medicine" space.  In reflection, I really didn't know what the hell this space should be.

But then came 2006 and 2007, my father became gravely ill, and social media was a wonderful outlet for me to reflect on all of the emotions, memories, and experiences that such an event invokes.  I found I loved writing.  To this day, I use this space as a diary of that time in my life, and even found my eyes blurring a bit this morning as I re-read my earlier Christmas reflection of the events that occurred that year.  Blogs, I've found, are really a good space for remembering certain events, certain times.

Later, I'm not sure where I went with social media.  I signed up for Twitter during the Twitter-craze and learned about "tweets" and "hashtags" and all that stuff.  I was amazed at how "up-to-date" I could be with the latest rage, outrage, sound bite and scandal in medicine.  Heck, it my cell phone would come alive!  Medicine is so, *ping* , i-n-t-e-r-e-s-t-i-n-g again!  *ping* *ping*

As if the latest cell phone vibration, chirp, and flash was really what mattered and dull ol' medical care was just, well, glacially stimulating by comparison.  What's not to like, right?  You could be a teacher, provocateur, and health care social media detective!  You, dear doctor, could make a difference!

But in reflection, reality's been very different than that.

I realize now that I am just one voice, one small individual in a the overcrowded mess that is the internet.  Everyone is trying so hard to be heard.  Entire social media companies are developed just to make sure you pay attention to your cell phone - just look at SnapChat, where if you don't immediately attend to your cell phone, the image, message or 10-second video is gone, never to be seen again.  Pay ATTENTION, people!

This is not to say people's voices aren't important.  In fact, many in this space say incredibly powerful things here.  But I am seeing something very interesting on social media now, especially as it pertains to doctors' participation in this space: propaganda.

There are very savvy, well-organized forces on social media now.  Everyone knows this is where the battleground of public opinion rests.  So forces are marshaled, teams assembled to make sure the party line is towed.

I ask you, dear doctor, who much time do you have?  So it is with social media in health care.

But recently in my evolution in this space, I realize I have matured.  I don't come into health care social media starry-eyed any longer.  It has a purpose.  You can meet some remarkably thoughtful and insightful individuals here.  You can make some pretty amazing friends.  And you can get lost.

But I realize there's a purpose, too.  People can tell a single, quiet, story  here - a small, transcendent one, too.

Nowhere was this more visible than in the recent quiet, painful reflections of a young boy suffering with leukemia and the wonderful stories he and his parents shared in their blogs.  These are not people providing propaganda, these were people with a purpose.  These were people who realized what mattered.  These were people who were an inspiration to us all.

As I reflect on all of this at Christmas time, I find it's more important to spend these short, dwindling, yet cherished moments with real life, not one manufactured by the media companies.

Time is precious.  Family is paramount.  And social media is, well, social media.

This holiday season I hope all of us will take time to pull our heads from our cell phones and computer screens.  There some amazing things going on around us, some amazing stories of hope and courage, and things we really need to appreciate.  Most of those things aren't represented by bits and bytes on an iridescent screen, but rather what we take for granted every day, if we dare to look up.

Merry Christmas.

-Wes

The Matrix

"As a third year medical student, I would also argue that this is creating a generation of dumb doctors. My school (average US MD school in the Midwest) has almost abandoned teaching physiology and understanding. We have the virtues of guidelines shoved down our throats instead. Recognize a pattern, apply the appropriate guideline. That's medical school these days...."
-Anonymous commenter
Dr. Wes blog

Dear current medical students,

Welcome to The Matrix.

-Wes

When Physicians Drown in Noise

The infrequent side effects of Paxil
(Click to enlarge)

I was just trying to look up the side effects of Paxil and was greeted to this incredible and quite ridiculous array of potential side effects.

I had to ask myself: how helpful is such a list? Why do we have this noise available to us?

The answer, of course, is obvious to anyone who understands our legal system in America.

But we should ask ourselves another question: in our effort to assure patient safety, might we be losing important signals to care-givers amongst the recesses of all of this incredible noise?

-Wes

If The Hunger Games Came to Medicine

““A totalitarian state is in effect a theocracy, and its ruling caste, in order to keep its position, has to be thought of as infallible. But since, in practice, no one is infallible, it is frequently necessary to rearrange past events in order to show that this or that mistake was not made, or that this or that imaginary triumph actually happened.”
                                               - George Orwell

* * *

The brushed, steel belly of the scalpel blade pressed down on the orange antibacterial film and released the subcutaneous yellow fat globules surrounded by small beads of red blood.  The movement of his hand was fluid, purposeful, and without hesitation.  The electrocautery pen carefully seared the points where blood appeared.  A retractor was installed to spread the tissues farther apart as he worked quickly to gain access to the tissue plane just above the muscle.  His movements were deft for he knew they were watching.

The Capitol's campaign to ensure perfect outcomes was well underway. They had installed cameras throughout the hospital just four short years before: in the halls, the changing rooms, at the scrub sinks, and in the operating rooms.  The Capitol had discovered that the operating room was like yesterday's boxing ring, or even farther back in the mists, the Coliseum.  In the New World unpredictable events and venues that stirred primitive passions were few - and yet they were longed for as they were feared.  This context explained the popularity of the annual Hunger Games, created as punishment for the destruction of District 13 by a failed patient uprising after the health care financial apocalypse.  Each year, one male and one female physician "tribute" from each of the surrounding twelve Districts were selected by lottery and performance metrics to fight each other to the death. Providing spectators with a window into the drama, and ensuring that drama by creating just the right conditions, gave spectators a sense of aliveness that they barely remembered, and just enough to stimulate fear.  The Games also served as the perfect venue to deflect blame from the Capitol's expedience in sacrificing people for their own avarice.   

The call had come after a full, exhausting day.  The patient had presented to the Emergency Room only two weeks after open heart surgery for coronary disease and to replace his critically-narrowed aortic valve.  The surgeon-tribute wasn’t sure why his conduction system should fail this late after surgery but it didn’t matter; his heart rate had slowed to a dangerous 19 beats per minute. His blood pressure, while low, remained stable.  A quick review of this medication list disclosed the mandatory heart medications that included an anticoagulant for the heart valve and antiplatelet agents for his coronary disease.  No heart rate slowing medication was being used so the Capitol's appropriateness indication to proceed with the procedure was indisputable.  It was also fortunate that the anticoagulant the patient was taking hadn’t thinned his blood too far.   He decided to take him to the operating room directly.  It was 3 am.

Meanwhile, back at the TV studio:  “I tell you, Frank, every year the footage gets better and better!  How did your team know that these untenable circumstances would result in such great late night viewing?  This is so exciting!” 

The call team had been called, but was short-staffed.  Efficiency meant lower cost, fewer people, and longer work hours.  The designated scrub tech had car trouble and would be delayed.  So the other technician and nurse worked feverishly to ready the room.  The call had already been made to the device representative who brought the new pacemaker hardware, but he was barred from entering the operative suite for he was not part of the medical team.  Rules were rules.   The patient, of course, was agitated, gasping for breath.  The doctor worked as fast as possible to establish pacing – the air was tense.

“Are you kidding?  I love seeing this, don’t you?  The nervousness of his voice!  The anxiety!  The skeleton crew at night!  Beautiful!  I’m not sure it gets much better!”

John had no idea why his car wouldn’t start that night (but the spectators did).  He turned the key again and again, only to hear the engine spit in return.  He slammed his hand against the steering wheel, frustrated that he was unable to keep his car tuned for poor weather.  But such concerns were luxuries now that hospital budgets were tight thanks to the Capitol’s Bundled Payments for Care Improvement campaign.  Finding a ride to work became the imperative.  He raced back into the house to wake his wife in a panic, asking her whom he might call to give him a ride – they each knew the consequences of failure.  They called their neighbor and woke him from a sound sleep.  The pressured nature of their voices convinced him to loan them his car and five precious minutes later, he was off to work calling ahead to notify them of the delay.

At the hospital, Chloe answered John's call as she sat behind the monitoring console.  She was one of the best young technicians to graduate from her training school.  Still, her hospital’s equipment was not up to date because maintenance contracts were left to expire in these cost-saving times.  Still, although the software it ran was now several versions old, it still reliably fed data to the Capitol's chargemaster.  She looked down at the dust on the keyboard.  Seeing this, it was clear she couldn’t enter the room to assist because the risk of surgical contamination was too great.

The surgeon-tribute was glad he’d placed two venous sheaths to gain vascular access, rather than just one.   He had successfully placed both pacing wires through the sheaths to the patient’s right atrium, ready to be secured to their appropriate chamber.  But he needed a softer shaping wire – the stylette – to insert into the inner lumen of the pacing wire.  Without the stylette, the pacing wire had the consistency of a well-cooked spaghetti noodle.  With it, he could place the pacing wire to its appropriate chamber.    As he turned, his eyes left the surgical field for just a moment.  He scanned the table crammed with scattered instruments and hesitated briefly as he located the proper stylette. 

A hush fell over the audience as they saw the opening.  They leaned forward in anticipation, reveling in their luck to see such a careless mistake.

John leaned his head in the room to notify them he’d finally arrived and would assist as soon as he could change.  The surgeon smiled, acknowledging his dogged efforts to arrive as quickly as humanly possible.  He turned to the field and shaped  the stylette to the perfect curvature that would allow him to affix the pacing wire to the lower, primary pumping chamber of the patient’s heart.  He focused his blurring vision to place the tiny stylette in the endhole of the pacing lead.   Chloe broke the silence of the moment: “Hey guys, did an electrode fall off?”

The doctor looked up briefly to see atrial P waves dancing across the monitor screen without any corresponding ventricular electrical activity. With that, his worst nightmare was realized.  The patient began posturing on the table, his head thrown back beneath the drapes, his arms slowly but powerfully raising.  The surgeon leaned forward to grab the patient while trying to control the leads, stylette, and surgical wound sterility.  The patient began violently thrashing beneath the drapes, his face turning blue and lips crimson as saliva and exhaled gases mixed into a frothy spraying mess.  He was seizing uncontrollably.  His once steady escape rhythm had chosen this unfortunate moment to stop. 

If the surgeon was expecting help from a sponsor it was unlikely to be forthcoming.  Just yesterday, the tribute's most likely supporter/sponsor, Sylvia, a well-to-do matriarch from the Central District, had noticed an incipient sign of aging on her neck – subtle crepe-like thinning of her skin, this despite her  rigorous adherence to all of the Wellness Initiatives the Capitol had advertised.  She had reason to hate, didn't she? She'd  been failed one too many times.   She remembered sitting with her 65 year old mother gasping for air in one of those infernal assembly-line clinics with the young doctor glancing at the red, flashing "Do Not Admit" guideline on the computer screen as he sent them home with morphine with that flat, dead, passive expression on his face!  He didn't care then and so she wouldn't care now!

Seconds felt like hours as the patient's body slowly twisted sideways.  The nurse did all she could to support his weight and keep him from falling.  The surgeon, too, felt helpless as the powerful frame shook uncontrollably beneath the drape.  The restraints tethered his arms but his involuntary leg movement forced him further sideways.  John felt powerless as he watched from the door.  Finally, he could watch no longer and ran into the room just as the patient fell to the floor.

Four cannon blasts were heard in the distance.  The spectators roared.
 

-Wes

MedTees for the Holidays

"Kori" - a patient with a MedTee
(Used with permission: click to enlarge)

In 2005, my wife and I started MedTees.com, a website powered by the t-shirt company Cafepress, to support various charities.

The idea of the website is a simple but important one: "We have few role models and few realistic stories about living with a less-than-perfect body, or less than perfect health. How we choose to deal with the cards that life gives us is what this site is all about."  About half of the slogans used on the various t-shirts sold by the site were donated by our patient-customers with proceeds directed to the charity of their choosing.  All proceeds that we receive from the sale of these shirts (about $3/shirt) is donated at the end of each year, proportional to the themes of the t-shirts sold.  (By the way, we're always looking for new ideas for shirts.)

Since we do not purchase advertising, this blog serves as our "ad space" for MedTees.com.  This will be the only blog post used this holiday season to promote the site, so if you're looking for something different to offer a friend who's been through a tough time medically this past year, consider a MedTee.

It might mean more than you realize.

Happy Holidays -

Diane and Wes Fisher

When Scientists Accept "Flawed" as "Reassuring"

A recent essay entitled "Understanding the Customer and the New MOC Changes" by David May, MD, PhD, chair of the Board of Governors and secretary of the Board of Trustees for the American Board of Cardiology, was published online and tugs at our heartstrings by describing the Maintenance of Certification (MOC) secure examination in Cardiovascular Diseases as "flawed but reassuring measure of our competence for the real customer here … our patients and their families who trust us with their very lives."

I read this piece after recently completing the MOC process in both cardiology and cardiac electrophysiology for the third time.  After devoting hundreds of hours preparing for an impersonal timed computer test yet again, I couldn't help but wonder if physician scientists should ever accept a "flawed" process as acceptable for our ourselves or our patients. Imagine the implications to scientific inquiry and the process of challenging (and thereby improving) the educational process if we did:  we might have to accept media reports to justify the process so we can make it even bigger.

Patients deserve transparent quality metrics of care provided by their doctors and the American College of Cardiology (ACC) has been a unique leader in bringing measurable care metrics to the public with the development of their NCDR databases. Yet instead of turning to these real life metrics of care delivery, it seems the leadership of the ACC also feels compelled to sell a "flawed" educational testing construct to its members too. Is this decision based on a self-imposed imperative to dispense social justice at the bedside or more for the direct financial renumeration received by the officers of the College or it's parent, the American Board of Medical Specialities?

I believe there is merit to becoming Board Certified in a subspecialty once. A baseline of knowledge is assessed by this process. But the move to the current model of "maintaining" certification through complicated, costly, and unproven methods of survey completion, administrative and academic busy-work, followed by a timed multiple-choice computerized test overreaches into unproven areas of quality assurance.

To me, a better measure of physician competence and quality would be this: Board Certification once followed by disclosure of the total number of patients treated or the total number of procedures performed pulled from databases akin to the NCDR databases in development.  Such a method would align with current documentation requirements for assuring quality patient care and would avoid alienating busy physicians already faced with unprecedented regulatory scrutiny, steep pay cuts and loss of autonomy.

Pretending that the MOC process is a better method to assess competence rather than one's clinical experience in delivering real, live, clinical care feeds unrealistic expectations and may even promote a false sense of security to our patients.
 
What patients and their doctors deserve (and need) is verifiable data, not propaganda.

-Wes

Appropriateness Criteria® and Our New Medical Ethic

"I swear by Apollo the physician and AEsculapius and Health (Hygieia) and All-Heal (Panacea) and all the gods and goddesses, that, according to my ability and judgment, I will keep this oath and this stipulation—to reckon him who taught me this art equally dear to me as my parents, to share my substance with him, and relieve his necessities if required; to look upon his offspring in the same footing as my own brothers, and to teach them this art, if they shall wish to learn it, without fee or stipulation; and that by precept, lecture, and every other mode of instruction, I will impart a knowledge of my art to my own sons, and those of my teachers, and to disciples bound by a stipulation and oath according to the law of medicine, but to none others. I will follow that system of regimen which, according to my ability and judgement, I consider for the benefit of my patients, and abstain from whatever is deleterious and mischievous.

I will give no deadly medicine to anyone if asked, nor suggest any such counsel; and in like manner I will not give to a woman a pessary to produce abortion.

With purity and with holiness I will pass my life and practice my art.

(I will not cut persons labouring under the stone, but will leave this to be done by men who are practitioners of this work.)

Into whatsoever houses I enter, I will go into them for the benefit of the sick, and will abstain from every voluntary act of mischief and corruption, and, further, from the abduction of females or males, of freemen and slaves. Whatever, in connection with my professional practice, or not in connection with it, I see or hear, in the life of men, which ought not to be spoken of abroad, I will not divulge, as reckoning that all such should be kept secret.

While I continue to keep this Oath unviolated, may it be granted to me to enjoy life and the practice of the art, respected by all men, in all times! But should I trespass and violate this Oath, may the reverse be my lot!"

(Adams, II, 779, cf. Littre, IV, 628.)

The Hippocratic Oath. Most medical students in America recite some version of this oath at their medical school graduation. Its text implies a sacred and overriding respect (ethic if you will) for the individual.

Doctors are currently witnessing the profession of medicine moving from the ethic of the individual to the ethic of the collective. The passage of the Affordable Care Act has solidified this treatment ethic and, as a consequence, often creates conflicts between the treating physician and their individual patients.

Nowhere is this shift to the ethic of the collective clearer than our expanding attempt to determine treatment "appropriateness" using a look-up chart of euphemistically-scored clinical scenarios owned and trademarked as "Appropriateness Criteria®" or "AUC®" by our own medical professional organizations. For those unfamiliar, these "criteria" label the care rendered in hypothetical clinical situations as "appropriate", "uncertain" or "inappropriate." (ed's note: oops, this year's update labels these "appropriate," "may be appropriate," or "rarely appropriate"). While touted as "evidence-based," these criteria simply are not - they are a consensus opinion of a collection of physicians for clinical scenarios unrelated to any real patient.

What happened to doctors serving as advocates for their patients? Are doctors really turning to these tables to decide which clinical care to render? Or do we really use them to make sure their EMR note reflects aspects that will assure third-party payment for care?

As we wallow in this latest unfortunate mandate being served to doctors, perhaps there is some use in investigating the origins of these ridiculously-complex criteria, for it is telling.

A few clicks of a computer will show the idea of "appropriateness" came from the Europeans via the RAND corporation. The organization quickly spread abroad and is now RAND Health in Santa Monica, California, USA and RAND Europe in Leiden, the Netherlands. Most of all, it is telling who now sits on the RAND Health Advisory board (ed note: Vice President, Global Affairs for Anheiser-Busch, really?). Not surprisingly, it is those who stand to gain from the business of medicine, the vast majority of whom are not even doctors. It is also worth noting that this is the same RAND organization that promoted unrealistic estimates of cost-savings to our health system afforded by Electronic Medical Records subsidized and promoted by the government today; the same business interests who make billions upon billions on Wall Street.

Our professional subspecialty societies, often funded by these very same organizations who sit as board members of the RAND Corporation, have turned a blind eye to this conflict of interest. They have adopted the process "in response to the imperative for improving the utilization of cardiovascular procedures in an efficient and contemporary fashion" and few have ever questioned its downside. In turn, doctors who use these methods collude with our well-meaning professional society colleagues to perpetuate a health care delivery model that prioritizes business interests on behalf of the "collective" above those of the individual patient. Why are we allowing trademarked intellectual properties like "Appropriateness Criteria®" to substitute for clinical judgment about our patient's individual clinical circumstance?  Could our societal self-appointed gurus ever know anything about the constellation of complicated medical and social circumstances that patients bring before us in the private confines of our office?  Of course not.

Yet here we are.

It seems a day never ends that physicians aren't being instructed on what else we must do to massage a chart for the good of the collective without a moment's consideration of what their "criteria" might mean for our patient's best care.

This is our new ethic, our new reality.

Speak out against this practice and the doctor is instantly labeled "non-evidence-based," "greedy," "self-serving," and "unconcerned" about the "patient collective." So doctors actively put their heads down and care for their patients as best they can.  Daily, doctors experience the angst of this movement. We don't want to admit what has happened. Time and again we find ourselves constrained by these "guideline"- or "appropriateness use"-directed care that has been authorized by our own "physician collective" as "appropriate" when, by its very nature, is outdated by the time the guidelines are published, static and fail to incorporate newly-vetted therapies, and conflict with our patient's actual medical needs.   Our field of medicine has become so complicit with this movement that we've even allowed our political and justice systems to threaten or impugn those who step outside these or other outdated care guidelines.

When doctors abandon our most basic ethic of caring for the individual for that of the collective, we are served our just desserts. Perhaps writing something like this will open our eyes. Or perhaps, as we've been so quick to do, we'll choose to keep them closed and not admit that this has happened.

Remember this when others say no to the care your patient needs.

-Wes

Mobile Health Apps and The Privacy Surrender

It has been interesting watching the development of Alivecor's mobile phone EKG app.

At first with the beta release of the device it just so cool to see your EKG in real time: just tap the app, put your hands in the device's over-sized electrodes on the specialized iPhone case and *bam* there it was - your heart's realtime EKG displayed right before your eyes.

Then a new software upgrade to the app came quite a bit later after the device's FDA approval.  You had to enter a name before the app would proceed to the EKG screen.

Okay, makes sense.  Don't want to confuse data.

Screenshot of Alivecor EKG app software
(click image to enlarge)

But now there's a new twist with the latest app release: before you can even load the app, you have agree to surrendering your "sensitive personal information" to the company "and other companies within the Alivecor group."

Welcome to the mobile health care privacy surrender. After all, these days if it's mobile, it's Big Data.

We've seen it with Google tracking their customers. We've seen it with Apple's Terms of Service agreement, too. And just like the big internet giants, the money in medical apps is not the app, but the data they produce. Alivecor has to develop a business model and nowhere in the world is there bigger business than health data, especially your personal data.

My purpose here is not to bash Alivecor.  On the contrary, I think they are leaders in moving forward in the mobile health care app arena that might be a viable business entity.  But I think patients should be aware of what we're surrendering each time we use any health care app that deals with anything medical and click "I Agree" to the app's broad "Terms of Service" that surrenders one's "sensitive personal information."

Perhaps people won't care about their privacy any more. Perhaps so much about us is already available on the internet, that we've already unwittingly surrendered our souls.  We want our iPhone or Galaxy visuals and we want them now.  So we agree.  But given the implications of what this might mean to a future insurance premiums or health care marketing tactics, shouldn't we at least wonder?

One of the most important abstracts at the recent American Heart Association this year was this little gem entitled "Do ICDs Prevent Hip Fractures or Are Physicians Selecting Appropriate Candidates for ICDs?" (thanks to John Mandrola MD, for pointing me to this).  The abstract underscores the pitfalls of observational comparative effectiveness research - the cornerstone for the latest internet promise of Big Data.  Believe it or not, correlation does not equal causation.

And yet increasingly we see Big Data analysis revered and marketed as scientific gospel.  Even our own FDA has used bench data over clinical data to specify pill dosages using this extrapolation, for instance.

Big data is becoming a means to justify the ends.

Think about that the next time you click on "I agree" and then see next month's higher insurance premium.

-Wes

When The Carrot Is Removed From the Stick

The field of medicine is one of the most rewarding occupations out there.  Few occupations allow such an incredible opportunity to directly impact the life of a fellow human being and see the amazing results of something you did.  Few occupations are allowed inside the most intimate and vulnerable moments of the human condition.  In a word: amazing.

But medicine for people has quickly given way to medicine for business.

Business needs results.  Business need productivity.  Business needs profit.  And profit in the increasingly competitive world of medicine is getting harder and harder to come by.

To assure these business needs, medicine has hired legions of support personnel.  These include administrators looking for ways to remain "value-added," collectors to assure the cash flow, insurance plan negotiators to cut the best deal, quality assurance and safety officers (you can never be "too safe"), database operators adept in last-year's technology, concierges to make it all seem happy, survey takers to under-sample opinion, and negotiators adept at keeping the price spread. 

To lower costs, patients are made outpatients, personnel ranks are thinned, and beds are closed. 

Yet for the most part, it has worked because doctors have stayed true to their calling.

But what if that calling dies?

What if the insurances hassles grow too great or the income doctors receive fails to cover the cost of their education?  What happens?

In truth, little right away.  Given the time commitment, it's hard for doctors to pull the plug entirely. Many doctors don't complete their training until their early thirties, and by then, they likely have families and kids, and if they are lucky, a home. So they hang in there.  They do the best they can.  Like most Americans, the cut back, budget, and make do.  But as their hours grow and incomes dwindle, some of the rose-color in medicine turns to grey.  They still love what they do, when they can do it, but if there is less reward, there is less effort. For some, mediocrity will replace exceptionalism. For others unwilling to bow to mediocrity, the desire to stay late to squeeze another patient in dissolves.

This morning's revelation of the latest physician cuts proposed by the insurance industry should give us all pause, because if it's true, you won't hear a word from doctors.

You just might not be able to see one.

-Wes

When We Empower Patients to Pay for Expertise

"I know what you're thinking, punk. You're thinking "did he fire six shots or only five?" Now to tell you the truth I forgot myself in all this excitement. But being this is a .44 Magnum, the most powerful handgun in the world and will blow you head clean off, you've gotta ask yourself a question: "Do I feel lucky?" Well, do ya, punk?

Harry Callihan (played by Clint Eastwood) in "Dirty Harry"

Today, Alivecor accounced the launch of their AliveInsights(TM) EKG interpretation service where patients decide with their own dollars and sense, who interprets the single-lead EKG generated by Alivecor's EKG iPhone case. If the patient feels fine with a technician and wants a response in 30 minutes, they can get their answer if they elect to pay $2. If that same patient wants a "Board Certified" US cardiologist to interpret their tracing and are are willing to wait up to 24 hours, they can elect to cough up $12 instead.

Gee, which would you take?

My bet is that Alivecor's guessing people will accept the cheaper alternative. But will prescribing doctors?

It is an interesting model. I learned from Dr. Dave Alpert, the inventor of the Alivecor iPhone case, that "board certified" cardiologists get to keep $10 of the interpretation fee for providing the service - no insurance forms to fill out, no worry about a technical fee for the patient - just a plain ol' cash payment model.

Perhaps what is most interesting to me is how incredibly disruptive this model is to our current medical model.

But there are other concerns for doctors who might elect to "prescribe" an Alivecor case to their patients.

If the patient elects to pay $2 and a "technician" mis-reads the EKG, is the prescribing physician legally responsible for adverse outcomes that might occur? Who is responsible if a cardiologist mis-reads the transmitted EKG - the prescribing physician or the interpreting physician (presuming they are not always the same individual)?

These are interesting questions to ponder as this service launches. Certainly other issues are likely to arise where the lines of patient responsibility become blurred. Still, I like the fact that Alivecor is moving head-on into this space. It sets an exciting opportuntity for patients to have more control over their health concerns, and if this helps them, then all the better.

So as Harry Callihan said, "Feel lucky, punk?"

-Wes

Appropriate Use Criteria's Next Steps

Dr. Kussmaul, you are my hero for publishing this letter to the editor:

"With detailed evidence-based regulation of our professional lives already in full swing, it seems inevitable that the same process will eventually extend to our personal lives. The SCAI (ed's note: Society for Cardiovascular Angiography and Interventions) has always striven to stay ahead of regulatory developments, so as to exert a leadership role.

In that spirit, I offer the following as a beginning of the conversation. Should an interdisciplinary committee be convened on this matter, I hereby volunteer to serve."

William G. Kussmaul III, MD
FSCAI Hahnemann University Hospital
Philadelphia, Pennsylvania

-Wes

PS: Heh. Reminds me of another post I wrote a while back along the same line.

Reference: Kussmaul WG. Letter to the Editor: "Appropriate Use Criteria: What's Next?" Catheterization and Cardiovascular Interventions 82:848 (1 Nov 2013), pg 848.

When Medical Content Providers Go Political

It is an interesting time in medicine.

If we step back a few thousand feet and look down on America's medical world, we see a mess.  We see rules and regulations run amok.  We see doctors under unprecedented pressure to click rather than to care. We see government websites built with the promise of access to health care, collapsing under its own weight.  We see politicians promising one thing, then delivering another.  Then we see them give exceptions to some or outright lying to others.  Then we see them get cozy with the insurance lobby after they're caught red-handed  in hopes of making a "fix."

We, the lowly patients and doctors in this political power game, turn our heads in disgust as we struggle to help people live (literally) another day.

US medicine is now all about power and money.  As such, medicine is now more about a political vision rather than reality.   Politics, after all, is all about sales: selling a vision to stay elected and to stay in charge.

So where better to turn to promote your political sales job than WebMD (and their subsidiaries like Medscape and theheart.org), that "trusted" purveyor of all things medical?  It seems WebMD and its MedScape affiliates like theheart.org have quietly accepted a $4.8 million grant  to promote the Affordable Care Act and have refused to disclose this little factoid to doctors and their readers.

There does not need to be a  Sunshine law for politicians and medical content providers these days, only doctors.

But it doesn't stop there.  Ironically, shortly after this disclosure by the Washington Times, an article entitled "Conflicts of Interest: Concepts, Conundrums, and Course of Action" appeared on theheart.org/Medscape Cardiology's website.  (Update: this morning there's an article on the Physician Payment Sunshine Act, too!)  As I tried to read this article I laughed as I clicked through a Brilinta ad and was subject to Bystolic and Belviq ads in Medscape's sidebar.

Here's a real "course of action" I'd suggest to doctors bothered by the double-standard of disclosure imposed on us from our political class: dump the Medscape app on your cellphone, give a little shout-out to theheart.org, er, Medscape Cardiology, and ask why they haven't said anything.

Then cancel anything related to WebMD.

Then, at least, we'd be sure we're getting past the political propaganda and back to medicine.

-Wes

h/t: A faithful reader.

Addendum 16 Nov 2013 @ 12:20 PM CST: It seems WebMD felt compelled to release this press release regarding their editorial integrity, but it did not reference the above conflict disclosed here specifically.

Maintenance of Certification in Cardiac Electrophysiology: Taking the Stick

Shuzan, a Buddhist monk of the tenth century, once held up a bamboo stick before his disciples. "Call this a stick," he bellowed, "and you assert; call this not a stick, and you negate. Now, do not assert or negate, what would you call this stick? Speak! Speak!"

From out the ranks, a young monk ventured forth, grabbed the bamboo, and, breaking it in two, exclaimed to Shuzan, "What is this?"*

After coughing up thousands of dollars and enduring months of test preparation for the third time to “maintain” my designation as “board certified” in my specialty according to a group I do not know called the American Board of Internal Medicine (ABIM), I have decided to do as the young monk has done in the passage above and take the stick. We need a different paradigm.  

So why not create our own, free and publicly vetted "certification?"  As part of this effort, I will ask for help from my physician colleagues who frequent this blog: please serve as test content providers.

While this will be a work in progress, there are a few rules (we must have rules, you see, to maintain legitimacy).  The rules for this high calling include the following:

1)      This certification process must, and always should be, free.  It is for doctors, by doctors.

2)      The development of this test and its scoring will be transparent.

3)      The content of questions created will always be relevant to clinical practice and apply to disease processes that occur with a prevalence of greater than one in a million of the population (no zebras allowed).

4)      Content created here can be re-used, reprocessed, and pureed without restriction and without cost, anywhere worldwide.  Any attempt to sell content created herein for purposes other than the support of patient care will be disclosed. (Enticements like "free" iPad Airs are particularly discouraged, especially when the content for a weekend course is sold for $1695.)

No conflicts of interest, period.

Here are my first two example questions so others get the point (I encourage others to add their own questions in the comments):

1. You are about to begin a permanent pacemaker implant on an 85 year old woman with a serum creatinine level of 3.2 who presented with complete heart block and a wide complex escape rhythm of 35 to your emergency room.  Her vital signs are otherwise stable.  You know you don't receive payment for placement of a temporary pacemaker wire before the permanent pacemaker is implanted.  Your patient is right-handed, so an IV is started in her left arm in anticipation of an ipsilateral pacemaker implant.  She receives appropriate skin prep (another question in this, perhaps?) and prophylactic antibiotics (maybe another on this?) before her procedure.  The next best approach before proceeding would be:

A.) Place a temporary pacing wire via the right femoral venous approach before proceeding anyway.
B) Use vascular ultrasound to carefully identify the precise location of the axillary vein before attempting a blind stick based on classic subclavian access techniques.
C) Withdraw the stylette approximately 2 cm before advancing the RV lead in the patient's ventricle to minimize the chance of ventricular perforation.
4) B and C above.
5) A, B, and C above.

2.  The new "pacemaker in situ" ICD-10 code to minimize patient hassles receiving payment for your services is:

A) 996.01
B) V43.3
C) Z95.0
D) 996.04

There, Questions 1 and 2 for our OWN new certification process are in.

Now, who's got some more?

-Wes

What Our Politicians Should Fear the Most

... is when patients start telling their real life stories:

"Before the Affordable Care Act, health-insurance policies could not be sold across state lines; now policies sold on the Affordable Care Act exchanges may not be offered across county lines.

What happened to the president's promise, "You can keep your health plan"? Or to the promise that "You can keep your doctor"? Thanks to the law, I have been forced to give up a world-class health plan. The exchange would force me to give up a world-class physician.

For a cancer patient, medical coverage is a matter of life and death. Take away people's ability to control their medical-coverage choices and they may die. I guess that's a highly effective way to control medical costs. Perhaps that's the point."

-Wes

The Day Before

I probably shouldn't be writing this.

Tomorrow, after all, I sit for my Maintenance of Certification examination in Clinical Cardiac Electrophysiology. It's my second time re-certifying after passing my original EP boards in 1994. And as I've been learning, things have changed. But I should do fine, right? There's no need to worry, right? I've been doing this my whole working life after all.

Relax, Wes!

But I do worry. That is my nature. I have spent countless hours worrying about this test. II took the sanctioned Heart Rhythm Society Board Review Course to prepare for this test. Why? Because I know from prior experience that there are tricks to these tests: certain topics that always get tested. The directors of these courses, sworn to secrecy mind you, give you clues what will be on these tests by the material they cover in their lectures. So I paid. Yeah, it's a racquet and I'm probably a fool, but knowing how to spend your precious time studying after a full's day work is helpful. After all, it would be embarrassing and even more costly for me if I do not pass.

So, for whatever reason, I just don't want to forget how I feel right now. Perhaps it's to let my patients know why their clinic date with me has been bumped. Perhaps it's to let others know what one doctor really feels just before doing this so late in one's career.

But honestly, I suppose I really want to write this post for me. I don't want to lose the memory of what it was like to watch the video about the unfamiliar corporate testing center where I must go, about the infra-red palm reader that I will have to use to prove the person there is really me. I don't want to forget the guy (or gal) that will be sitting behind the glass wall watching me as I sit staring at a wall and a computer screen in a tiny cubicle clicking at a keyboard for eight hours. I don't want to forget that even my watch and wallet won't be allowed in the room; that I will be unreachable in this tomb. I don't want to forget the foreboding sense of a robotic depersonalization; about my anxiety at the thought of constantly worrying about a tiny digital clock in the right upper corner of the screen constantly ticking, ticking, ticking - as if medical decisions are ever timed like this. Like Nineteen Eighty-Four.

And I especially don't want to forget how incredibly small I feel as doctor now...

... the day before.

-Wes

The House of the Month

I drove by this and nearly crashed my car:



(Click to enlarge)

Pure awesomeness.

-Wes


With Obamacare: Remember the Challenger

By now, the Obamacare insurance exchange debacle is old news. Our attention spans are so short, we're on to the next disaster.  So we sit before our TVs and enjoy the Humana ads with a smiling senior pointing to a whiteboards with their insurance plan name, or watch the news sponsored by Unitedhealth or Walmart's pharmacy department. Everyone's got a cheaper plan these days with more benefits than the other guy, and the good news never ends for you, according to our insurance companies.

Sign up people. No worries.

Even if they take you to the cleaners.

It was interesting reading the piece over at Kaiser Health News asking why a couple without kids has to buy dental insurance for children they don't have. Or  the free colonoscopy "catch" never discussed in the Obamacare ads that promoted by the law's proponents. More and more of these not-so-little details are not  as pretty and "free" as everyone had hoped, but it's what we as a nation have approved, hidden in the new law we never read.

Shame on us.

Shame on our legislators.

But we must take a different perspective now that it's becoming crystal clear what central control of health care delivery means.  I think most Americans have been incredibly tolerant of the rollout (and even appreciate the effort involved) since they have a rudimentary understanding of how complicated health care has become in America and how vital it is to our economy.

But I sense (like many others) that Americans' patience is growing thin.  People are wondering how will things be fixed?  How long will it take?  Will I have to pay a penalty for something so fraught with problems?  Who's responsible?  Whom can I call?  Can they be trusted?  Is this going to be how the rest of the health care coverage rollout happens? 

Years ago, millions of people watched the US space shuttle Challenger explode into a million tiny pieces on a crystal clear day shortly after its launch.  We were shocked at first, then deeply saddened, for our idealized notion of the space program so advanced and amazing quickly evaporated before our eyes.  We grieved with the crew's families as we watched in horror the events replayed on TV again and again and again. 

But then what happened?  Investigations followed.  Video tapes were reviewed.  A root cause analysis was undertaken.  Ideas were tested, the O-ring problem identified, and slowly, carefully, changes were made to the shuttle program.  New parts were engineered, other parts scraped.  More thorough testing than ever before occurred.  Then re-testing.  And slowly, cautiously, the shuttle program resumed, one baby step at a time.

And no one ever took a complicated shuttle launch for granted again.

So, too, should it be with our new health care law.

We should remember these lessons we learned from the Challenger disaster.  The Healthcare.gov rollout debacle was no less anticipated and certainly no less spectacular.  We need a root cause analysis of this mess.  We need to identify the problems and fix them if they can be fixed or scrap what can't.  We should stop and ask ourselves what of this law should continue, and what should be scraped.  We should ask the difficult questions and if it truly is in our best interest to proceed with certain parts, test and retest that which remains to make sure the systems are secure and the program functional.  And most of all, we should ask now if this whole grand health care idea is likely to be truly cost effective and sustainable for our nation before rushing ahead toward another disaster.

Because, like the Challenger, it's people's lives we're talking about here, not some stupid website catastrophe.

-Wes

Obamacare 2016: Happy Yet?

From Bradley Allen, MD in the opinion section of the Wall Street Journal this morning:

"The forecast shortage of doctors has become a real problem. It started in 2014 when the ACA cut $716 billion from Medicare to accommodate 30 million newly "insured" people through an expansion of Medicaid. More important, the predicted shortage of 42,000 primary-care physicians and that of specialists (such as heart surgeons) was vastly underestimated. It didn't take into account the ACA's effect on doctors retiring early, refusing new patients or going into concierge medicine. These estimates also ignored the millions of immigrants who would be seeking a physician after having been granted legal status.

It is surprising that the doctor shortage was not better anticipated: After all, when Massachusetts mandated health insurance in 2006, the wait to see a physician in some specialties increased considerably, the shortage of primary-care physicians escalated and more doctors stopped accepting new patients. In 2013, the Massachusetts Medical Society noted waiting times from 50 days to 128 days in some areas for new patients to see an internist, for instance.

But doctor shortages are only the beginning.

Even before the ACA cut $716 billion from its budget, Medicare only reimbursed hospitals and doctors for 70%-85% of their costs. Once this cut further reduced reimbursements, and the ACA added stacks of paperwork, more doctors refused to accept Medicare: It just didn't cover expenses.

Then there is the ACA's Medicare (government) board that dictates and rations care, and the board has begun to cut reimbursements. Some physicians now refuse even to take patients over 50 years old, not wanting to be burdened with them when they reach Medicare age. Seniors aren't happy."

Medicaid in 2016 has similar problems. A third of physicians refused to accept new Medicaid patients in 2013, and with Medicaid's expansion and government cuts, the numbers of doctors who don't take Medicaid skyrocketed. The uninsured poor now have insurance, but they can't find a doctor, so essentially the ACA was of no help.

The loss of private practice is another big problem. Because of regulations and other government disincentives to self employment, doctors began working for hospitals in the early 2000s, leaving less than half in private practice by 2013. The ACA rapidly accelerated this trend, so that now very few private practices remain."

Read the whole thing (subscription required, sorry).  Not surprisingly, it's not pretty.

-Wes

Back to One

It was a comment posted by "Cat, MD" on my prior post regarding my assessment of where the nation stood "week two" following the launch of the government's health insurance exchange website that caught my eye. To me, she(?) asked what might be the one of the more important questions posed on this blog that warrants consideration by every medical student and practicing doctor currently:

Dr. Wes,

You state that law and medicine do not mix, but it seems as if medical care will be driven by national politics for the indefinite future. The ACA and laws like it will directly affect how physicians can practice.

So what role should physicians try to play in this? The prospect of letting attorneys and accountants dictate medical practice unnerves me. But at the same time, few people go to medical school to become politicians. As a medical student, I feel that physicians need to be more involved in legislating, but how?

Perhaps this would be as good a time as any to step back and contemplate this incredibly challenging question. After all, more and more difficulties with our new law are appearing as its real nuts and bolts are revealed. Yet it is always easy to criticize the myriad of events that are unfolding: the botched Healthcare.gov website, the creation of new donut holes of health care coverage, or the real life problems with the restrictive health care system model we're creating. What can doctors possibly do to help resolve these challenges?

Like a difficult case that stumps the best of doctors, perhaps doctors should go back to one.

The idea is not mine but that of the late psychologist and disruptive thinker, Sheldon B. Kopp. When a doctor has a difficult case sitting before them and they have run out of ideas about how to help that patient, he recommends the doctor go back to one. What do you know how to do well? What can you contribute to this patient. What have you tried that did not work?

Back to one.

From Dr. Kopp's book, "If You Meet the Buddha on the Road, Kill Him: The Pilgrimage Of Psychotherapy Patients:"

“Crises marked by anxiety, doubt, and despair have always been those periods of personal unrest that occur at the times when a man is sufficiently unsettled to have an opportunity for personal growth. We must always see our own feelings of uneasiness as being our chance for "making the growth choice rather than the fear choice.”

We have tried Red and Blue solutions for health care reform and should be asking ourselves how they are working out. What has worked? What hasn't? What can each of us bring to the health care table? What needs to be done? Is a centralized control of health care our best solution, or might there be something else?

Of course, none of this is easy. It is not easy to take risks. It is not easy to think we might not just be able to sit back and ignore the difficulties that arise when biased third-parties control the show. But when we begin by going back to one, there is an opportunity for meaningful change that benefits doctors and patients alike.

For today's doctors, Dr. Kopp offers a useful visual:

“There is the image of the man who imagines himself to be a prisoner in a cell. He stands at one end of this small, dark, barren room, on his toes, with arms stretched upward, hands grasping for support onto a small, barred window, the room's only apparent source of light. If he holds on tight, straining toward the window, turning his head just so, he can see a bit of bright sunlight barely visible between the uppermost bars. This light is his only hope. He will not risk losing it. And so he continues to staring toward that bit of light, holding tightly to the bars. So committed is his effort not to lose sight of that glimmer of life-giving light, that it never occurs to him to let go and explore the darkness of the rest of the cell. So it is that he never discovers that the door at the other end of the cell is open, that he is free. He has always been free to walk out into the brightness of the day, if only he would let go. (192)”

If only we would let go.

To start, I believe there are a few prerequisites young and older doctors alike from either side of the political aisle should consider to help bring meaningful change to the health care reform discussion:

Be a Good Doctor: Nothing will improve your credibility as a spokesperson on behalf of your patients if you keep their interests first. This whole reform efforts is, after all, about them.

Get Involved: If you don't vote, you can't complain about who is elected. In the same way, if you don't get involved in voicing your concerns (and this is important) attempting to offer new, helpful solutions to problems faced by your patients, how will things ever improve for them?

Connect: None of us are politicians. None of us are lawyers (well, a few might hold dual degrees...). But doctors should be asking themselves, how have the politicians handled things to date? Maybe it's time to rethink our strategy for reform. Maybe Washington's solutions aren't our patient's best solutions. But is there a different way, an alternate strategy?

The vast majority of doctors are on the front line of caring for patients. Most are incredibly busy. And the majority are a devoted bunch with authority when it comes to patient care (believe it or not). We can offer solutions. Some are likely to fall on deaf ears, but some may not. But if we don't speak up and consistently advocate for our patients' medical needs over basic or mandated business concerns, our patients will suffer and we will be sidelined.

Some have suggested that social media might be a place where doctors' voices can be heard. Perhaps. But while doctors can voice our thoughts and ideas on social media, I am increasingly convinced that this is not where real change will occur. We need to bring our thoughts and ideas back home to our communities. Doctors need to take back medicine by going back to one and dig deep to offer small solutions one at a time locally, at home, not on some large bureaucratic national stage that is driven by special interests.

Cat, MD's question is the nugget: "... but how?" "Back to One" is just one idea. There are others. But maybe the best way to start changing health care for the better is to start asking the right questions and offering our own solutions for ourselves and our patients.

-Wes

Saying Goodbye to Drug Samples

Soon, doctors won't be handing patients drug samples from time to time, pharmacists will.  

Doctors were told that makes a difference.  It will soon be a national trend, they were told.  Instead of handing a patient a sample, just type in an order for a sample to the EMR and the pharmacist will make sure they get it.

Doctors were told that the Joint Commission has certain standards that must be met by health care organizations and hospitals when drug samples are given to patients.  After all, doctors were told by at least one of their own that drug company representatives bias the way doctors think and prescribe.  Doctors must also disclose gifts they receive from drug companies that exceed $10, according to the recently activated Physician Payment Sunshine Act.  Doctors were told drug samples might qualify as gifts.  It just looks bad, they were told.

Doctors were not told that their hospital system runs the pharmacy now.

Think about that.  Think about the unintended consequence when yet another small, kind, visible gesture that a doctor can make to his patient is yanked from his control.  Think about the fact that decreasing pharmaceutical sales representatives might decrease pharmaceutical sales of more expensive medications, but might also have the unintended consequence of decreasing access to new and important information to physicians and as one study pointed out, result in doctors who didn't see drug representatives prescribing less effective and potentially more dangerous drugs to their patients longer than those who do.

But at least the sample order will be there in the electronic medical record to track.  Hospitals will be in regulatory compliance and pass their Joint Commission inspections with flying colors.  And no doubt the pharmacist will do a better job of teaching patients at the drug counter when people are lined up in public four-deep to get their prescriptions. Surely the hospital's pharmacist will be completely aware of the patient's entire medical history and offer the correct number of tracked sample medications without any conflict of interest involved.   

And doctors will sleep better at night knowing their physician payment database record remains unblemished.

Yeah, no worries.  None all all.  It's all for the better good.

Really.

-Wes

Accountable Care Act Week Two: An Honest Assessment, Part II

Bob Doherty, MD gives his assessment of the Accountable Care Act's second week over at the American College of Physician's blog today. It's a worthwhile read and I encourage my of my three readers to head over there to see what he has to say. Remarkably, I agree with some of his assessment, especially his perspective that the miserable launch of the ACA's healthcare.gov website is not a reason to call the law a complete "failure."

But as things would have it, the ACP blog does not permit the "html" tag in his blog comments (I understand why: it helps limit blog spam), but I wanted to reference a few important links so I'm placing my different "honest" assessment of our law's second week here. So Bob, please excuse my comment being left here.

Bob -

Politics and medicine don't mix, yet today the two combined are our reality. As such, a brief comment about your post.

First on what we agree upon: tech problems on healthcare.gov are not a reason to declare the ACA a “failure.” No doubt the day will come after they pour in many tens of millions of dollars more to fix the website that things will be humming along famously one day.

But many are aware that the ACA as it was written is no longer the ACA, so as such, it has failed before it's website was launched. But if we ignore this fact, the ACA now is a patchwork of political favors and waivers that favors the politically connected and architects of the law and it is likely to continue to be such. We are also finding that the law is very expensive for many Americans, yet does little to address the expanding cost burdens that health care imposes on America’s economy, especially when one evaluates the law on the basis of health care cost sustainability. To me, this is the ACA’s Achilles’ heel and why it will ultimately be morphed into yet another "law," not because of some poorly-designed website. You see, it is anything but “Affordable” and even more importantly, certainly not “sustainable.” But we should acknowledge that for many Americans saddled with the prospect of bankrupsy from burgeoning health care costs, the law will offer relief and this is a good thing.

Still, after the debut of the exchanges 1 October 2013, out-of-pocket costs of the new health care “plans” put forth by the insurance industry became known and were nicely outlined by Peter Frost in the Chicago Tribune recently. People will soon be feeling the effects of these additional costs first-hand that have been created in large part by the regulatory requirements of the law and its giant bureaucratic overhead. In fact, I have already begun hearing from patients that the deductibles for many of them are so high that many are worried they won’t meet their deductibles in an average health care year before the next year arrives. So what have they gained from this law, just a sense of altruism for their fellow man?

Personally, I think this is why the ACA as it exists will fail: Americans’ realized out-of-pocket health care costs. And when it does, Big Box medicine will have to accommodate new, innovative health care payment strategies that actually create visible value to those who pay into the system, rather than just guaranteeing the rising stock price of insurance and pharmaceutical companies.

But physicians like us are also to blame for the law’s ultimate failure. Caught between the law’s political promise of "health care coverage for all" now, versus creating more sustainable health care delivery system for the long run, our political lobbying groups (the AMA, ACP, ACC and others) sided with the political expediency of approving the law’s construct as it was presented. And so now, we have no choice but to continue to ride along on our newly revised Healthcare Hindenburg whether doctors really like it or not.

Just my two cents.

-Wes