Friday, May 16, 2014

When We Worship Process More Than Patients

If you read nothing else this week, please read these words from Saurabh Jha, MD, Assistant Professor of Radiology at the University of Pennsylvania (republished here with permission):
Writing in the Wall Street Journal (WSJ) Dr. Daniel F. Craviotto Jr., an orthopedist, made a plea to physicians to declare independence from third parties and emancipate themselves from servitude to payers, mandates and electronic health records (EHR).

As rants go, this was a first class rant. But its effect was that of a Charles de Gaulle’s whisper to Vichy France rather than a Churchillian oratory at the finest hour.

The article went viral (it has been tweeted nearly 3000 times), though with little virulence. And it is not WSJ’s paywall to blame.

The author might have assumed that most the healthcare community in general and physicians in particular wish to be free from regulations. I have serious doubts that this assumption is correct in the aggregate. The relationship between regulators and physicians is more complex and symbiotic than it first appears.

Some physicians believe in bureaucracy. Rationalism will march us out of our healthcare wilderness. This belief in scientific managerialism, faith in technocracy, is the new theism. The rationale of the new theists is that regulations fail not because they are inherently useless but because there are so few of them, and even fewer that are actually smart.

Like the first religions started with polytheism, the new believers want more agencies, more alphabet soups, more gods.

This type of reasoning can empirically neither be proven nor disproven. Hence, the comparison to religion is apt. It is like the argument made by neo-Keynesian economists: stimulus failed because it was too small. How do we know it was too small? Because it failed.

This circular reasoning is immortal and akin to an infinite set; one can always impute upon it the promise of success if only one added just a little more.

Convinced of their own virtue and the vice of others, many physicians crave more regulations. They hope that in the next round will emerge the regulatory Thor wielding his nuanced hammer on evil Medicare serpents and fraudsters. Instead we receive the leviathanic, uncoordinated Moby Dick that throws Quuequeg out with Ahab and splashes a lot of salt water in the process.

Some meet any criticism of third party players, coding and regulatory waste with a false dichotomy “so now you want to abolish insurance and Medicare, what’s your alternative?” or “you are against ICD-10, so should we descend in to anarcho-capitalism and send poor kids to workhouses?”

This line of thinking reminds me of the willful scarcity of cerebral activity that allows some to interpret in any government intervention a short step to National Socialism. The phenotype is the same. The polarity is merely reversed.

The rest of us, those who can see the vast zone between a dysfunctional Electronic Health Record and Zero Government, are merely quibbling about the price, not the principle.

And quibble we must.

We should question the marginal utility of regulations, the evidence base from which they arise, the unintended consequences of their complexity, their opportunity costs and the waste of tax payer’s money for rules that do not improve outcomes.

Outcomes, remember outcomes? We hold a new drug or device to this metric, why not a regulatory decree that is both perennially alive and permanently fossilized?

And so the author of the rant has a point.

An inordinate time of physicians is spent on non-clinical work such as coding, billing and compliance. This has been estimated to be as high as 80 % (I am waiting for the regulated shape shifter to say this is clinical work, really). One recognizes that non-clinical work is unavoidable to an extent, and in saying that 80 % is too high I hope the binary minds of some do not infer that I think it should be zero percent. But if 80 % is not too high how about 90 %? 99 %? 99.5 %? Is there no limit?

If physicians spend more time in activities that allow them to be measured than the activity for which the measurements are sought, this is a sign of dysfunction. The clinical “horse” is being grounded by the regulatory “cart.”

And this has consequences for patient care. Physicians rarely make eye contact with patients these days staring, instead, at the vast dark matter of their EHR wondering how many words it takes to say the patient has a common cold.

As Nietzsche warned, well sort of, “If you gaze into the EHR, the EHR also gazes in to you. Beware physicians, lest you become an electronic health record.”

We are living an epidemic of documentation of such utter clinical irrelevance that one struggles to comprehend. And yet some demand even more rules, more codes and more metrics as more granularity is desired and imperfection of information even less tolerated.

To paraphrase Churchill “never was so little owed by so few to so many.” Never was so little achieved by so many. A giant bureaucratic sledgehammer is being wielded against a nut it repeatedly fails to crack.

Craviotto’s declaration of independence is misplaced. To rue government involvement in healthcare within the safety of a guild, protected from the vicissitudes of the market and competition with Rajeev from Bangalore is a tad rich and rather like the famous ungrateful climber who was carried on the back of Sherpas to within a canter of the summit of Everest.

He should, instead, have appealed to our sanity and common sense, the only weapons we have to tame the bipartisan regulatory Goliath.
Saurabh Jha, MD's (@RogueRad) piece first appeared on The Health Care Blog, where it caught my attention.


Anonymous said...

Please pay close attention to the upheaval within the VA system about false appointment lists. Watch closely when the federal prosecutors come knocking. Anyone familiar with the VA system knows that regulations come from the bureaucrats on high to be implemented by the grunts in the trenches 'pulling charts off the door'. The physicians were not capable of fulfilling the mandates so they 'buffed the chart/system' to make it look good for the bureaucrats. It is a win/win until patients start to die because they are waiting indefinitely for appointments.

With the entire affair blowing up in congressional hearings, who will be the ones frog marched to prison by the federal prosecutors? Will it be the regulators who demanded unobtainable outcomes or the physicians who artificially massaged the appointment lists?

The past is prologue.

W.O.R.M. said...


A pressing question is how did the medical profession drown in a maelstrom of regulation and forced hyper-documentation? It centers on the cost of healthcare, which has risen to unsustainable levels. Overt rationing is off the table, as it would lead to voter disquiet. It wouldn’t exactly be a popular campaign platform for any (pick your party) career politician.

We live in a world of all possibilities. If, in the darkest deepest recesses of your mind you can conceive of something, there’s probably someone out there doing it. So it goes with health reform ideations. Consider a few of the choices such as medical device and professional liability reform, increased insurance company competition, fair hospital pricing, and addressing big pharma price gouging. None of this will happen because of K street’s stranglehold on our political system. The major players are well positioned in the Congress (legislative) and Administration (regulatory) environments. That leaves the unguarded sheep in the pasture. The wavefunction collapses to physician disempowerment complete with forced EMR labor camps. Overwhelm the already demoralized plebes with cumbersome and non-productive mind numbing tasks. A race to the bottom. Encouraging selection of the time saving idealized Walmart priced single check box solution to a clinical task, thinking be damned. Reinforcing the new dogma of physician as technician. Mission accomplished, money saved. Oh, and what the hell. Cut their globally insignificant reimbursement to show them who’s in charge. K Street also becons the EMR machine makers. Don’t worry about ease of use and safety proven quality software. You’re protected. Besides, in true Orwellian doublespeak, easy is inefficient.

In the end, the current crop of politicians and shareholders will cash out leaving the healthcare system in continued fiscal disarray. An opportunity for a new generation of plutocratic pilferers to remind us of those “out of control” doctors.

Anonymous said...

I could be wrong. I is hard to take the pulse of something so complex, but it seems likely that much of the documentation idea stems from the demand for records when legal matters emerge. We want to have a record which shows we did everything right.

Malpractice came in like a flood when no fault car insurance eliminated an income stream for lawyers. Those who came up against the legal profession found that is was indeed a paper chase. Lawsuits often revolved around reocrds, more than reality.

So physicians allowed the nose of the camel into the tent, because EHR seemed to give some hope of showing that things went as they should.

The real solution to the regulation must surely involve some sort of tort reform, such as having patients pay a surcharge on every visit which informs them of the cost of malpractice. The present system is attractive to insurance companies, but does not inform the public of the cost.

Norman Briffa said...

"What gets measured gets managed!"

RD said...

Part 1:
Dr. Craviotto’s declaration rings perfectly true, because my practice environment for the federal government in primary care allows the independence he describes. Dr. Jha’s, and for that matter, Dr. Mandrola’s criticism* of his opinion piece both raise salient points, but I think that the main message Dr. Craviotto holds forth has been obscured.
Looking at Dr. Craviotto’s practice website, he is in solo practice as an orthopedic surgeon in California. From the standpoint of the solo clinician (not an academic radiologist or subspecialist) the world has been turned upside down, because as a result of mandates, designed and implemented without meaningful input from the clinician, the clinician now works for the regulator, rather than the patient.
Dr. Jha’s point that government support, and guild protection are substantial benefits afforded to medical doctors is relevant. However, those who are in support roles – the hospital administrators, insurance companies, government regulators, and even the legislature have taken it upon themselves to govern the nature of the patient physician relationship. If the Sherpa carried the climber part of the way to Everest’s summit, the climber is now carrying the Sherpa! It is only due to the passive nature, and perhaps equanimity, of past generations of physicians who failed to stand up and make their political demands heard for the sake of their patients. Here is where I take issue with Dr. Mandrola’s plea for a humble or graceful tone in public discourse on the direction of progress in our healthcare system. Was a graceful tone in order when there was a typhus outbreak in Upper Silesia?
What input to the ACA, or HITECH did clinicians have the opportunity to provide? Not professional organizations like ACP, AMA, etc. Both Dr. Mandrola and Dr. Fisher have readily pointed out the shortcomings of the ABIM with the implementation of MOC. This sorry episode serves as a ready example of the disconnect between the clinician and professional organizations who are intended to represent their interests.
Rather than clinicians being supported in their efforts to provide patient care, clinicians are working for the support elements. To use a military analogy, this is the infantryman on the ground being commanded and controlled by the cooks, truck drivers, intelligence, communications, and lawyers. Instead of the infantryman getting the food, vehicles, intel, working radios and legal advice he needs to go accomplish the mission, he is told to jump through hoops before carrying on.
Hospital administrators, malpractice lawyers, CMS, pharma, midlevel providers (PA’s and NP’s), and EMR’s exist to support clinicians providing good patient care. The clinician is the infantryman. The cooks work to feed the infantryman. The hospital administrators work to make sure that hospital lights stay on, the water runs, medical supplies get ordered, etc. Administrators have no more place dictating how patient care is carried out than cooks have telling an infantryman how to fire a rifle.

RD said...

Part 2:
What Dr. Craviotto’s writing said to me, is that he now sees it necessary to put the support back in their support role so that clinicians can get back to the business of taking good care of patients. The consequences of not doing so are manifest in the actitivities that prompted Dr. Foote and Dr. Mathews to blow the whistle on the Phoenix and St. Louis VA’s, respectively.
In past generations, physicians were firebrands for social and political change. Dr. Virchow said, “The physicians are the natural attorneys of the poor, and social problems fall to a large extent within their jurisdiction.” Our patients count on us to advocate on their behalf, to represent their interests when dysfunction creeps into the system. If a 15 minute visit doesn’t give them the time they need with the clinician to address their complaint, then it is the clinician’s responsibility to reform the system so that a longer visit can be provided to meet the patient’s need. That process of reform in modern medicine will now entail beating back hospital administrators who demand a requisite number of visits per day to meet financial targets, third party payers to get better primary care reimbursement to help meet those financial targets, and improved EMR systems that mean more time can be spent with the patient and less typing/dictating/clicking. The entire notion of medicine as a profession demands that physicians assume this responsibility.
My unique practice did not come with the independence to train my staff as I see fit, or to book appointments for however long or short I deem necessary. It took many hard won battles and drawing proverbial lines in sand in front of administrators to make sure that my practice is protected so I can protect my patients. It’s time to make the same thing happen on a national level. Truly, Dr. Jha and Dr. Mandrola are both on the record being in support of the same ideas. Rather small differences between colleagues are magnified in their objections. We are all on the same team in the same game as clinicians. Dr. Foote, and Dr. Mathews are on that team. Dr. Virchow helped invent the game. We just need to start acting, thinking and advocating like a team.


saurabh jha said...

I would like to thank Dr. Fisher for publishing my piece in his popular blog.

I've enjoyed reading the insightful comments. US medicine is certainly complex but all the more intriguing for it.

RD's military analogy is spot on.

And this line "If the Sherpa carried the climber part of the way to Everest’s summit, the climber is now carrying the Sherpa!"

That pithily summarizes the state of affairs.

We need to instill professional pride in both the climber and the Sherpa!