Wednesday, June 25, 2014

The Quiet

With the advent of social media and seconds-long news cycles, the internet noise grows louder.  Everyone is listening these days: new organizations, stock holders, businesses, special interest groups, and yes, the government.    There are even websites devoted to "secure" areas where the noise can permeate.

The Internet, you see, is it.

Yet what about The Quiet? 

The Quiet is the silent majority.  The Quiet smiles and seems happy.  The Quiet appears unaffected by policy changes and mandates.  The Quiet doesn't mind typing.  The Quiet follows rules. 

At least for a while.  The great cameleon.

So it comes as no surprise to The Quiet that the largest medical device company in the United States recently "purchased" another to avoid some taxes and improve its clout. 

A Quiet move.

And what about the National Quality Forum (here) or the Institute of Medicine's (here)  little conflicts of interest lapses?  And those electronic medical record  or insurance problems?

Shhhh.  Say nothing.  Smile.  No big deal, remember?

Dinner conversations with sons and daughters.  It's different now.  Consulting, enginnering, finance, or maybe nursing. Why be trapped by debt and a dwindling supply of paid residency positions?  There are other ways to help people.  Explore them.  See what you think.  You're young, remember?

The Quiet is marking time, working hard, advising.



Monday, June 16, 2014

Medicine's Great Disruption

"Disruptive innovation is competitive strategy for an age seized by terror."
- Jill Lepore, author of
"The Disruption Machine: What the Theory of Innovation Gets Wrong"

"What do you want me to do with all the stuff in this box?" my wife asked this weekend.

I looked inside and saw my former self: one of BNC and pin connectors, wires, a notebook with sin, cos, theta, and a host of other equations - a project I worked on but never grew - it came from a time of creativity and endless possibilities for me in medicine.  Engineering and computers were how I entered this field - the hope of solving problems, doing things a little better, safer, and maybe faster.  A chance to innovate and collaborate.  A chance to make a difference.

But the world of medicine has changed from one that promotes discovery and creativity to one that promotes productivity and the lock-step over the past several years.  See more.  Do more.  Don't sway.  Follow the guidelines.  Stay between the lines.  Want to try something new?  The message to doctors is loud and clear now: don't you dare!

Every month another set of guidelines and rubrics, as if the guidelines are how we want doctors to think, or rather, recite.  Medicine is rapidly becoming a staid world of group-think, as we are forced to use the latest "disruptive technology" to change our medical world.  Bit by endless meaningless bit.  The "value-added" ideas never end.  There is little ownership now.  Little personal investment.  Punch the clock.  Get 'er done.  Do what those grey suits say.

It's the era of the creative destruction of creativity. 

What kind of doctor we are breeding in medicine now?  The American Medical Association (AMA) and Accreditation Council of Graduate Medical Education (ACGME) want to shorten studies and push medical students through school based on competencies and "not based merely on a traditional time-based system."  Time with patients can no longer be trusted it seems.  In the place of time: competencies gained from simulators. Plastics superseding flesh. As though doctors should become technocrats that make a cameo appearance at the patient's bedside with their smart phone in hand.

Is the hurry-up push toward technology and Big Data really needed or what we're being sold?   Enter your note, doctor, click another box, you're being scored now.  Do as you're told.  What's that? A little software glitch?  Don't rock the boat.  Just work around it.  The fix will be here in September. We must do more with less.  Oh, and forget the staff, they're expensive. Hurry up.  Perfect data, remember?  Your pay depends on it.

Oh, and that idea you wanted to work on?  Sorry, no time or money.  Really doctor, we're on a time line. Could you move it along?  My kids have a play date.

The Disruption Machine is moving, alright.

But will we be better for it?


Wednesday, June 11, 2014

Damage Control

When you shine light on cockroaches, they scatter.

But we should not think for a minute that the cockroaches are eradicated.

That takes an exterminator.  And sadly, there are very few exterminators who deal in the shady cracks and crevices of the multi-billion dollar non-profit organizational world these people have created for themselves.  There are very few ways to hold individuals who hide behind this altruistic-sounding corporate facades that have been erected by the American Medical Association/American Board of Medical Specialty mothership and their flotilla of member organizations accountable.

But we should acknowledge the tremendous efforts put forth by these "key stakeholders:"
Internationally regarded leaders in medical education discussed data on the value of knowledge examinations. Members of multiple ABMS member boards presented proposed and in-place innovations that will impact these examinations. These innovations included use of evaluations taken at home, short segment continuous evaluation strategies and multiple strategies that provide important formative feedback to physicians as they mature in their careers while also providing the necessary summative data to meet their professional requirements of monitoring and ensuring the public good. 
Note how there are no attempts to rid doctors of this menace. And the conversations must have been remarkably short, since there are few objective data to support their tactics.  Instead, we see self-aggrandizing platitudes like "internationally regarded leaders."  We see fervent efforts being made to rearrange the deck chairs on the Titanic.   Bullying doctors and making them less available for patient care is not insuring the public good.  Making my profession more untenable is not for the public good.  Suggesting that organizational sycophants (payees) are the only ones who are concerned about physician quality and physician education is hubris and surely not ensuring the public good.

A real general does not turn around and open fire on his groups.

What these "stakeholders" don't realize is that US physicians are already doing their overwrought busywork at home.  Doctors are already performing "short-segment continuous evaluation strategies" called knowledge assessment "modules" and "practice improvement modules" that take months to complete on top of an already overwhelming clinical load.  And because eyes must remain on a computer screen as a means of providing  "important formative feedback," we see the hopium for effective clinical teaching perpetuated.   We also see how deeply these individuals have permeated the halls of Congress as the Physician Quality Reporting System incentive payments with CMS are still tied to this unproven and potentially destructive program to physician retention and morale.

It is one thing to sit inside a self-proclaimed ivory tower and preach.

It is another thing entirely to lead.


Monday, June 09, 2014

ABIM's New Research on Physicians

"A systematic, intensive study intended to increase knowledge or understanding of the subject studied, a systematic study specifically directed toward applying new knowledge to meet a recognized need, or a systematic application of knowledge to the production of useful materials, devices, and systems or methods, including design, development, and improvement of prototypes and new processes to meet specific requirements"

It's one thing to ask a doctor to stay current on his knowledge, it's quite another to insist he survey his patients for a private enterprise, especially if that survey represents unvetted independent research.

Recently, a colleague of mine was attempting to maintain his "board certification" credential with the American Board of Internal Medicine (ABIM) and signed up for the ABIM's requirement for a "practice improvement module" worth a required "20 points" of 100 total required before he could sit for his specialty board re-certification examination.  For his module, he optimistically chose to offer a survey created by the ABIM to his patients, receive feedback on how he did on the survey, then repeat the survey to a later set of patients to show "improvement" of care.  In return for his considerable efforts, he would be granted his required "points" from the ABIM so he could qualify to sit for his specialty re-certification examination.

Here is an exact copy of the survey (pdf - 3.52 MBytes) my colleague was sent in its entirety.   He received a packet of 70 of these surveys from the ABIM, neatly shrink-wrapped, to distribute to his patients.

What could go wrong?

First, imagine the time and work involved to distribute these surveys. Whether he provided the survey to his patients himself or he tasked others to do so, what lab result was not reviewed or phone call not answered as a result?  We can only speculate.

Second, informed consent about the true nature of this survey was not obtained from patients nor my colleague.  Rather, my colleague was coerced into purchasing the survey because he might not be able to continue practicing medicine unless he complies with this requirement.  Informed consent would suggest that the doctor and his patients are informed of potential harms or risks involved with the collection of such survey data.    For the patient: what might their responses mean for their doctor's ability to practice medicine?  How might the working relationship with their doctor be degraded or the trust he has in them be compromised?  For the doctor: how are the data collected on the non-secure website protected, how will they be used against him? Will the data be used for future health care policy development or sold to third parties?

I have no doubt that many will see this survey collection as a benign attempt to truly improve a physician's practice or as an opportunity to empower patients with an means of changing physician behavior.  But I suspect these same people never consider the potential negative consequences of such a survey.  The very idea that this survey is a destructive intrusion into the doctor-patient relationship is a foreign concept to its designers.  We can only imagine the moral outrage and disavowal that will arise in the halls of ABIM with such an assessment.  Yet like a bull in a china shop, the collection of anonymous survey data completely disrupts one of the most tenuous and vulnerable relationships in medicine.  It ignores the vulnerable, highly-charged and often emotional circumstances that accompany any visit to a doctor's office while rendering valid concerns a patient might have about their experience into the muddied waters of anonymous data aggregation.  

Also, this unscientific research survey contains a host of dependent variables like age, race and self-assessments of general health status and mental illness.  Self-assessments make a mockery of non-biased data collection, yet the destructive assumptions made throughout the survey are clear: doctors should have unlimited time, provide unlimited access, and perfect manners toward patients without regard to forces (such as this ABIM survey) that increasingly pull them from what they yearn to do: care for their fellow man, woman or child.   This lack of concern with scientific validity and objectivity  leaves the end game of any particular individual or group "findings" only left to the imagination.  If we are going to investigate whether an individual doctor's behavior reflects an age/education/gender/race bias toward their patients (see questions 42 through 46), this is a serious question, deserving of the doctor's consent, and requiring scientific validity far past that of correlational survey data on an n of 70 patients. The possible "end result" or accusation is far too damning.  Or haven't the ABIM committee members thought of that? But we shouldn't worry - patient bias/irrationality/emotionalism is controlled for by question 41 - where the patient provides us with an assessment of his overall mental health.

If doctor's are subjecting themselves to this kind of scrutiny, shouldn't they (and their patients) know how it will be used? Whether aggregated or individual data, this kind of helter-skelter approach is surely designed to lead to progressive "quality" initiatives to adjust doctor's behavior whether findings are valid or not. We are participating in the first step of yet another new initiative in micro-managing and control of the already besieged doctor.

The intrusion of this survey into the sanctity of the doctor-patient relationship by an independent and non-accountable non-profit organization that ignores sound research and ethical principles should be stopped.  It's negative consequences far outweigh any benefit to patients.   In a recent survey of their membership of over 4000 cardiologists nationwide, the American College of Cardiology found that nearly a third of their respondents indicated that the changes imposed by the ABIM's subversive "re-certification" process (that includes these patient surveys as one tool) will affect their future career plans and will likely accelerate their decisions, such as early retirement, part-time work, or transition to non-clinical work.  Approximately one-quarter of physicians in practice for 15 years or more specified that early retirement is a likely outcome.  Exactly how will such a survey help patients already struggling to access care?  Is ABIM responsible for the repercussions of their physician bullying?

I know this is a time of multiple instances of moral outrage and demoralization for physicians.  But I would ask that you take that outrage and forward this survey to colleagues.  I would also ask that you contact your local professional subspecialty organizations, state licensure boards, and appropriate members of Congress to insist on an immediate moratorium to the American Board of Medical Specialties/American Board of Internal Medicine Maintenance of Certification process as it currently exists.

Believe me, this discussion is ongoing and far from over.


Friday, June 06, 2014

On Mentoring

Recently, I had one of those "proud Daddy" moments: watching my son play in the Chicago Civic Orchestra's last concert of their 95th season.  (For those unfamiliar, the Civic Orchestra is the training orchestra of the Chicago Symphony Orchestra.) They played Prokofiev's Symphony No. 5 under the direction of Jaap van Zweden - one of the most amazing conductors I have ever seen (and I later learned, one of my son's favorites).   Afterward, we were invited to a reception and I had a chance to meet YoYo Ma who served as an inspiration, role model, and mentor for my son for the past year in his role as creative consultant with the orchestra.  What a wonderful guy.  He was fun, energetic, complimentary and thoughtful.

Later that night, my encounter with these artists got me thinking about my role as a mentor to young physicians.  I teach residents.  I teach EP fellows.  What are they thinking?  Am I doing all I can for them?

So it came as a surprise that I had just been offered to speak at a fellows conference later this year.  The conference was sponsored by a major medical device manufacturer in a lovely US city.  100 fellows would be there along with 40 industry personnel.  I would be paid well for my travel and speaking time.  I'd connect with other contemporaries of mine whom I admire that would also serve as speakers.  My topic involved an aspect of social media for physicians.

How could I resist?

And yet, here I am talking about the Health Care Industrial Complex and the Iron Triangle of comprised of Congress, special interests, bureaucracy and how doctors are swept up in their wake.  I thought about being a mentor, a teacher, a doctor.  I wondered how it might ever change.  I wondered if doctors would ever have the courage to push back against the seductive powers of ego and money.  Then I realized: probably not.  It's how we're groomed for this from the beginning.  We're human.  So  I have no doubt another doctor will be more than happy to serve as my replacement.

And so it goes.

But perhaps I could do what I love again, I could teach for the joy of watching young doctors get excited again, not because I needed to make a buck.  Perhaps I could teach those same doctors that we do what we do because it's not about the corporate boondoggle, but about the patient.  I could mentor.

So I declined the offer.

After all, I've got other priorities now.


Tuesday, June 03, 2014

Why Do Hospitals Side With Maintenance of Certification?

With the recent 22% percent failure rate of the most recent Maintenance of Certification (MOC) testing offered by the American Board of Medical Specialties/American Board of Internal Medicine, I was puzzled as to why any hospital systems would want to support the proposed Maintenance of Certification changes imposed 1 January 2014.  After all, wouldn't hospitals risk of looking like they have substandard physicians on on their staff if they failed to pass their MOC exam? Do hospitals really really side with the ABIM's leadership that MOC testing is for public good?  Or might there another motive why hospitals support the MOC process?

To reach an understanding of this issue, I asked a senior member of our staff who has served many policy roles within the leadership of the American College of Physicians, the Illinois Chapter of the American College of Cardiology, and served as a founding fellow of the Society of Cardiovascular Angiography and Interventions (SCAI), Joseph V. Messer, MD, MACC.  Joe is widely respected in the cardiovascular policy circles and has worked extensively on such things as "Appropriateness Use Criteria" and performance measures for cardiology. He carries a unique understanding of the challenges inherent to bureaucratic methods to measure quality care and (importantly) the limitations of creating such systems.  Joe is a luminary in many respects and thought hard about the question I posed him.  His response was both eloquent and insightful.  With his permission, I am publishing his response to me so others might enjoy Joe's perspective on why hospital systems want to "align" with the MOC process. Here is what he wrote:
Wes, your question yesterday at our Cath Conference started me thinking. Since I have decided not to go the MOC route, haven't given it much thought. Here are my ideas:

Both the Feds and the Hospital Systems prefer a single payer system. Several years ago at an ACC conference, the CMS representative told me their goal was to pour all the money into a single funnel and let healthcare systems worry about the distribution, providing a significant source of "handling" fees for the systems.

CMS and hospital systems seek alignment. The "funnel" analogy is one example. Further, CMS has very limited authority to define and require demonstration of quality from providers. They will encourage the hospital systems to handle this role, and will provide the $$ for same - thus more revenue for hospital systems, not unlike current support for residence and fellow training programs.

As we move toward a single payer system, hospital systems will continue their effort to control physicians - the most important of the distribution recipients in healthcare other than the systems themselves. By ultimate controlling MD's they can take a larger piece of the pie for themselves. Increasingly impotent physicians will have little recourse, since the public consumer now values convenience and low cost over quality.

Supporting MOC assists the hospital systems in controlling MD's. Systems will use public opinion, in part, as a tool in this effort. Hospital systems will vigorously claim that MOC assures higher quality. By requiring and advertising that all system employed MD's are MOC certified the systems will have another weapon against the "private practice" MD, many of whom will not pursue the MOC course, many of whom will be "concierge MD's" and the most vocal opponents of hospital systems.

Ultimately, I believe the hospital systems want to control the certification process. By supporting the MOC initiative they will likely destroy the ABIM as it loses its physician support because of MOC. The specialty societies are lukewarm at best about MOC's and I hear increasing criticism of ABIM for its ulterior financial motivations. Some specialty societies are receiving similar criticism for the fees they charge for educational materials crafted to meet MOC requirements. Thus, ACC and others may well suffer with the ABIM for not vigorously opposed MOC in its current form.

Marginalizing the special societies has already begun. It is very clear that employed cardiologists find less interest in the ACC. The largest grant the ACC has ever received just went to two Chapters - Wisconsin and Florida - to test local, grassroot proposals for health care financing. ($15.8 million over 3 years). National ACC supported this project for a while, but then fell away when the leadership lost interest. My concern here is that the ACC/AHA/STS/HRS/SCAI remain key supporters of quality, appropriate use and performance measurement. If they are significantly weakened by all of these issues - MOC, physician employment, decreased specialty influence in CMS and Congress, the hospital systems will surely move into the vacuum to control education and quality definition to their advantage.

But, when all is said and done, I doubt that the incoming crop of physicians care. In a recent survey (2-3 years ago) the primary motivation of medical school applicants was "job security".
Ugh.  Depressing.  Sadly, I think he's correct.

Thanks for your insights, Joe - 


On the ACC's Response to ABIM’s MOC Requirements

The American College of Cardiology (ACC) recently issued a response to the American Board of Medical Specialties (ABMS) and American Board of Internal Medicine's (ABIM) recent change to their Maintenance of Certification (MOC) requirements. The ACC's response was based in part on the results of a completed member survey that was distributed through their state chapters in the spring of 2014. The survey was completed within four weeks by over 4,400 members (12 percent of the total solicited). Nearly 90 percent of respondents opposed the changes to the American Board of Medical Specialty (ABMS)/American Board of Internal Medicine (ABIM)'s new Maintenance of Certification (MOC) requirements, citing, among multiple concerns, higher than expected costs. Nearly a third of respondents indicated that the changes will affect their future career plans and will likely accelerate career decisions such as early retirement, part-time work, or transition to non-clinical work. Approximately one-quarter of physicians in practice for 15 years or more specified that early retirement was a probable outcome.

If true, the implication of this change to MOC has significant implications for patients everywhere.

This must have prompted the leadership of the ACC to throw their considerable weight into the discussion with the ABIM. In their statement, the ACC promised to:

  • Have "ongoing discussions" with ABIM leadership, in partnership with other cardiovascular professional organizations whose members are similarly affected, to review these issues and to explore changes in MOC requirements that will result in more meaningful outcomes and less onerous burdens for ACC members (Editor's note: To date, MOC has never been shown to alter outcomes, so we are left to wonder what this statement really means.)
  • Request for ACC representation at ABIM to participate in discussions involving MOC, including its educational and financial aspects (Editor's note: What financial aspects might they mean? Does the ACC want in on this cash cow, too? Or might they want to strike a deal offset some of the fees since they want to keep their educational MOC-preparation income stream coming?
  • Review of the evidence base underlying current recommendations (Editor's note: Let me help: there are none. Any positive articles are likely authored by those standing to profit from the endeavor or research paid for by the ABMS. Negative articles are also suppressed from publications sympathetic to the regulatory world. And we should recognize that we have never developed a definition of the "quality" physician. Quality to whom? Is "quality" following rubrics and care pathways? Or might "quality" be something very different, like empathy, listening skills, interpretative skills, or surgical skill? The reality is, if you can't agree on what defines quality, you can't define how to measure it.)
  • Investigation of impact of MOC changes on non-ABIM certified members (Editor's note: I strongly agree with this - it is unethical to impose MOC mandates of any kind without first understanding how they negatively affect doctors, especially if a doctor should not pass and is unable to practice their vocation on the basis of a 180-question timed test)
  • In the interim, ACC will support its membership by:
    • Free provision of web-based MOC modules and navigation tools to ACC members
    • Expansion of Part IV MOC modules through ACC programs such as the NCDR’s inpatient registries and the PINNACLE Registry
    • Creation of mechanisms for ACC members by which patient safety and patient survey requirements can be efficiently fulfilled
    • Bidirectional communication with and engagement of membership through Chapters, Sections and Councils.
    (Editor's note: It's okay to make MORE MOC modules available to us? Is that what doctors want? How many more hours must we spend on this drill and for how much time in lost revenue? "Free" is in the eye of the ACC, not those who have to endure these processes.)

The good news (if there is any with the ACC's announcement), is that front-line doctors are starting to be heard. While the ACC's actions might be a step in the right direction (one can hope), it is disappointing that their statement still sides with the ABIM's requirements for the unproven MOC process in the first place, the busy-work requirement for "Practice Improvement Modules" (especially when quality measures are already required by hospitals), and for permitting a private organization to monopolize the ability of physicians to practice their trade. Furthermore, the ACC's statement does nothing to insist upon changes to the ABIM's non-transparent and self-serving Conflict of Interest policies that keeps conflicts confidential except to certain chosen individuals within the ABIM.

Unless the ACC can convince the ABMS and ABIM to come clean on these important issues, significant physician resistance to this process will remain. Furthermore, the lack of involvement by other subspecialty boards in resisting the ABMS/ABIM's MOC process is concerning. Hopefully, other subspecialty boards will be encouraged by the ACC's example.

After all, cardiologists aren't the only ones frustrated by this change in MOC policy.


Sunday, June 01, 2014

Clicks Unchecked

"Where did that menu item come from?" I recently thought.  "Come to think of it, where did the Allergy field go? What's that?  I have to enter an 'Order' for a consent now?  Whatever happened to speaking with the patient?"

Such are the myriad of thoughts the EMR engenders lately.  So ridiculous.  So time-consuming.  Death my a hundred thousand clicks.  It's like my fingertips are on high continuous suction. Pretty soon I'll have to click the "Excuse Me" or "Pause" button so I can use the bathroom.

Seriously.  In medicine, everything is entered on the computer now.  Everything.  Not just notes and orders, but schedules, message boards, meeting notifications, billing check-boxes that must be paired with diagnosis check boxes.  If it isn't clicked, it didn't happen.  Every time a new "idea" for process improvement that springs forth is codified for the computer.   And guess who's the data entry clerk?

It's gotten so bad we now must scroll to display all the menu options. Even filtering the notes to ones you wrote is dreadfully slow.  Unfiltering them worse still.  Precious seconds of patient care time are repeatedly wasted.

It was bad before, but it's getting worse.  The foxes are minding the hen house of patient safety and doctor overload.  Not that computers aren't wonderful at some things - they are - but to suggest, even for a moment, that they can fix what ails health care in America is ludicrous; to suggest they aren't silently inflicting their own patient care comprise even crazier.

Yet the drumbeat of unending support for computers, simulation, data manipulation continues.  Profit does this.

The data clerks are growing weary.

And patients are noticing.