Monday, September 7, 2015

Happy Labor Day IV

This is my fourtth Labor Day writing this blog and it is my custom to summarize the work environment for physicians like I did in Happy Labor Day I, II, and III.  Things have not improved very much and there was a timely piece by an anonymous physician filed on another blog entitled Confessions of a Burnt Out Physician.  That post is full of anecdotes about physicians being managed like production workers and to the point of not even having an adequate work space to conduct work that requires focus and confidentiality.  Another key element of managing physicians is to make sure that their days and nights are filled with the modern equivalent of paperwork - e-mails and charting that is read by nobody except the occasional coding and billing staff.  If that is not demoralizing enough, there are always the suggestions that physicians are not doing enough, even though they are easily in the hospital for 4 or 5 hours after all of the business people are long gone.  This can all be handled masterfully.  As an example, the RVU productivity system was in many cases introduced to physicians as a system of "fairness".  That is - the idea that everyone has to pull their own weight.  That works very well in any environment of competitive physicians.  It was dovetailed in nicely with multimillion dollar lawsuits by the Department of Justice that were based on charting.  Now physicians could be fined or imprisoned if their documentation was not up to snuff.  And of course the Department of Justice wanted every physician in this country to know that any discussion of fees was a potential antitrust offense.  When all of that business rhetoric had settled out, the only things that really changed was how easily physicians could be manipulated and overworked while their professionalism was completely ignored.  Apparently none of us knew how to work or act before managed care came along.

There have been some additional business innovations in the last year to make physician's lives even more difficult.  I read another blog recently where the topic of physician managers affiliated with Big Pharma were desired to bring money into departments and how that and key opinion leaders (KOLs) from that field was a key corrupting influence in medicine and psychiatry.  That influence is trivial compared with the business influences on medicine and their adverse effects.  Excellent clinicians, teachers and researchers now need to get an MBA before they are considered as a department head.  A managerial class that is progressively less competent to manage may be an acceptable business standard but it seems like an extravagance in medicine and one that has cost us hundreds billions of dollars and untold unnecessary work for physicians.

Furthermore, we know what works in terms of physician management.  I worked in tens of departments where the department head was a physician who was in that position because of skills pertaining to clinical care, teaching and research.  That doesn't mean that they were necessarily easy to get along with, but in teaching institutions their skill set was on display every day.  That model transitioned to one where a physician and an administrator of some type both co-lead the department.  The physician leader was still affiliated with physicians in the field at that point and could feel their pain.  The next step was removing any physician with those alliances from an administrative position.  In many cases, this meant people who had no hesitation to manipulate physicians either by a "It's my way of the highway" attitude,  making the environment so hostile that they forced selected dissenting physicians to quit, or after pretending that the physicians had some input (usually through endless mind-numbing meetings about the business) simply telling them that no matter what their opinion was - this was what would be happening.  Throughout the process there was an endless stream of "Change is good", "Cost effectiveness", and "Managed care friendly" propaganda.  But it didn't stop there.  Managed care run institutions have an entire cadre of case managers whose primary job is to "manage" physicians and make sure they are discharging people according to the companies proprietary standards.  If there are any disagreements that low level administrator can easily go up the change of command to get decisions in their favor or identify physicians who are not in lock step with the company.  Everywhere within these organizations there are rules about identifying "disruptive physicians" and penalizing them.  I am not talking about doctors throwing scalpels across the operating room.  The threshold can be so low these days that a "disruptive physician" is anyone who gets into it with an administrator for any reason, including legitimate disagreements.

The effect on the psychological environment of physicians has been corrosive.  Within a generation we have gone from a training environment where medical students and residents could identify with senior physicians who embodied professionalism and an intellectual approach to medicine to managed care employees who use a business approach.  Instead of rounding on patients and learning the importance of medicine as a life-long intellectual pursuit, trainees are focused on the business manager's pursuit of getting patients out of the hospital so that corporate America can keep making money by easily beating the fixed reimbursement scheme set up by the government.   The business rationalization has always been "of course we need to make money to keep the doors open", but that never addresses the trade-offs.  In this case the trade-off is no relationship or plan to assist the patient.  In the case of patients with psychiatric disorders, there are inadequate inpatient and outpatient services, both due to business rationing to maintain profits in a rationed and cost-shifted world.  In many cases health care systems have carried these plans to their absurd conclusion - just close any inpatient beds, close the outpatient clinics, and hope that some taxpayer funded clinic or jail can pick up the slack.  The typical health care manager has an endless stream of bad ideas.

Are there any bright lights on the horizon?  I think that there are.  I would count the movements against the medical specialty boards and the proposed maintenance of certification (MOC) programs.  It is very positive that physicians are standing up and saying that they are unnecessary, not evidence based, and a tremendous waste of time, money, and resources.  More importantly all of that stress falls squarely on overworked physicians.  There is now at least one parallel certification organization that depends primarily on initial board certification and then continuing medical education courses - the historical standard.  It will take a significant commitment, especially from younger physicians to keep this movement alive because it is just a matter of time before credentialing committees for clinics and hospitals will be putting the squeeze on their physicians to use the labor intensive MOC programs.  There is also the question of medical boards.  Will they require MOC for maintenance of licensure (MOL)?  Only time will tell, but like all things American - the bet is on the oligarchs and that currently is everyone making a lot of money out of managing physicians.  At some level that includes professional organizations populated by members who are very friendly to the business world.  If anyone doubts the benefits to professional organizations, just visit the American Psychiatric Associations Learning Center and the MOC offerings.  If the monopoly can be broken, it suggests that physicians may have the ability to counter the business and government strategies that keep what is basically an anti-physician system afloat.  Business strategies have nothing to do with the practice of medicine.

Another bright light that I neglected to comment on initially is the young psychiatrists going into private practice.  At first I was reluctant to endorse this idea, primarily because it contrasts so starkly with my experience in community psychiatry, acute care psychiatry, and general hospital psychiatry.  I was concerned that there would not be enough psychiatric expertise to care for very ill people.  But in conversations with many young colleagues they are some of the brightest, happiest, and enthusiastic physicians that I have seen.  The reason I am given by these docs is that they decide who they are going to see and what their schedule is and not some administrator.  They decide what their clinic policies are and not some administrator.  Some of them have worked in managed care settings and had the courage to walk away after the standard "performance evaluation", especially when it had become an exercise in a loyalty oath to the company and trying to dredge up anonymous critical remarks from coworkers.  My opinion on this private practice trend is that it is a good one.  Any person consulting these folks is going to get recommendations based on quality psychiatric care and not proprietary managed care guidelines.  They will also be talking with a psychiatrist who has not seen ten other people before them and one who has the energy to focus on their problems and possible solutions.  Some of these private physicians also spend days in community mental health centers and on community support teams - treating patients with severe problems.      

So my fourth Labor Day message is slightly brighter than the last three, but not much.   I have to say that there are a few of us around yet who know exactly what happened and what is possible -  and I feel your pain.  If you feel up to it post your anonymous story here.

George Dawson, MD, DFAPA


  1. Actually, many of the Pharma KOL's are quite the allies of managed care in this, with the exact same goal: to have every patient seen for five minutes by the doc - and put on meds on the basis of a symptom checklist whether they need it or not - and to destroy psychotherapy.

    1. I think that managed care plays a much more active role in this, especially now that practically all of the medication is generic. What could be more "cost effective" than a PHQ-9 done while the patient is being roomed by the RN followed by the Rx for a $4/month antidepressant? It is not like the old days where Prozac is the only SSRI and the manufacturer has unlimited pricing power.

      Managed care has also taken a very active role in thwarting therapy. I can recall being a clinical director and having therapists show me forms that took longer to complete than it did to provide the therapy. The form had to be filled out every three sessions. Now that managed care companies have acquired the providers it is quite easy to demand a culture where the person is seen only for crisis oriented therapy and discharged in three sessions. The only time I have seen a course of therapy on the same order as the literature was from private practitioners.

    2. I absolutely agree with you that managed care has been FAR worse than Pharma, but this does not change the fact that Pharma shills are still a big part of the problem - and I am concerned that you are underestimating their negative effects.

      For instance, in regards to your correct observation about antidepressants, The KOL's have been pushing the papers that have suddenly (now that most of the newer antidepressants are generic) claim the baloney that antidepressants don't work, so docs should instead prescribe Latuda and other expensive antipsychotics.

      See for a bit of proof. It's long but very revealing- since the author of a clearly misleading paper, who claimed directly to me that he was not pushing antipsychotics for bipolar depression, later was one of the authors of the big Latuda study in the Green journal.

      They did the same thing when benzo's were replaced by SSRI's for the treatment of severe panic disorder, which one honest academic called "... one of the most spectacular achievements of propaganda in psychiatry." ~ Giovanni Fava, M.D., clinical professor of psychiatry at SUNY in Buffalo.

    3. "They did the same thing when benzo's were replaced by SSRI's for the treatment of severe panic disorder, which one honest academic called "... one of the most spectacular achievements of propaganda in psychiatry."

      Well as an addiction psychiatrist I would have to disagree.

      The selling of Xanax was the propaganda coup, especially when lecturers were suggesting maintenance doses much higher than the FDA max dose and when clinical trials demonstrated the rapid development of tolerance. All of the people currently saying that benzodiazepines are adequate treatment for anxiety disorders are minimizing the addictive potential and it is significant.

      That any new high margin drug will be oversold by Big Pharma should not be a surprise to anyone.

    4. I figured you might disagree on that point, but I submit as an addiction psychiatrist you may be seeing a biased sample. I do see tolerance at higher doses, but the majority of studies on patients with panic disorder who don't abuse other drugs show very little tolerance or dose escalation in patients with panic disorder who are treated with the least effective dose. We have drug databases to weed out a lot of the people who do abuse them, but I've only had to do that rarely . I've seen an awful lot of patients over the last forty years who have been on stable doses for years without any escalation or loss of effectiveness. They don't get intoxicated, and they have almost no side effects. In psychotherapy, I work to get them off all meds, but it depends a lot on their genetic loading.

  2. I don't think there is a group of educated people in the developed world who are more gutless, masochistic and self-destructive than physicians, and especially those who see patients. It's not that they fight and lose, they don't even try and prefer to attack each other with the energy that should be spent battling hospitals, middleman and EHR hacks. ICD-10 is coming, and I hear a lot of grousing but not in front of administrators and politicians. I work with attorneys and they do not have any reticence to act in their rational self-interest nor the interest of their clients.

    In regard to Dr. Allen's post, if I read any depression study and the PHQ-9 is mentioned I immediately stop wasting my time.

    1. Agree to some extent but I would suggest mitigating factors including:

      1. The elitist factor: coming from a blue collar background I can appreciate the difference in attitudes from let's say a colleague who comes form generations of physicians. Blue collar folks like me are a little rougher around the edges. We are less likely to go with the status quo, we are more likely to be anti-authoritarian, and we generally believe the world is a hostile place and you have to protect yourself. I have been in meetings with the elitists and listened to a lot of rhetoric about how confrontation is not "very professional".

      2. The big tent factor: Professional organizations are so desperate for members they will let anyone in, including people who would like to think they can tell the rest of us how to practice medicine. Many bad ideas are foisted on the membership from these origins. In some cases, like the APA voting rules - the power of the few is consolidated.

      3: The self promoters: With all of the KOL talk, the basic point that there are thousands of physicians working within the managed care system to bring all physicians under control of the proprietary guidelines. They are the KOL equivalent of Big Pharma with one big exception - there are no illusions of science and no FDA oversight. They have the power to do whatever they want.

      Could not agree more with you on attorneys. I have talked with many of them who told me they could not understand why physicians are so easily intimidated and pushed around. Some have said they would not stand it for one second and in the case of attorneys I believe it is all framed in terms of ethics. Attorneys don't have the equivalent of utilization review or somebody deeply discounting their fees.