Medical Journals Continue To Support The Business Intrusion Into The Profession

Ran across an article that was posted to Twitter today entitled “The medical profession is breaking its psychological contract with medical students and trainees.”  It was not posted on Medline yet so I am concluding that this is a blog post on the British Medical Journal website. As far as I can tell none of the authors are physicians. The qualifications listed suggest they are all business school professors. Rather than accept my brief summation of the article, I encourage anyone reading this post to read the article in full at this link.

The authors develop their argument from a business concept called the psychological contract. They link to it in their post.  It is from a 1995 book written by Denise Rousseau called Psychological Contracts in Organizations - Understanding Written and Unwritten Agreements.  Searching the author shows that she is a University Professor at Carnegie Mellon University in Organizational Behavior and Public Policy.  The closest definition I could find in this section of pages occurred on pages 9 and 10:

“When two people work interdependently, such as a worker and a supervisor, agree on terms of a contract, performance should be satisfactory from both parties’ perspectives. As individuals work through their understandings of each other’s commitments over time, a degree of mutual predictability becomes possible: ‘I know what I want from you and you know what you want from me’. Commitments understood on both sides may be understood based on communications, customs, and past practices.”  

By the second paragraph the authors have concluded that a violation of the subjective psychological contract has led to the well-known morbidity and mortality within the medical profession although they are focused primarily on trainees for the purpose of their argument. They provide links to burnout, stress, and depression. They suggest that this provides direct evidence that violation of the psychological contract has occurred.  They go on to point out how training environments or “cultures” have a neagtive effect as a number of vaguely defined and poorly quantitated negative outcomes. They never really comment on how widespread the abusive culture is or the total number of people affected. One of their stunning conclusory statements is:

“A cursory examination of the first interactions that physician trainees have with medical schools and residency or specialty training programmes suggests that from day one, the relationships begin somewhat adversarially, suspiciously, and with potentially lower levels of trust between the parties.” 

When I looked at that sentence - as I hope any physician reading this will do - I asked myself if these were the kinds of relationships I had with attending physicians on day one of my residency training. I also asked myself if I had these kinds of relationships with my medical school professors and the residents and medical students that I was teaching. The answer was a resounding “No!”. Medical training is of necessity intense and prolonged but it is not focused on “book smarts” and "high-stakes”.  The authors lack an understanding of why medical training requires this approach and that has to do with pattern matching. Medicine is not learned by “book smarts”. Medicine is learned by seeing as many possible patterns of illness as you can during residency training. In the case of surgical training, that involves as many supervised surgical procedures as possible. Only when this pattern matching has occurred will a physician be safe to see patients and practice medicine independently. If there is any expectation at all on the part of trainees it should be that their training program provides them with these experiences and adequate time with attending physicians so that they might also benefit from the experience of those physicians. 

Every good training program provides that experience as well as the necessary relationships with attending physicians. All through medical school and residency training, a training physician has direct contact with senior residents, attending physicians, and various consultants. They all have varied skills and motivations for teaching, but it is hard to imagine that the training in the United States one cannot find several outstanding teachers and role models in any residency program. I have role models and residents that I trained who I am in contact with to this day. We are still all focused on patient care and united by the goal of quality care and being able to take care of patients with complex problems.

I also have first-hand experience with what directly interferes with the teaching experience. Without a doubt it is the intrusion of business practices into academic settings. Pharmaceutical sales and detailing has been the usual focus but that is completely benign compared with managed care. I have highlighted a few major problems with managed-care and academic medicine in the table below and will elaborate on some of those points.

Business Practices Adversely Affecting Medical Education

1. Lack of quality - before the intrusion of business practices there were medical standards of quality. Those of been replaced by business standards of “value” that have essentially no meaning in the practice of medicine.  The role of physician as a "steward of resources" is a business idea and not a medical one.

2. Unrealistic productivity standards - any academic practice that requires RVU production and awards no credit for teaching productivity necessarily detracts from medical education.

3. Unscientific metrics - medical students and residents can observe attending physicians being ordered around by nonphysicians based on business metrics such as length of stay that have nothing to do with patient care.

4. An unscientific environment - is there adequate time in a managed-care teaching setting to discuss something other than rationing techniques? Is there time on rounding to discuss the latest scientific research? In most cases it is seriously eroded.

5. Documentation burden - it is currently immense relative to before businesses took over the field and that necessarily leads to less direct contact with teachers and mentors and less academic discussion.  This is an artifact of a very low quality information technology environment both in terms of records and security that is the direct result of business based standards in medicine.

6. Less disagreement and controversy - one of the key concepts that every medical trainee must learn is that medical science is an active dialogue and critical papers and concepts change over time. The business influence on teaching environments suggest otherwise and make it seem as though completely unscientific ideas like utilization review and prior authorization represent some sort of immutable standard - the criteria for which never seem to be completely available.  Science is secondary to the proprietary business environment.  Physicians on the faculty who disagree with that are frequently scapegoated and fall into disfavor. Managed-care companies cull the ranks of trainees looking for “managed-care friendly physicians” to maintain the business-based practice.

7. Revolving door policies - there is probably nothing more demoralizing for an intern than to have to readmit a patient who has been discharged because they were in the hospital too long and who returns because they were not stable at the time of discharge. Those discharges are generally based on business metrics.  These policies also eliminate the possibility of residents seeing their patients recover and verifying that their diagnosis and treatment plan was correct.

8.  Unnecessary bureaucratic burden - I was fortunate enough to be an intern at the time managed care was just starting to take off. At that time I had a critically ill patient in an intensive care unit and I was contacted and told that they needed to be transferred to another hospital because of their insurance contract.  Today practically all physicians routinely encounter the managed-care intrusion into their patient care on a daily basis. With physicians in training it is no different. They are still subjected to the review processes and spending far too much time getting medications approved that are clearly indicated. All of this detracts from teaching and learning time.

I have directly observed all the above items taking its toll on teaching and learning medicine but I have a couple of anecdotes that bring together many of these areas. The first was my experience on a neurosurgery rotation as a medical student. I did two neurosurgery rotations with the same residents and attendings and at one point hoped to be a neurosurgeon. There is no more rigorous course of training. All of the senior residents were essentially on-call 24/7 all year long. In those days we were rounding on about 35 patients 10 of which were in the neurosurgery intensive care unit. We would typically be done with rounds in two hours and the documentation would be done at about the same time. Our documentation would include the postoperative day number, patient’s subjective status, what the surgical wound looked like, and review of their vital signs, labs, and physical exam. A typical note was no longer than five lines and we could complete it as we were moving from patient to patient. Over the years the federal government developed documentation guidelines that were turned over to the managed-care industry so that every medical encounter these days takes an excessive amount of documentation. If we were doing the same rounding procedure today it would take us additional 2 to 3 hours just to complete the documentation. That 2-3 hours would detract from time in the operating room where residents were learning how to perform neurosurgery and medical students were learning by observing those procedures. That 2-3 hours would detract from time where the senior neurosurgeons would teach imaging rounds and review all of the brain and spine imaging from all of our patients that week.  In short, business practices would have essentially cancelled out most of the teaching on neurosurgery.

My other anecdote has to do with materials available for teaching. At my last teaching position I enjoyed presenting an annual review for psychiatric residents taking the annual “in training” exam. This examination includes questions about neurology, neuropsychiatry, and brain imaging. As an attending physician focused on neuropsychiatry I always had plenty of brain images that were relevant to the practice of psychiatry. With the electronic health record implementation it was relatively easy to download and de-identify those images for teaching purposes. When I sought permission to do that from the medical director at our clinic she stated: “Why would we let you use our images?”  I was stunned because prior to the takeover by businesses, reviewing films even if they were not de-identified was standard teaching practice.

The final anecdote is probably the best. Back in the early days of the business takeover of medicine, the FBI was actually engaged in investigating medical billing and making sure physicians completed the correct documentation template. If they didn’t they could be charged with a crime up to and including a RICO violation. Of course these templates were completely subjective but that is not the way the FBI was treating them. There were several well-known prosecutions of large medical clinics based on the fact that attending physicians were not documenting enough when they supervised residents.  There were no guidelines at the time about what might be involved and so my business people were telling me that I had to document the standard note whether I was working with a resident or not. You can imagine the demoralizing effect that has on a resident when they notice their attending is putting in a separate note every day and their note seems to be irrelevant. When I noticed that happening I suspended all of my teaching of residents because I did not want to insult them just because business and government bureaucrats were telling me what to do. Eventually that guideline was relaxed so that I could go back to documenting that I had discussed the case with the resident but not until considerable damage had been done.

Based on these experiences and more, the opinion piece in BMJ strikes me as another effort to exert top-down control by business interests on the field of medicine.  It is an extension of three decades of failed business initiatives that nonetheless still dominate the practice of medicine in the United States.  Businesses and governments alike are still using the failed strategies. As I pointed out, the same failed strategies have already taken a toll on medical education. And yet these authors suggest that another vague business concept should be applied to medical education.

When I think about my mentors, my colleagues, the residents I have mentored, and what we have all accomplished - we need to keep business concepts out of medical education. We also need to look at the overall strategy and why business authors keep appearing in the pages of our journals. It all seems to be based on the premise that is business managers are experts at everything. 

That is clearly not true in medicine.  They have introduced chaos and stress into the clinical field.  They have already seriously stressed medical education and this opinion piece provides another non-solution that can only be suggested in the context of having wrested control of the clinical practice of medicine away from physicians. 

George Dawson, MD, DFAPA



Supplementary:

I have seen recent psychiatric treatment that may illustrate what happens when business managed settings limit patient contact.  In my current employment, I see a lot of people who are treated with antipsychotic medication, antidepressants, and mood stabilizers for a presumed psychiatric diagnosis.  The medications are started and titrated rapidly.  By the time they see me they are experiencing clear side effects, taking too much medicine, and the diagnosis is not clear.  Hospitalizations today are so short and so focused on doing something in a short period of time that physicians in training have limited exposure to the concept of substance induced psychiatric disorders and how they can be best treated.  That also includes the appropriate detoxification of these patients - many of whom are sent out to social detoxification units unless they worsen and are sent back.  All of this decision making should be part of the knowledge base of psychiatrists and primary care physicians.

The Non-Existent Chemical Imbalance Theory

I keep looking for it and can never find it.  The above picture is my stack of psychopharmacology texts dating back to about 1980 and none of them mentions "chemical imbalance".  I could add another foot or two to that stack and there still would be no mention of this theory.

Why is that important? The main reason is that one of the favorite arguments by anti-psychiatrists is that real psychiatrists believe that psychiatric disorders are caused by a “chemical imbalance” in the brain. This criticism showed up on this blog several years ago in a post that I critiqued that was largely a screed against psychiatrists. Accusing psychiatrists of promoting a chemical imbalance theory is an almost perfect rhetorical strategy. It uses what essentially was a marketing device for antidepressants in the late 1980s to portray psychiatrists as excessively reductionist at the minimum and at the worst biologically naïve and dishonest.

My colleague Ron Pies, MD has written a recent piece on the historical, philosophical, and rhetorical aspects of this argument. What I hope to accomplish in this post is taking a look at the science behind why no psychiatrist would consider the brain to be a substrate run by “chemical imbalances”. Some might find this argument to be quite boring but I can attest to the fact that the premises used allowed me to state unequivocally to the first pharmaceutical rep to use the term that no such state exists in the brain.

The main factor has to do with how physicians are trained. There’s still a lot of confusion about whether a psychiatrist is a physician or not. I can assure anyone reading this that we all are. That means in order to get into medical school certain prerequisites at the undergraduate level have to be completed. That includes a year of general chemistry, a year of organic chemistry, and a year of general physics. A significant number of psychiatrists that I have encountered were chemistry majors. That training means that physicians in general have had exposure to physical science and how chemistry works in solutions and gases.  In these basic two or three component systems there are limited possibilities in terms of reaction outcomes. Even electrochemical reactions produce electron flow that decays predictably over time but that is not able to transmit any nuanced signal.  In other words the information content in these systems is low – too low to run biological organisms.

In the basic science years of medical school biochemistry, neuroanatomy, neurophysiology, pharmacology, and all of the associated molecular biology provided medical framework that all of the physical science can be mapped onto. The study of enzyme and receptor systems highlight the basic concept that the chemistry involved can only occur because it is in a specific microenvironment. That microenvironment includes the protein structure of the enzyme or receptor molecules as well as associated membrane components and cell signaling components. The intracellular and extracellular environments are exquisitely controlled as is the synaptic cleft. Many of the reactions involve additional acid-base and ionic gradients. The degrees of freedom in these many component and many phase systems are large. They are so large in fact that I have been unable to find an estimate of degrees of freedom for neurobiological systems.

A good example of the kind of microenvironments and complex interactions that I am taking about is the GABA_A receptor depicted diagrammatically below. The GABA_A receptor is a transmembrane cylindrical receptor that is a member of the pentameric ligand-gated ion channel superfamily.   The diagram is a top down view of the receptor complex cylinder highlighting that it is composed of 5 glycoprotein subunits.   Each subunit is composed of 4 domains with one domain that lines the chloride ion channel through the center of the receptor complex. Binding sites on these protein allow for allosteric modification of the cylindrical receptor to facilitate chloride ion influx and fast inhibition of neuronal signals.  Allosteric modulation of enzymes and receptors occurs when a molecule reversibly binds to the protein molecule resulting in inhibition or stimulation of the overall process.  For example, benzodiazepines bind to a specific site at the α-γ interface leading to increased affinity for GABA at the receptor sites and increased chloride ion influx. Benzodiazepines are the classic allosteric modulators of the  GABA_A receptor but there are others.  Barbiturates, anesthetic agents, neurosteroids and ethanol are also allosteric modulators at the GABA_A receptor.  The detailed structure of both the benzodiazepine and flumazenil binding sites on the human synaptic GABA_A receptor have only recently been detailed (1). 

The above paragraph is a glance into the types of systems that modern psychiatry is focused on.  In the case of the GABA_A receptor global inhibitory effects can be expected at some point, but there are not the product of chemicals floating about inside the body or brain. They are the effects of complex interactions between proteins, positive and negative modulators, neurotransmitter effects, ion fluxes, and additional signaling.  The effects result from where these receptors are located in the brain and central nervous system. The education of physicians assures that this level of complexity in the brain is appreciated as both the basis for normal physiology and also the basis for pharmacology and toxicology. It may be tempting to try to simplify things - but real brain function defies simplification.  The basic working of the GABA receptor was discovered when I was in medical school back in the 1980s. The lectures in those days showed a simple structure with an arrow showing increased chloride ion permeability but nowhere near the structure that we currently have. 

This is one set of receptors and modulators very simplified. To get more of the story read the 22 pages of reference 1.  To understand the brain and modern pharmacology much more needs to be understood. Forgetting about the term "chemical imbalance" is a good first step.

George Dawson, MD, DFAPA

References:

1: Zhu S, Noviello CM, Teng J, Walsh RM Jr, Kim JJ, Hibbs RE. Structure of a human synaptic GABA(A) receptor. Nature. 2018 Jul;559(7712):67-72. doi: 10.1038/s41586-018-0255-3. Epub 2018 Jun 27. PubMed PMID: 29950725; PubMed Central PMCID: PMC6220708.

2:  Human GABA-A receptor alpha1-beta2-gamma2 subtype in complex with GABA and flumazenil, conformation A.  Detailed structure from the above paper.

Morning Report

I don't know if they still call it that or not - but back in the day when I was an intern Morning Report was a meeting of all of the admitting residents with the attendings or Chief of Internal Medicine.  The goal was to review the admissions from the previous night, the initial management, and the scientific and clinical basis for that management. Depending on where you trained, the relationship between house staff and attendings could be affiliative or antagonistic. In affiliative settings, the attendings would guide the residents in terms of management and the most current research that applied to the condition. In the antagonistic settings, the attendings would ask an endless series of questions until the resident presenting the case either fell silent or excelled.  It was extremely difficult to excel because the questions were often of the "guess what I am thinking" nature. The residents who I worked with were all hell bent on excelling.  After admitting 10 or 20 patients they would head to the library and try to pull the latest relevant research.  They may have only slept 30 minutes the night before but they were ready to match wits with the attendings in the morning.

Part of that process was discussing the relevant literature and references.  In those days there were often copies of the relevant research and beyond that seminar and research projects that focused on patient care. I still remember having to give seminars on gram negative bacterial meningitis and anaphylaxis.  One of my first patients had adenocarcinoma of unknown origin in his humerus and the attending wanted to know what I had read about it two days later.  I had a list of 20 references. All of that reading and research required going to a library and pulling the articles in those days.  There was no online access.  But even when there was - the process among attendings, residents, and medical students has not substantially changed.

I was more than a little shocked to hear that process referred to as "intuition based medicine" in a recent opinion piece in the New England Journal of Medicine (1).  In this article the authors seem to suggest that there was no evidence based medicine at all.  We were all just randomly moving about and hoping to accumulate enough relevant clinical experience over the years so that we could make intuitive decisions about patient care.  I have been critical of these weekly opinion pieces in the NEJM for some time, but this one seems to strike an all time low. Not only were the decisions 35 years ago based on the available research, but there were often clinical trials being conducted on active hospital services - something that rarely happens today now that most medicine is under corporate control.

Part of the author's premise here is that evidence-based medicine (EBM) was some kind of an advance over intuition-based medicine and now it is clear that it is not all that it is cracked up to be. That premise is clearly wrong because there was never any intuition based medicine before what they demarcate as the EBM period. Secondly, anyone trained in medicine in the last 40 years knew what the problems with EBM were from the outset - there would never be enough clinical trials of adequate size to include the real patients that people were seeing.  I didn't have to wait to read all of the negative Cochrane Collaboration studies saying this in their conclusions.  I knew this because of my training, especially training in how to research problems relevant to my patients. EBM was always a buzzword that seemed to indicate some hallowed process that the average physician was ignorant of.  That is only true if you completely devalue the training of physicians before the glory days of EBM.

The authors suggest that interpersonal medicine is what is now needed. In other words the relationship between the physician and patient (and caregivers) and their social context is relevant.  Specifically the influence the physician has on these folks.  Interpersonal medicine "requires recognition and codification of the skills that enable clinicians to effect change in their patients, and tools for realizing those skills systematically." They see it as the next phase in "expanding the knowledge base in patient care" extending EBM rather than rejecting it.  The focus  will be on social and behavioral aspects of care rather than just the biophysical. The obvious connection to biopsychosocial models will not be lost on psychiatrists.  That is straight out of both interpersonal psychotherapy (Sullivan, Klerman, Weissman, Rounsaville, Chevron) and the model itself by Engel.  Are the authors really suggesting that this was also not a focus in the past?

Every history and physical form or dictation that I ever had to complete contained a family history section and a social history section.  That was true if the patient was a medical-surgical patient or a psychiatric patient.  Suggesting that the interpersonal, social, and behavioral aspects of patient care have been omitted is revisionism that is as serious as the idea of intuition based medicine existing before EMB.

I don't understand why the authors just can't face the facts and acknowledge the serious problems with EBM and the reasons why it has not lived up to the hype.  There needs to be a physician there to figure out what it means and be an active intermediary to protect the patient against the shortfalls of both the treatment and the data. As far as interpersonal medicine goes that has been around as long as I have been practicing as well.  Patients do better with a primary care physician and seeing a physician who knows them and cares for them over time. They are more likely to take that physician's advice.  Contrary to managed care propaganda (from about the same era as EBM) current health care systems fragment care, make it unaffordable, and waste a huge amount of physician time taking them away from relationships with patients.

Their solution is that physicians can be taught to communicate with patients and then measured on patient outcomes.  This is basically a managed care process applied to less tangible outcomes than whether a particular medication is started. In other words, it is soft data that it is easier to blame physicians for.  In this section they mention that one of the author's works for Press Ganey - a company that markets communication modules to health care providers. I was actually the recipient of such a module that was intended to teach me how to introduce myself to patients. The last time I took that course was in an introductory course to patient interviewing in 1978.  I would not have passed the oral boards in psychiatry in 1988 if I did not know how to introduce myself to a patient.  And yet here I was in the 21st century taking a mandatory course on how to introduce myself after I have done it tens of thousands of times.  I guess I have passed the first step toward the new world of interpersonal medicine.  I have boldly stepped beyond evidence based medicine.   

I hope there is a lot of eye rolling and gasping going on as physicians read this opinion piece.  But I am also concerned that there is not. Do younger generations of physicians just accept this fiction as fact?  Do they really think that senior physicians are that clueless?  Are they all accepting a corporate model where what you learn in medical school is meaningless compared to a watered down corporate approach that contains a tiny fraction of what you know about the subject?

It is probably easier to accept all of this revisionist history if you never had to sit across from a dead serious attending at 7AM, present ten cases and the associated literature and then get quizzed on all of that during the next three hours of rounding on patients.
 



George Dawson, MD, DFAPA


References:

1: Chang S, Lee TH. Beyond Evidence-Based Medicine. N Engl J Med. 2018 Nov 22;379(21):
1983-1985. doi: 10.1056/NEJMp1806984. PubMed PMID: 30462934.


Graphic Credit:

That is the ghost of Milwaukee County General Hospital one of the teaching affiliates of the Medical College of Wisconsin.  It was apparently renamed Doyne Hospital long after I attended  medical school there.  It was demolished in 2001.  I shot this with 35mm Ektachrome walking to medical school one day. The medical school was on the other side of this massive hospital.