Managed for Mediocrity - Corporate Medicine in the 21st Century

I had in interesting conversation with a colleague the other day.  The focus was on the concept of population based medicine.  It has been a buzzword in managed care and HMOs for the past 20 years.  I have seen many physicians who were promoted to administrators in these organizations who had to start talking the population based medicine hype as part of their role as administrators.  Looking at Medline references the definition goes back to 1995, but I heard it long before that.  If you Google the term you will find a definition that is attributed to the American Medical Association:

An approach that allows one to assess the health status and health needs of a target population, implement and evaluate interventions that are designed to improve the health of that population, and efficiently and effectively provide care for members of that population in a way that is consistent with the community’s cultural, policy, and health resource values.

In trying to confirm that definition for the past three days through AMA staff and their web site - I have been unable to locate the specific document.  The problem with this definition should be apparent to any physician.  Physicians are trained to assess and treat individuals.  They are trained to treat people with diseases and illnesses.  They spend the majority of their time doing this.  The idea that this kind of approach is going to be implemented by a physician or even a group of physicians is overreaching and absurd.  It is very convenient for managed care companies, pharmaceutical benefit managers, and governments who want to ration resources across communities and intentionally discriminate against others.  What could be a better rationale for having fewer and fewer people being seen by physicians and more people taking inexpensive screenings or just being told that there are no resources.  It is also useful to mass market very expensive pharmaceuticals to people who will get minimal to no benefit from them.  Corporate management removes physicians from those decisions, but in some cases makes it seem like the physicians approve.  The best example is a corporation limiting choices and then making it seem like the physician is approving the course of action.

The business and government led movement to homogenize medicine has additional fall out that I am sure few people outside of medicine know very much about.  Physicians are managed to see a number of billing codes per day and those codes are typically optimized to collect the maximum billing per encounter.  They need to be because the payers are already gaming the system to pay the lowest possible amount per billing code.  That tension between the non-medical forces on three sides: payers, coding specialists, and physician managers creates a pathological assembly line of brief expensive visits where not much happens.  Have you ever been told by a physician or nurse that you can be seen for only one problem at a time and if you have a second or third problem you will need to set up new appointments? This is the pathological assembly line approach taken to its absurd conclusion.  Any slight glitch in appointment times or a patient suddenly requiring more intense treatment than anticipated throws a wrench into the works.  Some patients in the waiting areas can be backed up for hours.

Homogenization has another intended consequence - it makes it seem like all of the physicians in the clinic are the same.  That is always true to some extent, but there are always major unappreciated differences.  Some physicians gravitate toward specialty areas based on their interest and experience.  Some physicians have a natural talent to deal with certain problems and procedures.  Other physicians know that they should avoid certain areas of medical practice and for that reason stay out of specialty areas.  On this blog, I have posted that many physicians have told me over the years that they really like psychiatry but that they could never tolerate treating a certain type of personality or trying to determine the level of suicide risk when seeing patient with that problem.  There are differences within the same specialty.  Some psychiatrists are better at handling the medical aspects of psychiatry.  Others do a better job with psychotherapy.  Prior to homogenization, those differences were allowed to exist and they were developed across the entire professional lifespan of physicians.  When that happens in any group of specialists, these skills are recognized and patients with those problems are directed to the physician with those skills.   Today billing codes, patient visits, and electronic health record templates  preclude any differences between physicians and have them all producing the same rapid low quality product.

Physician evaluations are often set up to not recognize the unique contribution of the physician to the department and to insist instead on some kind of meaningless corporatized individual improvement plan.  The maintenance of certification (MOC) and maintenance of licensure (MOL) in some states is way to send the message that individual physicians don't have any particular expertise and in fact have to pass an arbitrary general exam in order to maintain certification - even if they have specialized in the area for 20 years, are recognized for their expertise, and know more about it than the physicians who designed the exam.

Physicians themselves know that I am speaking the truth about specialization because in many cases they still have this inside information.  They try to get at this information and use it to recommend care to family members and other patients.  If my spouse needs surgery, you can bet I am going to find the surgeon who does the most procedures and the one recommended by his or her colleagues.  Non-physicians do the same thing to some extent by talking to relatives and neighbors who have had surgery and asking them if they would recommend that surgeon.

There is probably no better term for this corporate tactic than suppression.  Current health care management actively suppresses physicians at multiple levels.  That is obvious in the initial interview in any health care organizational if the physician is savvy enough to ask directly about the expectations of the corporation.  They may discover unrealistic productivity and call expectations.  They may find out that although they were hired for some administrative, research or teaching position that there will also be at least a half time productivity expectation that involves seeing a lot of patients.  The associated administrative time cuts into their other role.  They will find that there is no time for the necessary phone calls for pharmacy and insurance hassles, documentation, or even meetings with an administrative agenda that are of no benefit to the physician.  Annual reviews are another place to observe corporate suppression in action.  One of the greatest tools ever created to suppress physicians and give them the message that they need active guidance by the less accountable is the 360 degree evaluation.  Today that typically involves soliciting anonymous negative comments from fellow employees and including that in the physician's review.  Many solid performing physicians many find it disquieting to put in a solid performance both in terms of productivity and other functions like teaching and presentations and leave their annual evaluation feeling like they have just been slandered.  In some cases, administrators may go as far as suggesting a performance improvement plan based on the fiction in the anonymous comments.

All of that is a far cry from the professionalism that used to exist among physicians practicing in groups and hospitals.  The current tactics certainly create more than enough leverage against physicians to keep the businessmen and politicians firmly in control.  The price is clearly a less vibrant, creative, and enthusiastic physician workforce.  The burnout syndrome has been written about extensively in the past several years and the single-most important cause of that burnout is bad management.

There is of course an asymmetry to the management tactics.  They are never applied to the managers themselves.  How would you manage the productivity of managers - the number of bad ideas they can come up with in a month?  Some of them make mistakes that approach a legendary scope in terms of losing money by restructuring employee schedules or signing licensing agreements with electronic health record companies.  They can make decisions that lose millions of dollars and shrug it off like nothing happened.  They can solicit employee complaints because it is currently the corporate ethos to do so and solve none of the problems.  There is no shortage of health care companies that hemorrhage professional employees because of their cookie cutter bad management approach.  It is probably logical from management's perspective because they see physicians and other professionals as production workers who could not survive without active guidance.  They fail to recognize that all of this active interference removes the best minds for treating the problem and relegates them to a secondary role.  In some cases, it appears that the administrators are practicing medicine.
     
These days bad management is about the only management that is out there.                      



George Dawson, MD, DFAPA




Attribution:

Graphic is from Shutterstock (Grayscale Town by Ganzaless) per their standard licensing agreement.   The use of the image does not imply any endorsement of this blog.

Do Businessmen Dream Of Medicine Without Doctors?

You bet they do.

My first exposure to the business-driven dystopian future of medicine occurred in Fort Lauderdale in 1994.  I was the Public Affairs rep for the Minnesota Psychiatric Society.  The APA decided that it would be a good idea to bring all of the Public Affairs and Legislative reps of the local district branches (DBs) to Florida for a conference.  On the surface it was supposed to be focused on getting solutions into the hands of the DBs.  In retrospect it was a shocking introduction to how the managed care industry would lay waste to the field of medicine in the decades that followed.

The keynote speakers for that conference were Governor Arne Carlson from Minnesota and a business consultant.  Minnesota has always been a hotbed of managed care activity and for the past three decades any physician practicing here has been a witness to what can happen when government and business bureaucrats practice medicine.  The end result of rationing psychiatric services over that period of time has been a system of care that is so fragmented and that provides such poor service to patients and family members that the current Governor Mark Dayton recently called for massive reform.  The result of that Task Force is quite unremarkable but that is another story.  In 1994 Governor Carlson was there to brag about MinnesotaCare, a government insurance scheme for the working poor and the Health Care Provider Tax on all health care providers in the state to finance it.  He was describing them as major breakthroughs but over the years they have proven to be very suboptimal programs.  The Provider Tax in many years acts as another revenue source for the State and that revenue is not directed at anything to do with health care.  I have never witnessed any of my working poor patients get on MinnesotaCare.  It appears to be rationed as tightly as a managed care option.  Some members of the audience were less than receptive to these ideas and the Governor did what he could to put them in their place.  The precedent of never telling a politician that they are wrong about their supposed health care reform was easily established.

The consultant provided an even clearer picture of the business agenda. He bombastically presented the first wave of fake news that helped establish managed care.  That fake news was - "Nobody needs specialists anymore.  There are too many of them and they are too high priced.  We are going to buy them out and put them out of business.  The only doctors we need are primary care doctors."  He focused on orthopedic surgery as a case in point, but he pointed out that the same was true of any medical specialty.  It was an implicit threat to all of the psychiatrists in the audience. Of course his statement was pure fabrication.  There is no way a businessman is going to spend a dime to buy practices when he can just manipulate them out of business.  It was the beginning of the full court press to manipulate physicians into doing whatever the business types wanted them to do.  In the following 2 decades - physicians and patients were manipulated into using primary care physician offices for a gatekeeping function for everything while simultaneously reducing reimbursement to those physicians to the point that they needed to see 30 to 40 patients a day to keep the doors open.

I was working for an altruistic multispeciality clinic at the time.  I say altruistic because one of our goals was to see all people presenting to our hospital or clinic irrespective of their ability to pay.  We had to work harder as a result, but were generally quite content.  The physicians were high quality and we were all collegial.  I never trusted any group of physicians more.  The work environment resembled the training environments that I had worked in - county hospitals and VA hospitals and clinics.  Billing, coding, and reimbursement were far removed from the work.  We had billing and coding specialists who came by, read our notes, and submitted the billing documents - totally unseen by us. All we had to do was focus on the practice of medicine.  Anyone working in those days would tell you that was more than enough.

But there was fear in the air.  Over the next several years the physicians in my group were talking about how the local managed care companies were going to put us out of business.  Since were were the largest provider of medical and psychiatric services in the east Metro area and had the market cornered on poor reimbursement,  I dismissed it as hysteria.  Over the next several years we were acquired by one of the three managed care companies that provide the bulk of medical services in Minnesota.  In the process our self funded malpractice fund disappeared.  The provision of care also started to change.  There was no longer an acute care Neurology service.  Stroke care was going to be provided by "an internist with an interest in strokes."  The internal medicine consulting service became the hospitalist service and primary care physicians no longer saw their patients in the hospital.  The decisions were not discussed.  There was no consensus.  Department heads were let go.  Physicians were just told what to do.  At some point my request to talk with the wizards behind the screen was met with a simple answer.  There was now a "firewall" between physicians and the administrators and there was no way that I would ever question their decisions or talk directly with them.  

The administrators began to proliferate.  An endless series of administrative ideas began to be put on the physicians.  Physician were no longer practicing medicine all day long.  Suddenly there were plenty of feel good meetings for administrators.  And so it went.    Outright bombastic contempt for physicians was no longer necessary.  The administrators had won.  Additional mechanisms were put in place to suppress any dissent.

The contempt is still palpable in some of those dissent suppressing situations.  These days - all it takes is a complaint against a physician to activate what is typically an airtight mechanism to scapegoat them within the organization.  It doesn't matter if the complaint is real or not.  In many organizations, a physician's annual evaluation actively solicits anonymous complaints about them.  It is part of a general effort by administrators to illustrate that physicians are really deficient human beings, only able to function in the context of a beneficent organization and supervision by a business person.  Some organizations have a "three strikes and you are out policy" and they don't want to debate the merit of any complaints.  They just list it as a strike.

This is how being a physician devolved from being a fairly autonomous profession to one that is clearly under the boot of the managed care industry and the government and everything that entails.  It was largely an exercise in fake news and rhetoric on the part of the business community and a complete lack of response from physicians or their professional organizations.  That practice is alive and well today.  There is no science involved in business management and no standards.  That alone would create some suspicion about how medicine is currently managed - but there are very few critics.  Physicians as a group have never been able to grasp one of management's unscientific techniques referred to as pushback.  Instead of standing there like deer in the headlights pushback against all of the fake news generated by these managers.

If that ever caught on with my colleagues - we would all start pushing now and keep it up for the next 30 years to just break even.


George Dawson, MD, DFAPA




Supplementary 1:  Businessmen here is used as a generic form of businessman or businesswomen.  There are clearly plenty of female managers who also do not know what they are doing.

Supplementary 2:  A few words about pushback.  According to William Safire writing in the New York Times - pushback the noun began to surface in business journals near the end of the 20th century.  In my experience it started to show up in medical meetings about a decade later.  The current Merriam Webster definition is "resistance or opposition in response to a policy or regulation especially by those affected".  That does not really capture the business application of this term.  In a business meeting for example, the strategy might be to exert some kind of pressure on a group or subgroup of people affected by the business and see if there is any pushback.  In some cases, no pushback is expected because the employees are fairly expendable.  I heard a business story about retail stores that use a clopening strategy where the same employee closes the store one night and has to open it in the morning.  That is very inconvenient if you are that employee and trying to coordinate daycare for children or a second job, but pushback is not really anticipated.  In the case of professionals who are required in certain positions pushback might be anticipated with certain mandates.  I have been in meetings where the question was asked: "Has there been any pushback from the doctors or nurses on that?"  If there is none, the leverage is typically increased until there is.  In the case of physicians it rarely (if ever) happens.  There have been numerous explanations for the lack of assertiveness on the part of physicians.  The general explanation is that it is unseemly behavior that is inconsistent with the professional image of the physician.  I think the real mistake is that physicians assume that the business manager class has the same degree of professionalism and values when they clearly do not.  Any physician being pushed around or bullied by business managers knows exactly what I am talking about.  They do not think or act like physicians.  It is time to stop acting like they do.

Ref:

William Safire.  Pushback.  New York Times.  January 14, 2007.    


Supplementary 3:  From Orwell's 1984 as O'Brien interrogates Winston Smith and plants the idea that the only way man can assert power over another is by making him suffer and goes on to detail how that is done.  He concludes:  ".....Always, at every moment, there will be the thrill of victory, the sensation of trampling on an enemy who is helpless.  If you want a picture of the future, imagine a boot stamping on a human face--for ever."

That is exactly where the business world and the government want the medical profession.

Ref:

George Orwell. Nineteen Eighty-Four. A novel. London: Secker & Warburg (1949).

Attribution:  Image from this post is downloaded from Shutterstock  per their standard licensing agreement.  Image number 59502138 by Stokkete (photographer).

Tic - toc......

Or why advising physicians on how to manage their time is not generally a good idea.

I will cut to the chase on this one.  The answer is two fold.  Medical practice is by its very nature inefficient.  Secondly, there are just too many people incentivized to waste physicians' time.   After reading another blog on this topic,  it is apparent that most people attempting to give advice to physicians either think that we are quite slow on the uptake or they have no appreciation of what medical practice is like.  The most misunderstood part is how much time physicians are forced to waste on work that is unnecessary to the work of patient care.

I preface my remarks by saying that in the many visits I have had to physicians of all specialties, I have never been seen on time and consider myself lucky to be seen within 30 minutes.  My all-time record was waiting about 30 minutes to be seen in the emergency department one day and then having to wait another 8 hours to be discharged by the physician who saw me for a rather uncomplicated problem.  So there is no expedited line for physicians in clinics, EDs, or hospitals.  We wait like everybody else.

The premise of efficiency in medical practice is a favorite of administrators and other salespeople pushing valuable time saving devices for physicians.  Primary among them has been the electronic health record or EHR.  I think there is finally a consensus on the fact that it has basically created a large pool of physician-stenographers that spend additional hours each day typing in documents that are designed for billing and coding purposes rather than enhancing the care of patients.  I will roll out my frequently stated comparison.  In 1981, two interns and myself could complete all of the daily documentation on a busy 30 bed neurosurgery service during the 2-3 hours that we were rounding with the senior residents and doing all of the other associated work that day.  Today it would probably take an additional 4-6 hours to do that work and it would mean less time in the operating room learning neurosurgery and attendings wondering about what happened to the team.  I have heard of some surgical services who hire retired surgeons to come in as scribes to do operative notes to reduce the paperwork burden.  The documentation burden is worse in primary care.  All of the advice on how to shift your time around to allow ample time for the documentation never considers the fact that time slots in clinic are rarely set in stone.  People show up 30 - 60 minutes late and expect to be seen.  Emergencies happen, and need to be dealt with while people are stacked up in the waiting area.  Labs need to be reviewed and all of the outgoing tasks (paperwork, phone calls, prescriptions, consults) need to be handled.  None of these are trivial tasks in terms of the time it takes to get them done.  Some of my friends in Endocrinology walk in on a typical morning and have over 250 test results stacked up in a computer queue that they need to review on top of the full patient schedule that day and do something about them - in some cases right away!

Outpatient clinics have certain routines every day depending on the specialties involved and the amount of staff available.  As an example, primary care clinics generally have many more staff to room patients, take vital signs, handle calls, and schedule patients than outpatient psychiatry clinics.  But even clinics that are more fully staffed can easily be overwhelmed by the demands placed on them.  There is no end to nonsensical ideas about how physicians can be more efficient, but there are always several facts that all of the advice givers typically ignore:

1.  There are mathematical laws called power laws that govern how many patients can be seen by physicians.  It is a mathematical fact.  All of the speculation about computers doing thousands of physician tasks per second are really meaningless at this point.  All of the administrators talking about "productivity" are as meaningless.  Productivity happens when real quality treatment occurs that changes a person's life.

2.  Despite all of the business focus on productivity, the business administrators in health care have done nothing but create obstacles to physician work.  Wasting hours every day doing tasks for insurance companies and the government is basically a case in point.  I would estimate at least 40-50% of all physicians time is wasted on these tasks.

3.  Every physician in this country who works in a clinic setting is an independent practitioner.  They don't need supervision, they just need to keep their license current and abide by the medical practice acts in each state.  The only time they are supervised is when they work in a clinic or hospital setting and suddenly they are vertically integrated into departments and placed under a supervisory hierarchy.  That hierarchy is by definition very inefficient.  A lot of time is wasted implementing the next great ideas of the supervisors and in some cases sitting in long drawn out meetings about the financial status of the department.  Apart from the administrators needing to demonstrate that they were actually doing something (that is frequently debatable) - these meetings were generally a waste of time.  I don't discuss all of my cases with business administrators - why would I want to read their spreadsheets?  How can putting 20 or 30 physicians in the same room for a meeting be anything but disruptive to clinic and hospital schedules?  The business and government initiatives to force physicians into these employment situations leads even less time to see patients.

4.  Physicians have been hit hard by the EHR and more.  Like many other jobs there is an implied 24/7 electronic access.  When physicians are not completing documentation after hours or at home,  they are answering e-mails and texts about patient problems.  It is not uncommon to start clinic and notice that is addition to a full schedule of appointments and labs to review that there are also 20 or 30 e-mails and messages through the EHR - many marked urgent.  If you are the first appointment in clinic that day and your physician said that she had to respond to an urgent problem - believe her.

I can understand that this post might elicit widely varying emotions.  Overworked and burned out physicians will see the obvious truths here and will wearily think: "Been there - done that."  There will be readers - like one who suggested that I drive a Porsche rather than a soccer mom van - who will be outraged that a rich doctor dares to complain about working conditions.  There will be readers who think that physicians should not complain on basic principles.  I guess they don't want physicians acting like other workers when this is supposed to be a privileged and noble calling.  They don't recognize that physicians are managed like production workers and not professionals.  There will be those trying to silence complaining physicians by suggesting it is "unprofessional" or characterizing legitimate complaints as "whining".  They generally have their own political agenda  that includes managing physicians like production workers.   It should be apparent that there is no extra time to manage.  There are many people who will say they are working as hard as doctors and therefore doctors don't have a legitimate point.  I would say that I don't doubt it at all that too many Americans are working long and hard hours.  The question is whether there is also a public safety consideration.  Most workers where there is an element of public safety have limitations on their hours.   Practically all physicians are running a huge time deficit that can't be overcome by gaining 5 or 10 minutes from the occasional appointment that goes well.

Irrespective of the emotional reaction to this post there is a very basic thought experiment that anyone can do.  It will highlight a suggested orientation to the problem.  The question is - when you see a physician do you want to see somebody who is burned out, fatigued from people wasting their time and trying to get them to do more busy work?  Or do you want to see a physician who is energetic, enthusiastic and has enough time to dedicate to you or your family member?

I personally will take the physician who is energetic, enthusiastic and has enough time to focus their energy on their family and learning more about their field.  That is not happening in many places today.      

And for all of those people who want to give physicians more advice on how to be more efficient in cramming 12-16 hours of work (much of it unnecessary) into 8 - here is a bit of advice for you.  Step back and let us do our work - we were doing quite well without you.

George Dawson, MD, DFAPA




Attribution:

Clock graphic by Dnu72 (Own work) [CC BY-SA 3.0 (http://creativecommons.org/licenses/by-sa/3.0)], via Wikimedia Commons.

Watson Replacing Radiologists?

I like reading the Health Care Blog.  It typifies what is wrong with the management of the American Health Care system and I suppose blogs in general.  It is a steady stream of bad ideas and political rhetoric.  The best recent example was a little piece about radiologists called Will Watson Replace A Radiologist - Ask A Radiologist.  Radiologists either don't read this blog or they can't be bothered since the only comment at this point is from a rheumatologist on the necessary consultation and collegiality with radiologists.  The author of the main article is taking the perspective of being both threatening (Can the IBM Watson machine acquire the image reading capabilities of a human radiologist by "reading" a large set of clinical images and reading them at a much faster rate than a radiologist?) and advising (The only way that radiology will survive is to demonstrate their value to patients and colleagues by connecting with them?).  The author's conclusion is very explicit: Connect or be replaced.

Over the past thirty years my experience with radiologists has been positive and in some cases outstanding.  That dates back to the early days of being the medical student or intern responsible for carrying a stack of heavy and awkward films around.  I remember not having a film on a Cardiology rotation and regretting it: "Mr. Dawson - what made you think it was not a good idea to have the chest x-ray of this patient with mitral valve disease?"  From that point on radiologists were my friends.  That was an era before there was a lot of managed care penetration and I always rotated at public  hospitals and VA hospitals anyway.  You could always find a radiologist back in the dark confines of a reading room.  The interns and residents had certain staff members that were the go-to staff in terms of teaching and also amazing observations.  They always pointed out what we were missing.  They collected teaching files and teaching cases for us to learn from.  Reading rooms could be bizarre places in those days.  Very large films clamped on reading boxes.  In some cases entire rows of films - 10 to 12 wide, could be rotated on a belt device.  The radiologist would need to recall when they saw the film and press down on a foot pedal until the correct film popped up.  On many days row after row of films would need to be surveyed to find the one you wanted.  In the early days of spinal CT, many films had to be viewed on each patient.

I did not forget my positive experiences as a resident when I became an attending physician.  All the images I ordered on my patients had to be seen.  I would still go down and pull the films and where necessary review them with the radiologist.  Now I had neuroradiologists to work with and they were excellent.  The medium was changing.  Eventually all of the films went away and when I went down to radiology, the reading room was still there, but now it was a computer terminal with two monitors.  The images could be immediately manipulated to show the best view.  It was no longer necessary to pull the film off the cassette and illuminate it with a bright light.  I could always ask them questions, but as time went by they were under a greater time crunch.  Now all of the dictated reports were available on the phone system and you were encouraged to listen to all of the reports.  Asking to review a series of films without listening to that report was frowned upon.  At one point in time we were all members of the same clinic, but soon all of the radiologists were spun off into a different company.  They were the same people,  just no longer affiliated with our clinic.  By  that time managed care was trying to get everyone on a productivity scale and radiology seemed like an ideal speciality to crank up the productivity expectations.

In addition to the direct experience with radiologists, the author here also seems to not recognize the value of a human brain as a processor.  I teach neurobiology to students, residents, and physicians.  Part of the job of any lecturer is to help people stay awake.  Just before I delve into the frontal cortex and its connections to the ventral striatum, I put up a slide with a fact from one of my IEEE journals:

"Equivalent computing power (depends on the simulation) using today's hardware may require up to 1.5 gigawatts to power and that is equivalent to 0.1% of the US power grid or the output of a small nuclear power plant..."   IEEE Spectrum 2012

I ask the students to speculate on how the human brain has such a tremendous amount of processing power and how it is different from computers.  Even though the audience is generally tech savvy young physicians or students, I have never heard the correct answer.  One of the correct answers is the fact that the human brain is an unparalleled pattern matching device.  There are papers where it has been estimated we can each recognize about 80,000 unique patterns.  I start to go down the list and end with studies of radiologists, dermatologists and ophthalmologists demonstrating superior pattern matching and pattern completion skill.  But I also point out, it is why that you can't learn medicine from a textbook.  It is why you need clinical exposure before you can safely practice.   You need to acquire those skills.  To my knowledge, there have been no good papers written on available pattern matching in human diagnosticians compared with the cognitive tasks they face.  For example to be a good radiologist, how many unique patterns and variations do you need to be able to see - 10,000, 50,000?  The answer to that question is critical and yet we do not know the answer for radiology or any other medical specialty.  If the number if less than 80,000 (and we don't really know this confidence interval) - Watson may have the speed but not necessarily the accuracy.  Will Watson be analogous to the current ECG computer - a general normal/abnormal reading, a reading on measurable dimensions, and then not much on equivocal cases?  Only time will tell.

So I think this Health Care Blog post has the valuable lessons of most of their posts.  I don't know the author, but it is clear that he has not worked with radiologists as long as I have.  Not just the consultations backlit by reading boxes, but the telephone conversations about the best possible test to use to investigate the problem.  If he had worked with radiologists he would know that they have always been connected throughout the careers of most physicians.  The only obstacle to that connection has been corporate medicine.  The author's seemingly friendly advice is disingenuous.  If the business administrators who run health care really wanted radiologists connecting - they would get reasonable productivity compensation for that activity.  They would not need to connect and then run back to their terminal and read enough films to make up for the period of time they were in a conference or informally teaching residents from other specialities.  I think that the admonition to connect probably means to connect with the business administrators running the health plans.  Come back into the herd and let us tell you how many images to read, just like we tell other physicians how many patients they have to see.  Advising physicians on how to behave is also a well known strategy to manipulate them.

The real message is come back to the herd or be replaced, because there is nothing that would make an administrator's day more than replacing physicians with machines - especially physicians that they have no direct control over.

IBM knows that and I know that........

An equally important question is why Watson can't replace business administrators?  They seem to have the requisite lack of technical expertise and creativity.  They need a very basic level of pattern matching to do the job, certainly no training in it.  It would seem that a very basic program to optimize the working environment for physicians, health care workers and patients would be more ideal than dabbling in an area where real expertise and collegiality is required.  I can only conclude those concepts are alien to the ever expanding group of administrators whose reason for existence seems to be managing people - whether they need it or not.


George Dawson, MD, DFAPA


Supplementary:  Although I could not work it into the above post another insidious effect of corporations on medicine has been taking teaching out of the loop.  Radiology teaching files and teaching rounds were always a rich source of learning for students and residents.  It is a required skill on most board exams.  I recall approaching an administrator about preparing teaching slides for the residency in-training exam.  It is quite easy to copy de-identified images onto PowerPoint slides for review and these images routinely appear in all major medical journals.  I will never forget the response:

"Dr. Dawson - why would we want our images to appear on teaching slides?"

Just another sign of the apocalypse.










      

Live by the Customer Satisfaction Ratings and Die By Them

My original intent was to look at the problem of what happens to a group of physicians who are sailing along with very high patient satisfaction ratings.  Then for no particular reason, their ratings drop by about 20-25%.  At the high point they did not question the validity of the ratings.  They just assumed the satisfaction ratings reflected their high quality work.  The problem is that nothing they did changed and suddenly their ratings were significantly lower and people were looking for explanations.  Hence the title of this post.  If these ratings really mean something in the first place the physicians are suddenly thrown into a lot of self doubt.  If they believe the ratings are unscientific, designed by people who don't know much about survey design or sampling, and are actually biased because of the way the staff presents the surveys - they are much less worried.

I posted to above bar graph as an introduction to this post.  It is a composite of the opinions that several primary care physicians have given me about the correlation between benzodiazepine and opiate prescriptions and customer satisfaction ratings.  More prescriptions for controlled substances equals greater customer satisfaction.    Some clinics have adapted to this by letting patients know that they do not prescribe benzodiazepines or deal with psychiatric disorders.  That eliminates physician-to-physician variability in prescribing.  It also demonstrates that certain overprescribed medications are viewed as more serious than others.  I have not for example seen any similar clinic rules for antibiotics even though they are also widely over prescribed.

I hope it is not a news flash to anyone that highly satisfied customers in the health care system have the highest mortality and probability of hospitalization (1).  I know that at least some of the customers out there may be very surprised to hear that doctors can't be rated like a Toyota dealership.  Toyota dealers after all have a product that is high in quality, uniform, and the same irrespective of those pesky human factors that we all have to deal with in human encounters.    I am referring of course to things like communication,  interpersonal skills, thinking capacity, personality traits and personality disorders.  A Toyota dealer is out to satisfy all customer needs in the very circumscribed area of personal transportation.  Even then there will be bumps in the road.  A customer may not like the way the vehicle has turned out or some of the results from the service department.  But generally Toyota dealers have a great product and most of their customers are highly satisfied.

This may be hard to believe but the MBAs that currently run medicine in the USA decided to introduce management principles into the field that were designed for the auto industry.   The details and names of those management principles is irrelevant at this time, but when they were introduced it was a big deal.  I had to listen to several hours of lectures on Six Sigma.  Feel free to read about it and let me know how it possibly applies to the practice of medicine.  After those lectures it was obvious to me that the MBAs running medicine were completely clueless about medical care.  One small piece of evidence in what is now a mountain of evidence that the business emphasis in managing hospitals and doctors is completely off the rails.   Most business concepts are introduced to groups of physicians as a manipulation.  They have to be because no rational person would buy what appears to be Dilbert style management.  It goes something like this:

"Look - we know that physicians don't like the idea that they can measured.   We know you don't like that idea, but let's face it, this is a new era.  Things aren't like they used to be.  The day of the physician running things is over.  You are all going to have to be accountable now.  Some day your reimbursement is going to be tied to these satisfaction ratings."

Administrators like to seethe a little bit when they play the authoritarian act with physicians.  They think it gives them more credibility.  They could also be playing off the collective seething in the room.  The logical questions followed:

"Well what about clinicians seeing patients with cognitive impairment or who are being treated on an involuntary basis.  What can you say about the validity of those satisfaction ratings?"

That led to some laughter, but no explanations.  Everybody would be rated and that was the end of it.  There would be no exceptions.  The irrational authoritarian business model rules.

Before anyone gets too bent out of shape about my view of the business model let me illustrate with an second example of what I mean.  Earlier this evening I consulted with a colleague from another state on an inpatient problem.  When that was over I asked her how things were going in general and she told me:  "It's really kind of tough.  The patients are never really stable, they have multiple psychiatric, substance use, and medical diagnoses and they are very hard to stabilize."  She was thinking about moving on.  She was in a meeting and an administrator said:  "This patient has been here (x number of days) what is the plan?"   She said:  "What do you mean what is the plan?  The plan is what the plan always is - stabilize the patient and discharge them."  Managed care administrators have the uncanny ability to blame the physician for any discrepancy with a pure business approach to medicine.  They apparently believe that hospital treatment and discharges are as predictable as Toyotas rolling off an assembly line.  That is as true for customer satisfaction ratings as length of stay outliers.  It give the administrators leverage against physicians, especially any physician who buys in to the idea that these are valid metrics.

Let me illustrate by considering two different physicians Doc A and Doc B.  Both are very competent psychiatrists, but for some reason Doc A consistently scores lower on customer satisfaction ratings than Doc B.   From the research in this area, it may simply mean that Doc B gives his patients more of what they want than Doc A.  My speculation is that personality is a big factor.  A simple mismatch between extroverts and introverts can fuel a lot of dissatisfaction.  The extroverts on both ends (doctor and patient) like to be engaged and they like the conversation to have no dead air.  A doctor that is too reserved may be perceived as being disinterested or not giving them enough in the interaction.  Some patients want special treatment and others just want confirmation of their perceptions of other doctors and in:  "I was not really impressed with your colleague.  What do you think of him?"  Psychiatrists generally know better, especially psychiatrists who recognize that their organization is set up to facilitate splitting and chaos.  There may be a difference between the doctors in terms of prescribing patterns in terms of my previous analysis of the overprescribing problem.  In this case Doc A may be known for no sleep medications, no benzodiazepine prescriptions, no opiate maintenance prescriptions and no high dose amphetamines for narcolepsy and no stimulant prescriptions for adult ADHD when the patient is functioning well in school or work.  Denying those groups of prescriptions will not only result in low physician satisfaction scores but threats of violence and suicide.  That is not to say that other tests or medication would not result in and extremely dissatisfied patient.  There are thousands of scenarios where the patient does not take the physicians advice in the manner with which it is intended and that is - the best possible advice to diagnosis or treat a problem at a given point in time.

I did not write this post to "prove" that being satisfied with your physician is necessarily a good thing or a bad thing.  If I wanted to approach problems like that I could probably get my own TV show.  The whole point here is that any potential patient-customer needs to know what these things mean.  You may not want to keep hearing the word but politics is the major reason.  People trying to sell their business based idea about medicine versus physicians who have no similar notions.  People trying to sell their idea that medicine is just like making widgets rather than treating people who have tremendous biological variability.  You don't want your Toyota to have tremendous mechanical variability, but for human beings biological variability is both a fact of life and a distinct advantage from an evolutionary standpoint.

And finally what about news from your physician that you don't want to hear.  Certainly there is widespread fear of a dreaded incurable diagnosis.  There is the concern of diagnoses associated with disability and loss of function.  But there is also straightforward advice on how to avoid fatal illnesses and disability.  The way that is presented varies considerably from physician to physician.  You have to ask yourself: "Would I rather hear that I am overweight and need to lose weight or that I should stop smoking or that I should stop using hydrocodone or alprazolam or would I rather be talking with a physician who would keep quiet on those issues?"

I don't think there is a good study of the issue and if somebody knows one please let me know so that I can post it here.  I can provide another anecdote.  I worked with a group of women once many of who consulted a female internist who was bright, attractive and wore very high fashion clothing (their characterization not mine).  Things were generally going along pretty well until this internist told some of them that they were overweight and needed to lose weight.  That elicited a very strong reaction and it seemed amplified by their perception of this physician as being "perfect".  When I thought about my experience with physicians - nobody has ever told me to lose weight even in situations where they should have.  I suggested it to a physician once and he said: "I concur with your recommendation doctor" but never told me that outright.  Social and cultural factors all play a part in the patients perception of the physician and their satisfaction ratings.

It is a good idea to keep all of those factors in mind in attempting to interpret physician satisfaction ratings especially since most consumer web sites focus entirely on these measures.


George Dawson, MD, DFAPA

1:  Fenton JJ, Jerant AF, Bertakis KD, Franks P. The Cost of Satisfaction: A National Study of Patient Satisfaction, Health Care Utilization, Expenditures, and Mortality. Arch Intern Med. 2012;172(5):405-411. doi:10.1001/archinternmed.2011.1662

From the reference:

"Patient requests have also been shown to have a powerful influence on physician prescribing behavior, and our findings suggest that patient satisfaction may be particularly strongly linked with prescription drug expenditures." (p. 408)

"While we do not believe that patient satisfaction should be disregarded, our data suggest that we do not fully understand what drives patient satisfaction as now measured or how these factors affect health care use and outcomes. Therapeutic responsibilities often require physicians to address topics that may challenge or disturb patients, including substance abuse, psychiatric comorbidity, nonadherence, and the risks of requested but discretionary tests or treatments. Relaxing patient satisfaction incentives may encourage physicians to prioritize the benefits of truthful therapeutic discourse, despite the risks of dissatisfying some patients." (p. 409)

Supplementary 1:  If you are a primary care physician I am very interested in your thoughts about how patient satisfaction scores correlate with prescriptions for benzodiazepines, opioids, and stimulant medications as qualitatively depicted in the above bar graph. 

A Better Way To Manage - Lessons From the Coach

I ran across a basic article on Phil Jackson the other day in the AARP newsletter.  Like most people unfamiliar with his story I get the occasional stories about him that describe him as a guru.  I can see the movie now with novices climbing to the top of some mountain in the Himalaya's only to find him seated in an wooden temple, speaking the basic truths about NBA coaching in a way that only he is capable of.  He is a legendary basketball coach.  The AARP newsletter was brief but it contained huge advice.  In it we learn that he is the son of two clergy and spirituality naturally guides his decision making.  When people think about spirituality they frequently equate that with religion and react to it on that basis.  They miss the point that spirituality can be the essence of a person.  It can be a connection with a process greater than one's self and have nothing to do with religion.  One of my colleagues John MacDougall captures this well in his definition of spirituality as:  "the quality or nature of our relationships in three dimensions - relationships with our Higher Power, with ourselves and with other people."

The other Phil Jackson observation from the article that impressed me was the notion that he used nonauthoritarian methods to empower his players and these methods came directly from a spiritual direction that allowed him to be true to himself.  He talked about knowing that "things of a higher calling could unite groups of men."

"I've learned that the most effective way to forge a winning team is to call on the players need to connect with something larger than themselves......  It requires the individuals involved to surrender their self interest for the greater good so that the whole adds up to more than the sum of its parts."  -  Phil Jackson in Sacred Hoops (p. 5)

Contrast that with typical managed care or business strategies that leave the people out of the equation.  The best way to look at that contrast is by looking at some team situations I have been in the past.  I wrote about my Renal Medicine team in the past.  It was my last rotation in medical school and I walked off that service at about 8 PM on the last day before graduation.  The whole raison d'etre of that team was the two goals of excellent medical care and education.  The approach to both goals was intensive.  Even as a medical student, I felt like a critical part of the team.  My job was to go out into the large medical complex on the grounds of the Milwaukee County Medical Center and do consults.  On the last day, the two residents I was working with approached me and said: "Look George, we know this is your big day but we are getting killed.  Can you do these consults?"  Of course I did.  The only meaning that my action had at the time was the I was a part of this team and I wanted to share the workload.  After we completed rounds that night at about 9 PM, those same residents joked about how I was a super medical student and some of the jokes were quite funny.  But that rotation (with a few others) was one of the most meaningful educational experiences of my life.  To this day, I miss working with that team.  It was a spiritual experience!

Teams on inpatient psychiatric units can be a different story in part because they are influenced by the typical silo style management of big hospitals.  The managers are ego rather than team driven.  There are separate nursing and physician structures.  Some of the team members may be in separate unions.  There are multiple disciplines that can be split be numerous administrative hierarchies.  It is always easy for administrators to try to play one discipline against the next.  Institutional attitudes can affect psychiatric teams at multiple levels.  At various times I have been in teams where one or more members were being influenced by administrators to the detriment of the team.  That almost always translates to suboptimal patient care.  The administrative message to teams can be fairly extreme.  At one point I can recall being told that we were no longer doing team meetings.  Productivity measured as individual physician-patient contacts was more important.  At that time we had already been told that our documentation was supposed to include a blurb about observations made in the team meeting or it would not "meet criteria" for the correct billing code.  At other times we were plagued by observers - bureaucrats, consultants, or business types who clearly did not know anything about the work or at least the work we were doing.  Many were hired guns brought in by our own administration as the "next big idea" or an attempt to manipulate the team in some way.  In the most extreme situation, a representative of the administration was sitting in team meetings and telling us what to do.  I say extreme because the administrator had never assessed any of the patients and did not know them.  They also did not have the expertise to make a diagnosis or treatment plan.  All of their decisions were strictly financial.  They needed us to carry them out to provide the legitimacy of having licensed professionals names in the charts, especially on the discharge orders.

All of those last scenarios are at the extreme other end of the spectrum from Phil Jackson's approach.  My guess is that Phil Jackson would not have been able to keep Kobe Bryant in LA when he wanted to be traded with just financial incentives and a business approach.  It took a spiritual one.  He had to feel like he was part of a larger process.  That is the spiritual atmosphere that needs to be created on treatment teams.  You won't get to that by expecting physicians or nurses or social workers or occupational therapists to be mini-administrators focused on "cost effectiveness".  In fact, it is exactly the wrong approach.

The correct spiritual ground for a team is unity, appropriate concern for other team members, common goals and positive affect associated with being on that team.  Team members need to  to have a uniform neutral and spiritual approach to the people they are trying to help.  One of John MacDougall's suggested approach to improve spirituality is:  "try treating every human being that you meet as if he or she were a beloved child of a Higher Power."  It has nothing to do with being a bean counter and in fact if the bean counters can't support the development and maintenance of teams - it is time for everybody to walk away and start over.

Phil Jackson's elaboration of a non-authoritarian spiritual approach to managing people on teams is just another important way that the government and the managed care world miss the boat and end up providing the worst possible management of health care workers, especially mental health care workers.  Micromanagement and a general cluelessness about managing knowledge workers is another.  We don't have a shortage of worker productivity or a shortage of workers - we have grossly mismanaged workers and some of the worst managers in the world.

George Dawson, MD, DFAPA

John A. MacDougall.  Being Sober and Becoming Happy.  CreateSpace Independent Publishing Platform, 2013. p. 40.

Phil Jackson and Hugh Delehanty.  Sacred Hoops.  Spiritual Lessons of  a Hardwood Warrior.  Hyperion, New York, 1995.

Lessons From Google on How To Manage Physicians

This month's Harvard Business Review has an interesting article on managing technical professionals entitled:  "How Google Sold Its Engineers on Management."  One of the secondary goals of this blog is to point out how people who manage physicians are not only technically inept but in many cases openly hostile to the physicians they manage.  That is largely because the entire system is based on artificial productivity measures and practically all of the management is focused on how to get more artificial productivity out of physicians.  A classic example of this kind of management focuses on how many deeply discounted patient visits are seen per day.  Other tasks like chart checks, telephone calls, paperwork of various kinds, and the tremendous burden of managing the electronic health record and all that involves are not counted as productivity of any sort.  Physicians are basically expected to do all of that plus teaching and lecturing on their own time.  In one system where I worked you were given points for being a good citizen and eligible for some trivial reimbursement if it was apparent that you were doing more than cranking out RVUs (the standardized measure of productivity).

This whole system of management is archaic in that it is a system that was set up to manage production workers and not knowledge workers with technical expertise.  Physician managers seem oblivious to the fact that the product of their organization rests solely in the expertise of their doctors.  A healthcare organization will only be that good and it is in the interest of that organization to retain and develop the careers of the best physicians they can find.  That is not the prevailing way that employed physicians are managed.  In fact, physicians are micromanaged and their decisions are routinely second guessed.  In the worst case scenario, if the physician disagrees with the financially based decisions of their managers they can be fired or politically scapegoated for not being a team player.  Some physicians may be subjected to several of these confrontations per day often over trivial cost savings.  In psychiatry for example, the arguments often arise over length of stay considerations where there is a set reimbursement for a hospital stay and the manager wants the person out sooner so the hospital can make more money.  The patient care goals of the physician based on their technical expertise and the financial goals of the case manager are discrepant.  That conflict is compounded by the fact that the managers do not have the professional credentials or the accountability of the physicians they are literally ordering around.
    
How do they do it at Google?  I consider engineers and doctors to be equivalent professions.  They  both require years of study and ongoing study.  They both have professional codes of conduct.  If there is any management on the technical side, engineers and physicians both want those people to have the best technical qualifications.  In that context the HBR article was interesting.  At one point Google wanted to try a completely "flat management system" with no managers.  Many of the engineers thought that it might recreate an academic environment similar to graduate school and produce a similar level of excitement and creativity.  That model resulted in upper management being flooded with human resources issues.  They eventually developed a system of managers with few layers designed to reduce micromanagement.  The example given was that some of the managers have up to 30 engineers reporting to them.  According to the engineer interviewed for the article: "There is only so much you can meddle with when you have 30 people on your team, so you have to focus on creating the best environment for engineers to make things happen."  This is a foreign concept in managed care.  Not only are physicians micromanaged but their work environment if frequently manipulated by various managers to decrease both their productivity and work-life balance.  It is a set up for burnout and suboptimal intellectual performance.

The following table is a good example of the differences between how Google manages their engineers to remain a state of the art engineering company with an emphasis on technical expertise.  There are very few medical organizations that have a similar focus.  The ones that do are usually criticized by managed care companies and dropped from their networks for being "too expensive."  As a physician ask yourself which environment you would prefer to work in.  Imagine working on the most exciting and intellectually stimulating team you have ever worked on in your training compared with where you currently work.  As a patient, the question is no less significant.  Do you want a physician who is excited about practicing medicine, who is intellectually stimulated, and not burned out or do you want a physician as they are currently managed?

Google Managers	Physician Managers
Micromanagement is prevented	Micromanagement is the rule of the day
Work environment is optimized for engineering work	Work environment is optimized for managers
Respect for technical expertise and problem solving rather than title and formal authority.	Strictly chain of command often flows from people with no technical expertise.
Good manager empowers the team.	Good manager empowers themselves and their boss.
Helps with career development.	At the minimum does not care about career development and at the worst may try to actively interfere with professional career.
Has technical skills to help and advise the team.	Has no technical skills and often has no medical degree or license.
Productive and results oriented.	Productivity is measured in adjusting physician productivity units

I used to work in a clinic that was analogous to Google in that we were: "A clinic built by physicians for physicians."  Our mission was to provide care to all people irrespective of their ability to pay.  We did not have a lot of resources, but we were good at our mission.  The collegial atmosphere was excellent and we did not make a lot of money.  It was an incredible learning environment where psychiatrists routinely interacted with colleagues from all specialties.  It was acquired by a managed care company and was managed less and less like Google.  Today all of its management parameters rest fully on the right side of the table.

The best management for knowledge workers is known.  Why don't we see it applied to physicians?

And yes, that is a rhetorical question.

George Dawson, MD, DFAPA

The Dog Quadrant

Before anyone gets the wrong idea, this post is not about pet therapy.  It is not about the purported advantages of owning a dog.  It is not even about the new research on dog intelligence that I was frankly surprised by, especially the research showing how easily dogs can beat non-human primates on specific tasks.  So much for that massive frontal cortex conferring supreme advantage over the animal kingdom.  No - this is about managed care and using the term "dog" in its pejorative context.

Several years ago, I was burned out and suffering from the type of large scale mismanagement that is so common in organizations that run on managed care principles.  I attempted to approach the problem with humor by reading Dilbert cartoons.  Read the first few pages in the Dogbert Management Handout to see what I mean. I soon realized that this stuff was too close to the truth about health care management and decided to look for other management styles.

I happened across the work of Peter Drucker and his ideas about managing knowledge workers that were considered revolutionary.  There was certainly nothing like that going on in health care.  The managed care approach to managing physicians was to actually treat them like they were not knowledge workers but assembly line workers.  Drucker's stroke of genius was in recognizing that managers know much less about products and processes than knowledge workers and that the business was essentially the product of the knowledge workers.  Managed care techniques are diametrically opposed and are based on the fact that business guidelines are somehow relevant to medical care and even may actually be called medical quality.  There is no health care process more autocratic and primitive than managed care. I have reviewed how this bizarre set of circumstances evolved in several posts on this blog.

Along the way, I also interviewed a health care business management expert and asked him if there were any definitive texts that are used to train business people about managing health care and he referred me to the text Strategic Management of Health Care Organizations.   I started to read and study the text, initially trying to find out why Drucker was completely ignored by health care managers.  That was when I encountered the BCG Analysis for a Health Care Institution (p 254).   BCG is an abbreviation for Boston Consulting Group who came up with this technique for analyzing products and services.  In this case, there was a four quadrant graph that differences in market growth rate and relative market share position.  I don't have permission to reproduce it here so I will do my best to describe it briefly.  The high growth/high market share quadrant was termed "Stars" and contained services like orthopedics, cardiology, oncology, and women's service.  The medium/high and high/low quadrants were called "Cash Cows" and "Problem Children".  The lower right hand quadrant of the graphic were the "Dogs" and they included psychiatry, ENT, pediatrics and others.

I am no financial analyst, but what is wrong with this picture?  Let me give you a hint.  If you have a portfolio of medical services and one of them is selected for rationing and the others are not - it should easily end up in the Dog quadrant.  The selective rationing of psychiatric and mental health services is a known fact for the last 30 years.  When you ration a service you naturally slow its growth and reduce the market share.  The market share is reduced even more precipitously when you start shutting down bed capacity and hospitals.  Early in the course of all of these events some high profile teaching units in hospitals affiliated with prestigious medical schools were shut down and it was described as being secondary to a lack of reimbursement from companies using managed care models.  If you are in a business that severely distorts the market by controlling growth and market share it makes little sense to pretend that you can analyze portfolios across an imaginary market and make decisions about resource allocation in an organization.

If you were a physician unlucky enough to be trapped in this process it played out in several ways.  There were endless meetings that formed the base of misinformation.  There was the suggestion that productivity was the only fair way to reimburse physicians and the implication that some physicians were much less productive than others.  That was a good way to provoke the competitive, even though in practically all cases that was not true.  Then there was the usual barrage of financial information.  Overhead figures from who knows where.  The suggestion that physicians may need to cover the salaries of any physician assistants working with them.  It was an unending painful process designed to give the appearance that physicians had a say in the business, except at every critical decision they did not.  In the end all there were was a long series of Dogbert management PowerPoints.

I have not seen the latest edition of the book and I wonder if there have been any additional pejorative classifications for mental health or psychiatry.  One thing is for sure.  You don't end up in the Dog quadrant because of lack of real demand or free markets.  You end up in the Dog quadrant because of managed care and their supporters in the government.

And then they can use this analysis to remove even more resources.

George Dawson, MD, DFAPA

Financial Blogger Gets It - Sort Of

I was buoyed to see this line as the title of a financial blog today:  "Coming Corporate Control of Medicine Will Throw Patients Under the Bus".  You don't usually see that level of insight into what is going on in medicine from financial people who have usually bought the "cost effectiveness" dogma, even at a time where middlemen are siphoning off hundreds of billions of dollars from the direct provision of health care and producing an inferior product.  I will say it for the thousandth time - what other industry can make money by selling you a rationed product and denying your access to that product?  Can you imagine what the automobile or cell phone market would look like with that guiding principle?

The article is  focused on two critical issues-physician management by people with no medical experience and the message from the top.  The first part of the article discusses the situation of a pediatrician who had successfully managed a clinic but found herself being managed by a non-physician who told her that she either had  to see very complex patients in a shorter period of time or not see them at all.  The second part of the article focuses on a blog post where a CEO/physician for a managed care company flat out encourages physicians to get rid of difficult patients to improve their managed care style performance measures.

The blogger in this case is Yves Smith.  I have been reading her blog for years.  She wrote the book Econned and takes a generally skeptical view of that way that financial markets are regulated and run.  I have seen her do commentary on some financial television but infrequently.  I would tend to see her commentary as legitimate criticism and welcome in the area of physician and health care management.  As a blogger she is highly successful.  This post alone has about 40 pages of commentary.

In this article she has some additional comments about what physicians face in the assembly line of today's managed care environment:

"As an aside, it's hard to stress enough that this sort of demoralizing micromanagement an unwillingness to listen and learn from workers is a weird shortcoming of management American style.  And it has been weirdly airbrushed out of the media."    

I can't agree more with the second comment in particular.  The American public gets a glimpse of how their health care management occurs only when Michael Moore makes a movie about it or they are confronted face to face with an impossible situation.  That happens all of the time in psychiatry with restrictions on treatment to the point that it seems like treatment has never occurred.  To get that accomplished takes both micromanagement of physicians and a general management style that greatly emphasizes profit margin over patients.  At the public relations level, physician opinion especially physician dissent is not tolerated.  The personal experience of the physicians in these systems is considered the property of the organization.  Any public disclosure of the severe shortcomings can be ruthlessly suppressed either by firing or a series of political maneuvers designed to force resignation at some point.  

There is a divergence of medical and corporate culture at the level of disclosure of errors or wrongdoing.  For most of my professional life I have been in monthly conferences - some type of mortality-morbidity conferences where real or potential errors were discussed on a department wide basis.  I don't think that happens in the corporate world.  I think that errors in the corporate world are acknowledged if they are widely known and there is an emphasis on public relations and maintaining an almost unrealistic positive light on the company.  That has been most evident in the past decade with an abundance of managed care public relations.  Wherever I turn it seems like I come across a hospital or clinic that is proclaiming themselves as the "best" - usually in the country.  That kind of advertising by physicians was widely viewed as unethical by state medical boards.  These ratings are usually based on a few process parameters that can be actively "managed".   Contrary to what health care management tells you the quality of any hospital or clinic depends on the quality of the physicians working there and the level of autonomy they have in their medical decision making.

You can have the best surgeons, internists, or psychiatrists in the world and if they are managed to see as many patients as possible and provide the care that will provide the best profit margin for the company - their medical and surgical care will not be appreciably different from a mediocre staff.

I wrote a piece several years ago about an informed approach to managing knowledge workers that originated with management guru Peter Drucker.  The details can be found in the original piece in this newsletter (page 3) and a earlier posts on this blog.  Everywhere I look in health care we are at the opposite pole from Drucker.  Managers are generally far too authoritarian in dealing with physicians especially in cases where (like the Yves Smith blog post) - the mangers know far less than the physicians.  This managerial style is also disruptive.  Many health care managers think that they can implement any idea they wake up with that morning if they accompany it with enough "Change is good" or "Cost effective" rhetoric. All of this micromanagement and mismanagement illustrates that Dilbert has changed professions.  He is currently wearing a white lab coat.

The other bad news of course is that corporate control of medicine is not coming - it has been here for years.  In the case of psychiatry it has been here for 30 years.  Anyone who wants to see how corporate control of medicine changes things only has to look at the state of current psychiatric services or their "shortage" for a lesson.

George Dawson, MD, DFAPA