There's
a lot of loose talk in medicine, a lot of loose talk by people who
don't know what they are talking about, by people who are casually
referred to as “thought leaders.” They say that the days of
doctor dominance are over, that teams are the important thing, that
doctors need to recognize how replaceable they are by algorithms and
technicians, such as Advanced Practice Nurses, who are pushing
legislatures all over the country to be able to practice
independently. After all, they are professionals, too, and how much
anatomy and pathophysiology and clinical training and wide knowledge
and candidate selectivity do you really need? How much do you use in
the day to day? And how smart do you really have to be?
They
say, look at the quality statistics, and who does better, a doctor or
an APN, a private practice or a Retail Based Clinic? They look at
“consumer acceptance,” and they say, doctors aren't nearly as
necessary as they think they are, because “public opinion” seems
to indicate as such. Doctors, they say, are simply protecting their
turf to the detriment of the public, and to the detriment of those
alternative “providers.”
As
my college roommate from Caribou, Maine, used to say: “bull-diggy.”
Just, bull-diggy. You can always build a cheaper mousetrap, it's
true, but it's just as true that you can always sacrifice quality for
price, that there is always someone who will work cheaper and provide
worse, and therein lies the rub. Sit atop the policy pyramid and all
you can do is rely on statistics, no matter how misleading they may
be. You watch the quality indicators and you think you are seeing
something real, because if you are not a careful observer with a
clinical background, you won't detect that “did you run a strep
test before you treated with antibiotics?” doesn't mean that the
strep test was positive, it just means did you run the test. It
doesn't indicate if you did run the strep test (or, rather, that you
charged for running one) and then decided to ignore a negative
result and tell the patient, “Well, the strep test doesn't pick up
some real strep infections that don't test positive, so we're giving
you an antibiotic.” Such bull-diggy.
If
the policy “thought leaders” ventured forth and looked at
reality, they might get another picture. I wonder if they have
doctors of their own, personally, or if they consult APNs and
algorithms and the internet and their local RBC staffed by an APN
with no backup. It reminds me of the 1960's in Washington, DC, when
all the liberals (my friends, including George Silver and Phil Lee)
were pushing “pre-paid health care,” and large group practices,
before they were labelled as “HMOs” by Paul Ellwood and the Nixon
Administration and thus became adopted by the corporate community.
At that time there was an internist in Washington named Michael
Halberstam, the brother of the soon to be famous journalist David
Halberstam. These liberal DC docs, the cognoscenti pushing prepaid
group practice, used Halberstam as their PCP (another term yet to be
invented.) He was a wonderful guy and a wonderful doctor and he
wrote a wonderful article in the New England Journal that really
pissed me off, because I had had those same thoughts and he beat me
to it, although I could never have reached his level of argument and
eloquence.i
But the point I'm making is this: Halberstam asked these elite
patients, if you guys are pushing this prepaid group idea, and we
have such a group right here in Washington, how come you are all
visiting me, a solo practitioner?
Exactly.
They knew what the best really was. Not that they were hypocrites,
because they weren't. It's perfectly possible that for the average
patient, given the burden of a large population, and given the
average abilities of doctors, and given the disorganized nature of
medical care, on average, for the average person, putting your health
care in the hands of a prepaid group might have made the most sense,
on average. Everybody can't be special. But, if you are an insider,
and you really can evaluate good health care because you yourself are
a professional in the field, then seeing the best of the best might
trump the best of the average. So, it's a complicated proposition,
this choice of to whom you entrust your health care.
An
Example
Let
me show you an example of what someone entrusted with your health
care faces. This is not in some fancy place, the Peter Bent Brigham
Hospital and Partners Healthcare, for instance, whence cometh many a
prescription for health care improvement, and ever increasing size of
the group. This comes from averageville, where the institutions are
what they are on average in America. But in this case, not with an
average PCP, but one who is Halberstamesque, the redoubtable Suzanne
K. Berman of Plateau Pediatrics in Crossville, Tennessee, a
distinguished member of SOAPM, the most distinguished unit of the
American Academy of Pediatrics that concerns itself with actual
practice, and a gifted writer. Here is what she contended with the
other day:
A
24 day old baby has a fever and is feeding poorly, so the mother
takes her to the ER. A fever in a neonate is very concerning, and in
this case especially so, because the mother had a Group B Strep
positive culture pre-delivery, and was not treated for it in the
hospital, which constitutes a strong risk factor for serious
infection in the baby. Any competent ER doc should know this is a
life-threatening emergency, do the cultures and a spinal tap and
admit the child for iv antibiotics. But this doctor and this ER just
does some blood work and sends the patient home. This is pure and
simple malpractice, but truth to tell, it happens. In fact, Suzanne
says that it happened just this same way for another patient at the
same ER a few weeks before. The next morning the mother visits her
PCP, who is Suzanne:
“Baby
comes back to our office for f/u. We do the spinal tap on the baby in
our office, do a catheterized urine culture, give antibiotics and
ship baby to children’s hospital. Baby arrives safely,
stable.
1.5
hours later, after cerebral spinal fluid has been hand-delivered by
our medical assistant to the lab, and after arrival and tucking in of
baby at children’s hospital, CSF results still not reported.
Why,
do you ask? Because:
1.
The lab can’t run the specimen until there’s an order in the
computer in the patient’s name to process the specimen, and
2.
There’s no order in the computer to run the specimen, because
3.
Registration “can’t” put the baby in, because we say that
baby’s name is “Maria Ochoa” and their records show that the
baby’s name is “Maria Fernandez.”
- And, WAIT FOR IT: lab can’t enter results on Maria Fernandez when the CSF tubes are labeled Maria Ochoa.
- Supervisors leave at 3:30 pm on Friday 'evenings.'”
Holy,
holy cow! Make no mistake, this is a question of life or death. If
the baby hadn't come to see Suzanne, it could have been curtains,
easily, very easily. And here is the lab dicking around with a
crucial test that would determine whether or not it was a case of
meningitis, and if the proper antibiotics were being used.
OK,
all you fancy pants health care policy analysts. Do you still object
to the picture of the pediatrician in charge, or would you want a
comprehensive team with APN's in charge, or trust in the bureaucracy
of the lab which seems caught in its own downward spiral, or the ER
that persists in pediatric malpractice?
I
remember my own experience when I was Chief of Pediatrics at Summit
Medical Center in Oakland, and we were confronted with poor pediatric
practice – not to this extent, but clearly poor – in the ER. I
informed the Chief of the ER of the poor practice, and instead of his
receiving our help to improve their performance, he successfully
moved to ban our ability to review pediatric charts in his
department. Amazing, but true, so I don't disbelieve Suzanne's
account of her ER for a single moment, not one.
Observations
There
are a number of observations that flow from this scenario applicable
to current health policy issues. Let's let them fly.
One,
as they say in the seminal text of Ghostbusters, “Who You Gonna
Call?” Are you going to your local prepaid medical care group, or
are you going to Michael Halberstam? Are you going to trust in the
standard operating procedures of a bureaucratic operation, or do you
want your Lone Ranger? And is your Lone Ranger going to be a doctor,
or a nurse, or a technician of some sort, or maybe some algorithm and
computer? Call me an elitist – go on, do it! – and I'll agree
with you. I am. I have always aspired to be outstanding, and I want
to trust my care to someone who has done the same. I want to have
someone who knows what he or she is doing, in depth, and someone who
will move a bureaucracy even when it's his or her time for lunch or
time off, because he or she cares as a professional should care. I
want someone, male or female, with balls. I want someone who has
progressed through a rigorous training program not just for the
knowledge garnered thereby, but who knows what it means to insist
upon high performance from oneself and from others. Which, if you
think about it, is a major function of education at any level.
Corporatists
may disagree. They might say that with care, bureaucracies can be
perfected, that organizations can learn, that not everyone can be
outstanding, that care for the average person is best entrusted to a
system, and that system engineering is really the key to high
performance. To which I reply, this
is not either/or. The
best clinicians function best within high performing systems, and it
is crucial for them to have such systems, because otherwise their
functioning is compromised and in fighting the endless fight they
will burn out. But for a system to be genuinely high-performing, the
clinicians themselves need to have had a strong voice and a strong
hand in creating it. A counter case in point would be Electronic
Medical Records, those systems designed to decrease clinician
productivity by transforming health care provision into data entry
activity. The health care system accepts what Boeing would never
tolerate, or rather what the pilots and airline companies would never
tolerate from Boeing.
Are
corporations and high performing individuals incompatible?
Sometimes. Within corporations, something there is that doesn't love
an individualist, and for their part high-performing individuals need
to give unto routine procedures and other “providers” that which
is routine, and to reserve for unique treatment that which demands
uniqueness. A corporation has difficulty with the individual who
knows what is right for the individual patient. Within a
corporation, if you know what the individual needs, you often have to
“fight for it.” “Fight for it?” Fight for the lab test
result here and now, despite the lab techs being rigid and the
supervisor taking off early? You have to “fight for it?” What
kind of SOP is that? And yet, I bet you can't find me a practicing
doctor who hasn't had to fight to get a lab test, or an imaging
study, or a specialist report, or to find the crucial element of an
ER visit in 200 pages of boiler plate in an EMR report. Is the Lone
Ranger doctor dead? Well, if you want excellence, he or she better
not be, because you show me any system, and I'll show you elements
that need to be fought. The bigger you get, the less control you
have.
And
yet, large size is what is happening. Large size is not only
accepted, but lauded “because coordination is easier in larger
vertically integrated companies.” Merge CVS and Aetna and expect
improved services say the corporate apologists.
http://www.nejm.org/doi/full/10.1056/NEJMp1717137.
Right, vertical integration for improved services. "We can
coordinate better when we're all under one roof."
Not! Vertical
integration is pursued in the great majority of cases to further
market dominance rather than improve service or reduce price. Larger
units provide larger lacunae. See the brilliant relevant essay:
http://buddshenkin.blogspot.com/2017/06/policy-for-emerging-organizational.html.
Size
is an impediment to productivity and responsiveness. In general, the
farther away anyone is from the actual patient, the more the work is
impersonal, and the less actual caring goes into actions. This is
"off my plate" syndrome. Labs don't see patients.
Administrators don't see patients. Neither techs nor administrators
have to look a patient in the eye and say, I'm doing everything
possible for your welfare, not my own personal agenda. Neither needs
to lie outright when they favor their own interests or indulge their
own laziness over the welfare of patients. “This is the way we do
things” reigns in large organizations. Large organizations spawn
more and more personnel not personally responsible to the patient.
And
yet, it is not right, obviously, to lionize doctors excessively.
After all, for all the Suzanne's who put the patient first and know
what they are doing, there are all the others who persistently do the
wrong thing in the ER, who are mal-trained and underperforming and
self-indulgent and who resist improvement. It is the clinician's
responsibility to make a diagnosis, and the Institute of Medicine
estimates that more than 10% of the time, clinicians have have made
an incorrect diagnosis on a patient, and what could be more important
than a correct diagnosis? (And for those of you with faith in how we
evaluate quality, please note that there is no attention paid in
quality measurement to correct vs. incorrect diagnosis. What could
be a more serious indictment of the present state of quality
assessment than that?).
But,
even given that serious caveat of the fallibility of doctors, it is
still important to contrast the eons-old ethical burden of the
physician with the ethical burden assumed by less qualified personnel
(techs) and by administrators. Given the state of business ethics he
observed, Arnold Relman, late editor of the New England Journal,
concluded that all medical organizations should be run by doctors,
and that all such organizations should be non-profit. Although he
cast this as a serious proposal, I view his prescription as more a
cri du coeur
than something practical. But it is hard not to believe that as
organizations get larger and dominated by non-practicing personnel,
the ethical responsibility gets very diluted. Who is going to be
more upset by lab intransigence, the hospital administrator or
Suzanne?
Size
and leadership inevitably play a part. If Suzanne were running the
show at the lab, if it answered to highly motivated doctors, would
the do-si-do of this patients specimen happen? When I had a Kaiser
option with my health insurance years ago I thought I would scout the
opposition and get a checkup there. The receptionist was nice and
the doctor was nice. The scowling medical assistant, however, wore a
badge that didn't say “Kaiser Permanente” but rather “SEIU,”
and when my appointment ended during her lunch time, it was my doctor
who had to go out to the station and do the MA's job herself. Is
this really where we want to go, big and bureaucratic organizations,
with less and less control on average for the patient and the PCP who
takes care of that patient?
We
can discuss quality of care all we want, but the individual doctor
taking care of the individual patient is where the rubber hits the
road. I severely doubt the capacity of ordinary measurements to
comprehend the reality of these encounters in any organization.
Anecdotal they may be, but the stories we hear from docs and patients
are probably as close as we will be able to get to understanding what
is going on. As of now, it seems to me that the most important
variable in a patient's care would be, how good is your doctor, and
secondarily, how well does the system support him or her? And if
that is the case, what we should emphatically not
be doing is figuring out how to supplant the doctor with less-trained
personnel,ii
and we should not
be building ever larger units where poor quality and patient
unresponsiveness can hide out.
Cowboy
on a white horse? Maybe not a good idea. Team leader? Maybe a
better idea. Large units with lesser-trained personnel or
independent lesser-trained personnel? Doesn't sound like progress to
me.
The
independent opinion, advocacy, and concern of a highly-trained
physician backed by a system that enhances his or her capacity to act
intelligently should be the goal. Defining medical deviancy downward
to save costs and preserve large organization preponderance isn't
something doctors signed up for, and America shouldn't either.
Budd
Shenkin
iHalberstam
MJ, Liberal thought, radical theory, and medical practice. N
Engl J Med 1971; 284:1180-1185.
iihttps://www.mercatus.org/publications/us-health-provider-workforce
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