Thursday, February 22, 2018

What Is The Place Of Doctors In Medical Care?

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.”
  1. And, WAIT FOR IT:  lab can’t enter results on Maria Fernandez when the CSF tubes are labeled Maria Ochoa.
  1. 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.
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. 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:
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.

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