Dick Clark

Well, Dick Clark is dead. Sic transit gloria mundi.

I remember Bandstand. Not that I watched it more than one or two times in my life. But I passed through it.

Until 8th grades I lived in West Philadelphia, 47th and Osage for most of the time, in the penumbra of the Penn campus some 15 blocks to the east. It was white then and not run down, with alleys for playing ball, and corner drug stores for playing pinball and very occasionally sitting at the soda fountain and discovering a cherry coke, and inside the houses we sat down for Leave it to Beaver dinners with no TV. From 4th through 8th grades the Shenkin kids deserted the local public school Henry C. Lea Elementary and Sayre Junior High in favor of suburban Friends’ Central School out on City Line. In the morning we would either take a green station wagon school bus, or my mother would drive me and my three siblings to school. The route was always the same, and we listened to Ed McMahon on the radio with my mom, or we would talk and have our little games in the station wagon. Kids can be a little ghoulish, and just a few blocks north of 63rd and Market Streets, as we passed a long, low sign on a grassy front lawn, we would recite in low-pitched sonorous unison, “J. McCullough, Undertaker!” And laugh at our own impertinence.

But that doesn’t have anything to do with Dick Clark, yet. That was saved for the ride home. By 7th grade I could come home by myself after late afternoon sports, taking a bus, the El, and another bus. You could do that then and parents wouldn’t fear for you. The Red Arrow suburban bus from the school to the 69th street terminal was populated by school kids with important conversations. I remember telling Richie “Boop” Reinhart that I had discovered that “fuck” was a dirtier word than “shit,” because after all, everyone had to shit. It seemed perfectly clear at the time.

At the 69th Street Terminal I would walk from the bus terminal at one end to the El (elevated train) terminal at the exact opposite end, punctuated in the middle by the donut shop, with big, glazed donuts staring me in the face as I passed. I disciplined myself not to stop because I knew they weren’t good for me, and also the fact that donuts cost money I think was also in there somewhere. Two Friends’ Central girls seemed to hang out there, one small, blond, freckled, slightly coarse and loud; the other taller, darker, shyer, and to me much more attractive. There were guys from other schools around there with them. They were racy. But while I looked, I don’t think I stopped more than once or twice, just to get a donut.

OK, still no Dick Clark. The El had stops at 63rd street, 60th, 56th, 52nd, and 46th. I was 46th. While the train worked its way there I diverted myself by trying to hold my breath between the stops, from doors closed to doors opened. Usually I think I had to take one or two breaths, or maybe I made it without breathing between 63rd and 60th. One time I read the other side of the Daily News someone was reading and saw banner headlines, Bannister Runs Four Minute Mile!

At 46th Street is where Dick Clark comes in. I climbed down the stairs to get the bus that would take me from Market Street to Osage. At 46th and Market were the studios and offices for WFIL, the ABC local outlet. I knew it because my brother and I and best friend Arnold Bernstein had gone there on various Saturdays in the past to be in the little audiences for Pud’s Prize Party (Pud was the rotund character for Fleer’s Double Bubble Gum), and Tom Morehead’s radio kids sports show, where I was once an interviewee plucked from the audience to aver that I liked playing defense better than offense in football, which was a surprise to me as I said it, having never been asked before, but true. That was about all I said. I was probably picked for interviewing because he saw me talking loud and laughing in the audience pre-show, or because we kept coming week after week. But beyond “defense,” I don’t think I said too much, gentle as Tom was in urging me forward and filling the verbal space, but what can you do with stage fright?

But that was before I commuted. Later, in the midst of my commute, coming down from the El, I would see a snaking line outside WFIL, filled with kids from West Catholic and maybe some from West Philly, and other high schools, waiting to get into Bandstand. The “American” came later. At first it was to be hosted by Bob Horne, but when he was discovered taking girls from the show home with him – understandable but regrettable – he was replaced by squeaky-clean Dick Clark.

A friend who was another passenger in the school station wagon reciting “J. McCullough, Undertaker,” recounts how he was 27 blocks away from the 1968 Chicago Democratic Convention watching one of the most famous and influential events of the 20th century on TV, just the same as he would have been watching in Tulsa. I can say that I passed by the pimpled crowd from West Catholic, as a good private school boy heading home, in much the same fashion. I knew what I should be doing, and I got on that bus to go over to Osage Avenue and home. Bye bye Dick Clark.

OK, I have to admit, that’s not much of a brush with celebrity. But in fact I did see Dick Clark in the flesh once. We had moved out to Wynnewood and I was a senior at the great Lower Merion High. American Bandstand had guest schools for some of its shows, to leaven the West Catholic crowd, and I heard from my friend Lynn Sherr that it was our turn. She tried to organize a group of us to go down there, but actually only a few of us actually went. I was one of them. I don’t think I was one of the dancers the cameras focused on. I hope not. We were definitely out of place.

But I did see Dick Clark. As I lurked nearby, he introduced a new act, a guy named Chubby Checker (this was the era of Fats Domino, so I think the hefty Chubby was not using his real name.) Clark introduced him as a great new talent and only 18 or 19 years old or so. Then afterward I heard their private conversation.

Chubby said to him, with come distress, “I’m not 19, I’m 23!”

Clark patiently but firmly and I think pedantically explained to him, “The public likes youth!”

Chubby took it and didn’t argue back.

Right there you could see the beginnings of Clark’s later, greater career as a producer. But me, I really didn’t think about it or analyze it. I just remembered it. I was headed to college and medical school.

RIP.

Budd Shenkin

Election Time!

There is something about country club business Republicans that stinks. It is the entitled bullying, the use of money not only to keep score, but to batter someone else. First it was Bush II from the country club; now it’s Romney. What jerks.

“I’ll bet you $10,000!” What a threat. “I have $10,000 and it’s pocket change – what about you, Rick?” Nice man, no?

“I made Ted Kennedy take out a second mortgage on his house.” Is he bragging to his Bain friends, his B-School friends, or the other guys at the club bar? Enjoying inflicting pain, using money as the preferred tool. Cruel.

He uses his money to assassinate his opponents, not that they don’t deserve it. In Florida the ads were 13,000 pure negative ads by Romney to 200 against Gingrich. I can see Romney saying, “Just wipe him out.” Not that any of it was untrue, and not that Gingrich is not despicable, and I don’t know what I would have done. But I can just see Romney gloating and bragging. Bullying is his SOP.

What would he do as a President, playing these confrontational games? What kind of bullying would he engage in? He wants a very big military so no one would even dare oppose us. He’s nuts. Size isn’t the issue, Mitt. It’s being smart, not being a big, stupid, giant Empire.

What would he do domestically? Play to his own guys, the way Bush did, another country club guy at the bar. I’ve got mine, Jack, tough on you. Let’s see you guys crawl up from the bottom, he’d say. And he would pretend that that’s what he did.

He exudes a lack of compassion. He’s not at all nice. He doesn’t have a Jewish bone in his body. He’s a jerk.

Budd Shenkin

Three little observations in this informal post.

One – more anecdotes in the never-ending story of medical pricing transgressions from reasonability.

The nurses at Alta Bates Medical Center are on strike again! They will spare no efforts in their mission to bring better care to patients, as their picket signs proclaim. That has to be their motivation. The logic is inescapable: happy employees produce the best work, and how better to make them happy than to pay an average wage of $138,000, with top earners making $295,000? And in the bargain they get the extra kick of besting their eternal rivals, the physicians. That must really make them happy.

I received my billing information for visiting an ENT doctor to check on my nose bleeds after my surgery. We waited two hours (by the clock, two hours), he spent no more 10 or 15 minutes with me, stuck a fiber optic device up my nose to view it better, finding no specific lesion and a slightly deviated septum. He billed for a new patient visit at the intermediate level – absurd, as he hardly asked me anything at all and they collected no significant history – and for the procedure, which as I said, was only slightly more advanced than looking at ears through an otoscope. He billed a total of $500 and got paid $349.65. That’s a lot of money for a brief visit. I should have billed him more for the 2 hour wait.

Finally, my friend and colleague Charley Woodard told me about a patient who was referred to Alameda Hospital for a basic x-ray of an arm, I think it was. Charge - $1,400, and the insurance paid it.

Reflection on these anecdotes: there are many fancy ideas of how to fix medical costs, how to make things more efficient, etc. I hope a lot of these ideas wind up working. But the heart of it is, so many people charge too much and no one can stop them, it seems. The prime component of increasing medical costs is hospital costs, and 30% of hospital costs are nursing costs. Is anyone up to challenging the nurses? Do we need a Margaret Thatcher? Reagan put it to the air traffic controllers. Who can put it to the nurses? I love a good nurse, and I found my care excellent last August. But there is a right price for everything, and these prices I’ve cited are not the right prices.

Medicare has actually been pretty effective in going after one specialty after another – last hit was cardiology, as I understand it. The ROAD to wealth in medicine is now said to be Radiology, Ophthalmology, Anesthesiology, and Dermatology. That seems to be a pretty good agenda to me.

We need a government with guts. Sure won’t find it with Obama.


Which brings us to item number two, politics. We’re in the middle of the Iowa caucus season. The whole Republican panoply of ignorance and incompetence has been remarkable. I can only believe that the majority of those running don’t expect to win, but hope that their publicity will lead to enhanced speaking fees. What a racket.

The very ordinary Mitt Romney is not certifiably stupid or insane, and thus stands out. Most of the others will fall of their own weight; some, like Gingrich, have needed to be shot down by a healthy airing of the facts.

But what a dispiriting prospect -- the ineffectual Obama facing a fairly empty suit, Mitt Romney. The Days of the Pygmies have arrived. I believe in the economic analysis of Paul Krugman, and all the contenders are still bowing to the convention of let’s try austerity – for everyone else, that is, since all the proponents are pretty well fixed themselves. Dispiriting.


Finally, number three, the role of war in economics. Everyone talks about the causes of the economic decline as due to so many complicated things. Then they add at the end, “And fighting two wars without paying for them doesn’t help.” I’m wondering, aren’t the wars more important than a postscript? Yes, the mortgages and CDO’s and CDS’s and the housing bubble and the smothering of the middle and working classes and the Bush tax cuts and everything else, yes, they are all too true. Too true.

But isn’t war the ultimate wasting of resources? War made sense for Hitler, I was reading in “1938: Hitler’s Gamble,” by Giles MacDonogh. They kept running out of money to finance the war machine, so annexing Austria and absorbing Czechoslovakia and taking their treasuries and their factories, and taking all the assets of the Jews made sense (until they found out that they couldn’t run all those businesses they took over, and the money stopped.) The great Aaron Wildavsky said, “Never do anything for just one reason,” and the Nazis followed that advice. They wanted to get rid of the Jews because they hated them, but they also wanted their wealth. Two reasons added up to a policy.

War also made sense for the Romans, who absorbed the territory, awarded the lands to their generals and others, and reaped the taxes. War can make economic sense.

But our wars in Iraq and Afganistan? It’s pure outgo and no income. When you spend a lot of money and get nothing in return, isn’t relative impoverishment the inevitable result?

I’sn’t that what happened in the 1970’s, the time of stagflation? I forget how much the Vietnam War cost, but it was another fruitless expenditure. When you spend a lot of money and get nothing for it, aren’t you going to suffer economically?

World War II was a war of total necessity, and is praised in economics for getting us out of the Depression by pump-priming, after Roosevelt mistakenly adopted austerity in 1937. We paid wages and manufacturing costs for product that was not exchangeable (war-making), but was necessary. Everyone was amazed that the post-war period did not bring inflation, but instead sustained and orderly growth. What makes that period different from the 1970’s and the present?

I would nominate the spirit of victory, as well as and the foresightedness of the government with the GI Bill and the Marshall Plan, expenditures that would result in increased productivity. That’s what we need now, government investments in education, infrastructure, and technology, to prime the pump now and to yield increased productivity in the future. We also need severe regulation of the financial world, and measures to repair the financial health of banking and mortgaging victims. But with no spirit of victory and no confidence, retrenchment is all the country can come up with, which is bad news.

Anyway, that’s what I think. Bad wars lead to bad economics. If you win a war and get money and territory, that can work. If you win a war and gain confidence and spend money in real investment, that can work. But if you lose a war, or don’t win it, and there is no spirit of victory and no confidence that investment can yield fruit, stagnation is the result, or worse. That’s where we are.

Happy New Year!

Budd Shenkin

Quality Improvement in Medical Practice - Need for Balance

The quality improvement movement in medicine has been important and fruitful. Nonetheless, many of us have had reservations. The complaints have ranged from the indisputable fact that P4P results reported to our practices are often inaccurate, to concerns that meeting standards and reporting to authorities is often just busy work, to worries that standards often lead to teaching to the test, to the criticism that practices that treat the lower socioeconomic strata (or, practices that treat non-vaccinators) are penalized by the shortcomings of their patient bases. These are all valid. My own concern has been that with a strict emphasis on the measurable, important aspects of quality that are difficult to measure have been neglected. Let me explain.

Two Methods and Two Types of Objectives

There are two methods we can use to effect both clinical and clerical change in our offices. One could be called Systemic Re-engineering (SR); the other would be Professional Enhancement (PE).

SR builds techniques into the office environment with such devices as checklists, explicit protocols, flow sheets, questionnaires, and computerization. SR solutions are “outside the head” and relieve the clinician or staff of the burden of remembering.

PE, on the other hand, happens inside the head, as in, “Remember to….” PE is very familiar to us from our training. We are educated in basic facts, basic procedures, precepts, attitudes, etc.

Just as there are two ways to effect change, there are two types of objectives. Type one is a Quantifiable Objective (QO); the other would be Non-quantifiable Objective (NO).

A QO is generally related to a stereotypical event, such as vaccinating, or diagnosing and treating streptococcal pharyngitis. QO’s are familiar to us as P4P measurements.

An NO may be a non-stereotypical event. Pursuing a difficult diagnosis would be such an event. There is no current way to measure how a clinician pursues signs and symptoms with his or her own acumen, strategic tests, and referrals.

Other NO’s would be based on the human behavior of the clinician. Caring for patients with empathy and compassion would be such a behavior. Another would be attentiveness to a patient’s communication, and patience in eliciting information. A patient satisfaction survey is far too blunt an instrument to capture these qualities accurately, and we have no other applicable means of measurement.

Matching Methods and Objectives

The two methods and the two objectives tend to pair up, SR with QO, and PE with NO. An example of the SR-QO pair would be the stereotypic case of prescribing controllers for asthma and not relying on rescue medications excessively. The PE approach would be to bank on the attentiveness and memory of the clinician when the refill requests come in (“Remember!”). The preferred SR approach might be to institute an office procedure that forbids albuterol refills, and instead compels the staff to schedule a visit when an albuterol refill request is made, and has a flow sheet in the chart that details all prescriptions. The results of this QI effort would be clearly measurable, as we know.

A clerical example of office functioning would be keeping track of vaccine stock. One could admonish clinicians and staff to remember to bill for every vaccine given (PE – remember!), or one could institute a procedure of daily balancing of stock vs. billing sheets (SR). Clearly, for these stereotypical events, SR would be a more reliable and efficient approach resulting in higher quality and less variation.

I have two favorite examples of the PE-NO pair. The first is the issue of pursuing a difficult diagnosis. Perhaps clinical prompts in an EMR would be helpful, but in general it is difficult to think of an SR approach that would arrange a system to help and encourage a clinician to be smart and persistent in pursuing a diagnosis. Yet it is difficult to think of a more important aspect of quality care than this.

A second favorite example is improving the “caring” function. Imagine a possible SR solution: the placing of a sign on the wall reading “We Care!” Clearly, teaching and encouraging how to care for a patient, how to reduce emotional distance is something that still belongs in the realm of PE.

In both of these issues, the PE approach would seem more apt. I can’t think of any fancy and modernistic approaches, but practice conferences with case presentations and feedback (hopefully positive), and in the case of conferences on caring, the presence of professionals from outside the practice with relevant expertise (social work, psychiatry, clergy), could be of great help.

The key is for the practice as a whole to care about these issues, and to make them part of the practice culture. The fact that the effect is not quantifiable should not deter the practice from emphasizing these very important practice characteristics.

Keeping the Balance

As QI has risen in importance in recent years, QO has been emphasized and NO neglected. Perhaps this has occurred because of our scientific prejudice to pay attention only to the measurable and to distrust the impressionistic. Maybe it has happened because of a perceived need to “prove” quality to insurance companies and payers. Both are understandable.

But the imbalance is regrettable. What can be more important than pursuing difficult diagnoses? What can be more important than the caring function? Yet, because they are not easily measurable practices are not paid to excel in these functions. The measurable has pushed out the unmeasurable.

Still, although we are influenced by QI professionals and organizations, and by financial incentives, in the final analysis our practices are ours to shape. If we take steps to improve our practices in these very important but non-quantifiable aspects, we ourselves will feel the richer for it, and it is quite possible our patients will benefit from it. The key is "Not everything that counts can be counted, and not everything that can be counted counts.” (William Bruce Cameron.)

Budd Shenkin

Steve Jobs and My Credit Card Woes

I think it’s time for a few smaller blog posts. I can’t be hamstrung by trying to make every one better than the last. Even at the risk of triviality. But after all, some of my favorite writers – Dave Barry, say – dwell in that region and thrive.

So, I just read Walter Isaacson’s Steve Jobs biography, which is well worth reading, sports fans. Great story and Isaacson is in a class with David McCullough and Michael Lewis and Alan Furst– you can’t go wrong reading what they write. Steve’s wife, Laurene Powell, said he’s a great man, but great men are not great at everything. So personal relations and being nice to others weren’t his strengths.

But he was frank. There were a lot of gadgets, devices, architecture, a lot of things that he pronounced as shit. The whole music industry didn’t get it as their business went kerplunk. It took Itunes to get it right and save them, and it was an outside agency that did it, not they themselves. Sony had everything together to do an Ipod and they didn’t do it – why? Because they were divided into divisions and the divisions didn’t and couldn’t work together. So an outsider, Jobs, did it.

BTW, this invention is an example of the incorrectness of the description of innovation as “find a need and fill it.” Instead, he visited Toshiba, I think it was, and they said, we invented this 1.8 inch hard drive and we can’t figure out what to do with it. Jobs thought, I can do something with this, and brought together technology, his love of music, and his identification with the general consumer to think, Ipod. The technology advanced and he found the use for it. This is generally what happens – like the telephone, recording devices, the computer itself.

Anyway, let me be inspired by Jobs’ ready indictment of the ignorance of others. About three years ago I made a mid-year’s resolution. I was leaving my credit card behind at too many restaurants, and in my car I was pulling out of my lane without looking too often (all the time, actually). So my resolution was to stop forgetting my credit card, and to look before I pulled out.

Perspective: whenever there is improvement to be made, there are two ways to do it, personal improvement or systematic re-engineering. When I want to make an improvement at Bayside, that’s the choice I have – ask people to try to remember, or build it into the system. Sometimes one strategy is appropriate, sometimes the other. In the case of my credit care forgetfulness woes and my driving woes, since I’m just an individual, only the individual strategy is open to me – be aware, remind myself at the table and at the wheel, take the card and look first.

Jobs was in the position that he could look at a device, how much a customer needed to remember to use it, and say, This is ridiculous, and make a better, more intuitive device. In the Apple stores he realized how inefficient it was for a customer (the customer’s view!) to have to line up to pay for a purchase. Reminds me of the old Soviet stores where you lined up to look at something, lined up again to get the item, and lined up again to pay for it. So Jobs had the employees have those little devices that paid for the item right on the floor – just as in Europe as they do in restaurants.

But what do they do in restaurants here at home? Here, they take your card away, bring it back, and then they HIDE THE CARD INSIDE THE CUSTOMER’S RECEIPT! How many of us want that receipt, for God’s sake? The way they do it now, I have to prompt myself to take the hidden card out and put it in my wallet. It’s just not going to work all the time, but this is the way they keep doing it. Ridiculous. Where is Steve Jobs when I need him?

So, I’m here in Hawaii and the other night I left my card behind again – got it later, but what a pain. This is a stupid system and they’re all doing the same damn thing, hiding the card! At least I can rant and recognize that this is what Jobs was a specialist at, ranting about the idiocy of others. I’m in good company.

Oh, and one more thing – in my new car, an Infinity, there is a little light by the door that lights up when there is a car in my blind spot. All I have to do is remember to look at it. What they need is a bell that goes off when my wheels start to turn and the light is lit.

I read the Steve Jobs book, I understand the power of being right – No More Mr. Nice Guy!

Budd Shenkin

The Desert of Quality of Care in Diagnosis

The reader will remember the stirring account of my recent neurosurgical adventure. The initial part of the adventure was essentially a misdiagnosis by my ophthalmologist. Despite the facts that, one, my eyesight was clearly deteriorating, and two, the very small cataracts in each eye were unchanged -- nonetheless, my ophthalmologist sent me home with literature on cataract removal, and instructions to tell him when I was ready to have them removed. I struggled with my feeling on the one hand that something was more profoundly wrong than that, versus my respect for a doctor’s opinion on the other. Silly me. Eventually, as I exerted pressure for a better diagnosis, my pituitary macroadenoma impinging on my optic chiasm was revealed as the cause of my progressive blindness.

What I didn’t anticipate was the response of fellow physicians to this misdiagnosis. One friend, plastic surgeon Steve Daane, was outraged: “You were misdiagnosed!” My pediatrician friend Arnie Blustein noted that this is a classic case of the kind of mistake in doctor thinking described in Jerry Groopman‘s book, How Doctors Think. As Arnie said, once they get an idea what the diagnosis is, they twist logic to come to that conclusion and just hang on. In my case, the cataracts had nothing to do with my decrease in vision, and if the ophthalmologist had used his head and gotten a simple visual fields test, he would have discovered my pituitary tumor impinging on the optic nerves. But he didn’t. Funny, I had read the book but it took Arnie’s observation for me to connect my plight to Groopman’s, as recounted in the book. I guess I’m not so smart as I sometimes think I am; I’ll have to reread it.

But what’s even more interesting is the number of doctors who recounted similar incidents in their own medical care! Here is the list:

• One pediatric colleague had had GI symptoms for some months, and his doctor said, you’re just constipated. My colleague didn’t think so, but went along with the suggested remedies. He subsequently arrived in the ER with fecal obstruction. The diagnosis in the ER was constipation. My colleague objected, insisted on and pulled strings to get an MRI, and an obstructing colon cancer was found. (He is now fine, having finally gone to UCSF for treatment.)

• Another pediatric colleague, a runner, was recovering from back surgery when he took a turn for the worse. The diagnosis was that he hadn’t rested enough and was “pushing it.” He objected to the diagnosis, insisted on blood tests, and he was ultimately diagnosed with osteomyelitis at the surgical site.

• Another colleague had had nagging pain in the right buttock and leg. He was advised to get physiotherapy. He insisted on an MRI, got his internist to sign off on it, and a five pound tumor was found in his buttock.

• Just yesterday, a neonatologist colleague told me about his searing right upper quadrant abdominal pain, diagnosed by a GI specialist as a clear case of a spastic gall bladder, which should be removed at once. My colleague suggested an MRI or CT scan, which the specialist refused to order because the case was so clear-cut. My friend went back to his internist to get his wish for a study fulfilled, and the culprit turned out to be a ureteral stone just above the bladder, not a gall bladder case at all.

What to make of these cases? An anecdote is just that, an anecdote, and even multiple anecdotes do not rise to the status of data. But while they don't prove anything, I think these anecdotes really do illuminate a probable truth. I think it i probably true that diagnostic medicine as commonly practiced has a very high rate of errors. This is a sobering thought, but probably true. It’s what my father told me long ago; as a community based neurosurgeon he saw a lot of how medicine is practiced, and it didn’t inspire confidence. His counsel to me was to be very careful whom I chose to be my doctor.

All these anecdotes concern doctors as patients. It’s possible that doctors get worse care than do ordinary patients. Treating physicians might be more nervous with a doctor as a patient, and they might not treat their doctor-patients as they do other patients and leave things out, try extra hard to appear confident, etc. But I think it is more probable that doctors are more alert to physician mistakes than are lay people. We just know more about what goes on, just as a general can tell a bad battle plan and bad commander reactions to enemy actions better than an architect can. I think that there is a lot of this bad diagnostic medicine practiced all the time and everywhere, but doctors get away with it.


From another point of view, it's amazing that such a poor diagnostic landscape exists. After all, there is a very active movement in medical care to measure quality of care. I won’t recount the history here, because it is long and complex. But the amazing thing is this – none of these adventures in misdiagnosis would be caught and cited by any current effort to measure quality of care!!! (That’s right, three exclamation points. After all, what could be more important than these misdiagnoses, and yet they are off the radar screen, by design! OK, now I’m down to one exclamation point.)

In outpatient medicine, it is very hard to measure quality of care, or even to define it. The most recent quality movement has been P4P, or Pay For Performance. P4P uses data from billings – the ease of data acquisition in P4P is its biggest selling point – and assesses to what extent regular, stereotypical procedures have been carried out. For instance – immunizations. There is a regular schedule for giving immunizations to children, and each shot should be billed for. Thus, a quality indicator for a practice is, what percentage of patients in a practice have gotten all the required shots by age 2? Or, another example, in a patient hospitalized for a heart attack, what percentage of patients had a beta-blocker prescribed by the time of discharge? Again, the ideal percentage would be 100%, so the rating is unambiguous. These are stereotypic procedures that should be done for every patient of that age or with that diagnosis, every time.

In the case of my ophthalmologist, a regular, stereotypic procedure would be, does the practice measure intraocular pressure every year, to detect glaucoma? I assure you, in this practice, they measure 100% on this; I have never been there without my intraocular pressure being measured.

But how could there be a method for detecting the timely (let alone early) diagnosis of my problem? How could the diagnostic acumen of the doctors in thes other cases of misdiagnosis recounted above, be assessed? Actually, I can think of several ways, but each would be difficult, expensive, and not possible in the typical small office. Quality assessment is really hard to do.

But, I do have a proposal. It goes against the grain of current quality assurance or quality improvement programs, because it is not quantitative – quantitation has infected medicine worse than MRSA has. You just can’t mention anything in quality assessment until somebody’s left brain kicks in, and someone pipes up as though they had a personal connection to the scientific Taliban, “How can you measure that exactly?” As though they were the smartest ones in the room. Drives me nuts.

Anyway, right now practices get paid extra (actually, their withhold of payment is restored, but that’s not the way the insurer’s portray it) if they meet the quantitative measure of keeping enough patients fully immunized. My proposal is this: the practices should be paid if they can show that they regularly review diagnostic problems within their practices and discuss them with each other.

The scientific measurement Taliban will reject this as “inexact,” but still, what gets talked about and what gets paid gets the attention, and the more we ignore diagnostic prowess the worse it will get. So I say, tell the practices they should have these procedures of diagnostic review, set some criteria for them and pay the practices that set such a review up.

There is a legal problem that would have to be solved for this proposal to work. In the hospital a quality committee’s deliberations are legally non-discoverable. This confidentiality allows true quality work to proceed, for obvious reasons. Without that protection, the quality committee’s work would be adversarial from the start and no one would agree to staff it. The diagnostic quality review committee in outpatient care would need similar legal protection.

So, in summary, I think diagnostic accuracy in community medical care probably is sorely deficient. If my colleagues and I can’t get it, you probably can’t get it, either. Caveat emptor – get that second and third opinion whenever you feel uneasy. And second, I propose that the quality movement change its focus from being exclusively on the repetitive, stereotypic, quantifiable procedures, and start to focus more on the harder to measure but ultimately at least as important area of accuracy of diagnosis.

Note to insurance company – I am available as a consultant, as I am not currently otherwise occupied occupying Oakland.

Budd Shenkin

Bookstores, The Kindle, and a Solution to a Moral Hazard

My wife is a bookstore junky. We’ll be walking along, or even driving along, and she will spot a bookstore and head for it. Even in the shoppers’ paradise of the Dubai Mall, the main attraction was a great bookstore. She even has destination bookstores at various locations – it used to be the Thunderbird in Carmel, that bookstore near the Metropolitan Museum on Madison in NYC we were in earlier this week, and is it Smith’s in London? And I have to admit, I’m right there with her – she’ll be on her feet more, but I’ll settle into a chair and read a likely candidate for purchase.

There is really nothing like a bookstore. The best stores display books they recommend that you might otherwise not notice, each has its own personality, and you can look the book through in your own way to see if it’s for you. Plus there is the group experience as other book lovers mill about.

So, you want to support bookstores and buy the books you find there, and not run home and order the book you found from Amazon at a cheaper price, often substantially cheaper. You want to discipline yourself to buy the book there where you find it, and keep those stores in existence. Which we do.

But now the Kindle has made it harder. Not only is the book substantially less expensive on the Kindle, sometimes you don’t want the physical book, you want it on the Kindle. I love reading on the Kindle, even though I enjoy the look and feel of real books, the memory of book covers, and the ability to scan back in a way that is better than on the Kindle. But for me somehow I read the Kindle faster and easier, and it travels very, very well. So, there you are in the store, you have found a book you want, but you want it on the Kindle. It’s a harder choice than it has ever been.

Plus, there are probably people less scrupulous than we are, who make it a regular practice to shop actual and buy virtual. They can rationalize that they are pressed for cash, they can make other rationalizations, but the moral hazard still exists.

I don’t know how widespread this problem is, or if anyone knows how widespread it is, but if it is widespread, I have a solution. Here it is:

HAVE AN AMAZON CONNECTED COMPUTER IN EACH BOOKSTORE. IF A CUSTOMER CHOOSES TO ORDER THE BOOK ON THAT COMPUTER RATHER THAN BUY IT DIRECTLY FROM THE BOOKSTORE, THEN SPLIT THE PROFIT BETWEEN AMAZON AND THE BOOKSTORE.

I don’t know how the numbers would work. Would people do it? Would they order right there in the bookstore? Would too many people be tempted to buy it on Amazon, when without this connection in the store they would just have pIcked it up at the store and the store would have enjoyed the whole profit themselves? Would this be an attractive proposition for Amazon?

I don’t know the answers. But I do think it would help me out of my moral dilemma. I see the book, I want it on my Kindle, and what am I going to do? I sure would like to give each of them some profit, and have that book the way I want it.

Budd Shenkin