Monday, March 24, 2008

Interviews - Surprises and Challenges to Conventional Wisdom

I have published about 500 interviews. They never cease to surprise. Last week, I recorded six of them. Here I share with you a few interviewees’ surprising and challenging thoughts. The thoughts don’t always reflect conventional wisdom. They may even strike you as irreverent.

1. Doctors have little to do with outcomes - Pay for performance will likely fizzle because doctors don’t usually determine outcomes. Patients do. A population’s health depends 10% of medical care, 20% on environment, 20% on genetics, and 50% on life style. The key to boosting outcomes is changing patient lifestyles. As every doctor knows, changing patients’ lifestyle daunts, often discourages doctors. Once patients leave the office or hospital, they tend do what they used to do.

2. Primary care doctors don’t need to compete- Hospital systems, high tech specialists, health plans, drug companies, device makers compete, but primary care doctors rarely do. The demand for their services is so great, their supply so limited, that there are more than enough patients to go around. Why compete? You have enough to do, and you don’t have to worry about where the next patient is coming from.

3. Technology doesn’t replace doctors, it spawns demand - Experts say technology will ease doctor shortages. It will cause consumers to treat themselves, to patronize nurse practitioners or physician assistants, or even to replace doctors with sophisticated algorithms. These things rarely happen. Internet websites drive consumers to see doctors for second opinions, to seek the latest technologies offered by doctors, and sets off chains of diagnostic events such as MRIs or CT scans and visits to multiple specialists, if, for not other reason, to assuage lawyers.

4. America has a doctor shortage with no coherent plan to produce more - We’re now 50,000 doctors short, and we have no rational national plan to produce more. The answer isn’t new medical schools, larger enrollments, more primary care doctors, more foreign-trained doctors, but Congress lifting the cap on funding for more residencies. That’s where trained doctors are who are nearly ready to enter practice, yet we’re not filling these slots, so we don’t have enough doctors in the clinical trenches or in the neighborhoods.

5. The gender factor – 50% of medical students now women – will influence doctor supply estimates. Because of their dual roles, women doctors are likely to be salaried, to take maternity leave, to work shorter hours, and to retire earlier because their spouses are usually professionals and they can afford to. These choices are inevitable and understandable, and have nothing to do with quality of care delivered. The choices simply mean we must take gender into account when calculating the number of doctors needed to meet an aging population’s demands.

6. Consumer-driven care allows people to make mistakes and to learn from those mistakes - In federal and private bureaucracies, paternalistic attitudes reign. Bureaucrats believe they possess superior wisdom and are smarter than patients, who need to be protected from bad decisions and greedy caregivers. In a consumer-driven system, attitudes differ. Intelligent informed consumers will make mistakes, but they will learn. Markets, in other words, have their own wisdom, and it generally surpasses the wisdom of bureaucrats and technocrats.

7. EMRs will not lead to “paperless” offices - Paper will not disappear. It will proliferate, as doctors download more, keep permanent records of evanescent cyber documents, process paper from others, and preserve a more secure l private corner of their universe. Most of the outside health care world still deals in paper, and that paper never seems to go away. And remember, the Canadian and American pulp industries thought computers would be their ruination. Instead, with downloading of Internet documents, the pulp industries are booming as people download to keep something of permanence. Paper is more real than what one sees on the screen. Unintended consequences strike again.

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