Physician Morale at All Time Low

 

September 27, 2012 -  This article is from Healthleadersmedia.com, a respected website directed mostly at hospital leaders, but at leaders of other health sector leaders as well. If the material sounds familiar,  it may because you read my September 24 post , which was also based on an interview with Walker Ray, MD, health of the research committee for the Physicians Foundation.

6 in 10 Physicians Would Quit Today

John Commins, for HealthLeaders Media, September 26, 2012

Doctors are working less, seeing fewer patients, and many would quit if they could, a sweeping survey of 13,575 physicians from across the nation shows.

The survey, A Survey of America's Physicians: Practice Patterns and Perspectives, was commissioned by The Physicians Foundation. It is the latest, and perhaps the largest and most comprehensive of a number of surveys that have identified wide, deep and increasing discontent among the nation's physicians regardless of their age, gender, specialty, location, or employment status.

"It is downbeat and it is a concern. What we are documenting here is a trend and the trend is pretty solid," Walker Ray, MD, vice president of the nonprofit foundation, told HealthLeaders Media.

"Physicians feel powerless. They don't feel like their voices are being heard. They don't feel like they were heard on the run up to healthcare reform and they don't feel like they're being heard now."

"The problem to summarize it is there is an imparative now for physicians to care for more patients, to provide higher perceived quality at less cost with increased tracking and reporting demands in an environment of high liability and problematic reimbursements," he says.

Physicians report working about 6% less than they did in a 2008 foundation survey. "That doesn't sound like a whole lot until you calculate the full-time equivalent physicians who are lost from the workforce," Walker says.

"If this trend continues that would be 44,250 full-time equivalents lost from the physician workforce over the next four years and there is every reason to think that this will occur."

The survey shows that 52% of physicians have already limited the access of Medicare patients to their practices or are planning to do so and 26% have already closed their practices to Medicaid patients, blaming higher operating costs, time pressures and falling reimbursements.

One hundred thousand physicians will transition to employees over the next four years, and more than 50% of physicians will cut back on patients seen, will switch to part-time, switch to concierge medicine, retire, or take other steps that will result in about 91 million fewer patient encounters, the survey shows.

Walker says that 75% of physicians don't believe that the migration to employment is a positive trend. That includes 62% of employed physicians who consider it a negative. Those physicians who are opting for employment are doing so, he says, for economic security and relief from "an extreme regulatory environment."

"Physicians think of themselves as being autonomous in making decisions in the patient's best interest, but employed physicians have to have one ear open to what their employer is saying. Otherwise they put their jobs in jeopardy," he says.

Most physicians just want out.

"We found that 60% said they would retire today if given the opportunity. What was worrisome is that this is up from 45% in 2008," Walker says. "We also know from the survey that we disaggregated it into certain categories, 47% of physicians under 40 said they would retire today if given the opportunity."

Walker acknowledges that some physicians could be speaking out of frustration and that they do not intend to leave practice. "But even if only a small percentage follow through on any of that it could be worrisome to the workforce," he says.

"We have 75 million Baby Boomers transitioning to Medicare starting last year over the next 12 or so years. We have a growing population. We have 32 million people who may be gaining health insurance and yet we have the same number of doctors. We have a bottle neck for training. We are training 25,000 or so doctors a year and the fact that we are finally building some new medical schools is not going to increase the doctor supply because the residency level is fixed at 25,000 or 26,000 positions."

The online survey was conducted from late March to early June by Merritt Hawkins with an overall margin of error of less than 1%. Phil Miller, vice president of communications at Merritt Hawkins, says physicians are caught amid crosscurrents in healthcare delivery and it's proven challenging to find incentives that work for everyone.

"We have a doctor shortage, so we want doctors to stay busy and be productive and see a lot of patients. But you are rewarding them with a salary which they know they are going to get regardless of how many patients they see. So you try to build in incentives that will keep them focused on volume," Miller says.

We have a doctor shortage, so we want doctors to stay busy and be productive and see a lot of patients. But you are rewarding them with a salary which they know they are going to get regardless of how many patients they see. So you try to build in incentives that will keep them focused on volume," Miller says.

"At the same time, you have this crosscurrent that says 'let's not reward them for volume. Let's reward them for quality and patient satisfaction and these subjective metrics.' So we have two trends working at cross purposes and at the end of the day the doctors are going to take the salary. They may achieve some of their production bonuses, but it is going to be more of a nine-to-five, do-your-job-and-go-home-type of profession," Miller says.

Walker says the issues that zap physicians' enthusiasm run deep. "We have to improve the medical practice environment and the things physicians are most concerned about are autonomy, regulatory issues, liability issues, and reimbursements," he says. "We've got to fix some of those things to keep the workforce together because we not only want to train more physicians, we want to retain more in their practices and that is not happening now."

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John Commins is an editor with HealthLeaders Media.

Notable and Quotable:  Obamacare and Innovation

"Even in advance of the path now underway with the 2010 PPACA legislation, the U.S. health care system was already among the most regulated industries in the nation, adding hundreds of billions of dollar per year on the backs of America’s taxpayers.  Meanwhile, entrepreneurs in the health care sector are beginning to understand that enormously bloated regulations and government intrusion by the FDA are even now hindering research and development and creating untenable delays and costs to product development. Innovation, the core to the advancement of health care, is at far greater risk under the PPACA with its new regulatory bodies, its new taxes on entrepreneurs and the very industries responsible for medical innovation, and its top-down shift away from specialty care toward less sophisticated primary care."

"But the true costs will ultimately be borne by Americans, Costs to patients and their families including delays in access to innovative medical technology that is safer and more effective, higher costs of new technology passed  on to consumers, and limits and delay in gains in life expectancy and quality of life improvements are all inevitable. Stifling innovation by the PPACA will dramatically impact American entrepreneurs, doctors, investors, and companies as well.  Economic effects to this $80 billion American industry will be profound.  High-way, high-skill jobs will be lost from the medial technology insure that employs 357,000 Americans, and every med-tech job means up to more than 3.5 additional jobs in the overall economy, spending on the state. Inevitably, the spiral of higher health care cost due to government intrusion will invite even more government creations, so that potential reduction in health care costs from innovation will never see the light of day."

From In Excellent Health: Setting the Record Straight on America’s Health Care (Hoover Institution Press, 2011), by Scott W. Atlas, MD, Professor of Radiology, Stanford University Medical Center

 Tweet:  Government intrusion intrusion into health system will result in less innovation and higher costs,

Book Review: Scott W. Atlas, MD,  In Excellent Health: Setting the Record Straight on America's Health Care, Hoover Institution Press, 2011, 359 pages, hardcover, $26

To my father, who often joked, “My mind’s made ‘s made up, don’t confuse me with facts.

Dedication by Scott Atlas, MD,  Author of In Excellent Health,  Hoover University Press, 2011

September 25, 2012 -  This is a must read for defenders of the U.S. health system.  As such, it is rare. Most books on health reform attack the U.S. as too costly with poor results compared to other developed Western nations with nationalized universal coverage.  

The author, a professor of radiology at Stanford and head of the Neuroradiology Department at Stanford,  begins his book with this anecdote.

In the summer of 2007, he attended a dinner party with six adults.  All had  undergraduate degrees from prestigious undergraduate university as well as postgraduate degrees from Princeton, the University of Chicago and Stanford. 

Four had MD degrees, one held a PhD in molecular biology, and another had a master degree in Public Health.  Four  were practicing physicians. All agreed with the thesis of  Michael  Moore’s film  Sicko!. Moore argued the U.S. health system was inferior to that of Cuba and other socialist and communist nations.  None of the party-goers had seen the film. They took  for granted Moore  spoke some Great Truth, that the American’s capitalist, market-driven,  greed-based system, was inferior to government-directed systems.

The discussion shocked Dr. Atlas and his wife, who had seen the Moore film, and Atlas  decided to write this fact-based book as a counter to  blind liberal bias.

His first chapter is a critical appraisal of the 2000 WHO ranking of health systems, which placed the U.S. as 37^th among nations in its health system.  He systematically demolishes the study as deeply flawed, agenda-driven, and subjective without basis in fact, unrelated to actual health system quality.

The WHO ranking served as the pretext for Obamacare, which said, in essence, that the U.S.spends twice as much on health care as any other nations, achieves less in terms of longevity and infant mortality, and is unfair.

In subsequent chapters – limited vale of live expectancy comparisons,  limits of infant mortality at indicator of heath care, measures of medical quality, Americans' access  to health care,  the important of specialists and medical innovation, and solutions to maintaining excellence of the American sysem , Doctor Atlas demolishes the argument the U.S. has an inferior system.

Atlas  points out,  for example,  that health statistics on longevity and infant mortality are flawed and are based on a  nation’s culture and  individual behavior of its citizens.  if one takes into consideration such factors as obesity and smoking, which are beyond the control of the health system;  if one eliminates murders and automobile deaths from  the statistics, the U.S. ranks number one in longevity. 

Furthemore, if one considers waits for treatment, access to doctors,  number of Nobel Prize winners,  and superior results in cancer outcomes,  joint replacement, hypertension, heart disease, diabetes, we are the world’s best.  

Atlas backs up these facts with numerous bar graphs and tables to buttress his argument that the U.S. has the best health systems in the world with the best results. Atlas ends his book with his suggestions for health reform – increased competition in insurance and health care markets, consumer-drive cae,  value-based purchasing, and minimal government intervention.

Tweet:  Scott Atlas’ book In Excellent Health :Setting the Record Straight on America’s Health Care, says that America has an exceptional  health system compared to other nations.

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Physicians Foundation Survey of 630,000 Physicians: Morale, Practice Patterns, Career Plans, Perspectives, and Aggregation by Age, Gender, Primary Care/Specialists, and Practice Ownership/Employment – Interview with Walker Ray, MD, Chair, Research Committee, Physicians Foundation

September 24, 2012-  This interview is important because it addresses a fundamental question: Who shall care for the sick once the forces for reform are spent?

Interview

Reece: Good morning, Dr. Ray.

Ray: Good morning. I appreciate the opportunity to speak with you.

Background

Reece: What is the Physicians Foundation, and what is your position within that Foundation?

Ray: The Physicians Foundation is a nonprofit 501/C3 Organization. As a non-lobbying organization, we do not lobby. We do our work through policy statements, research, and surveys to advance the work of practicing physicians to help facilitate the delivery  of health care. Part of our mission is to strengthen the physician-patient relationship and to help physicians sustain their practices in a difficult medical environment. The P.F. is  committed to demonstrating the link between a dedicated robust physician workforce and patient access to the highest quality of medical care.

I serve as Vice-President of the Physicians Foundation and as Chairman of the Research Committee from which this survey originated.

The Survey

Reece: This survey is a 127 page document. It is the most comprehensive examination of physicians’ mindsets ever undertaken. The purpose of this interview is to humanize, summarize, and highlight what is said in the document. Give us a little background how this survey evolved.

Ray: There is a tremendous amount of data in this survey. It will be our job here to bring its contents out in such a way as the public, policy makers, pundits, and politicians can understand. Our Foundation has representatives from 20 states and county medical societies.

We represent blue states, red states, states from New York, New Jersey, Vermont, Connecticut, New Hampshire, Southern states – Georgia, North Carolina, South Carolina,  Tennessee and Florida  and Western states, such as Texas,  Nebraska, Colorado, California, Washington State, Alaska, Hawaii.

We are non-partisan. But we have known for quite a while there is a great deal  of discontent and disaffection among physicians with the medical practice environment. The trend is growing stronger, and it has alarmed us how this has impacted  access to care. We needed data. We did our first survey in collaboration with the Merritt Hawkins organization in 2008. We did another comprehensive survey in 2010. This 2012 survey is our third in collaboration with Merritt Hawkins.

Physicians at Vortex of System

Reece: As you know, physicians are at the vortex of the health system. They diagnose patients, admit them to the hospital, order tests, perform procedures and supervise treatments. Without them, there would be no system. They are there when Americans enter this world, and they are there when Americans depart from it. To me, this is the most extensive documentation of how doctors feel about reform and how they are reacting to it. What are the highlights and general tone of this survey? And what about its accuracy and validity?

Survey Data: Extent, Accuracy, and Validity

Ray: That’s tough to answer. This survey is replete with data. There are over a million data points from 47 questions within the survey. Many of these questions call for multiple responses. There are also 8000 written comments by physicians.

We are very careful to make sure this survey was representative of all physicians. We contacted a PhD statistician at the University of Tennessee business school, Chad Autry, who is an expert on survey validation. We talked to him before we did the survey and discussed  how to bring a high level of confidence to our survey. After the survey we asked him to validate and estimate the reliability of the data. He said the margin of error was .99, indicating a tremendous degree of reliability for a survey as comprehensive as this one. The survey drew 13,575 responses among 630,000 physicians representing 80% of all practicing physicians. The validity and trustworthiness was at the 99% confidence level.

Morale of Physicians

Reece: Could you comment on the general morale of physicians? I detect a sense of powerlessness and helplessness among doctors of where things are going and whether they have any influence over the direction of reform.

Ray: That is entirely correct. From this survey, we know physicians are suffering from low morale and disaffection with the practice of medicine. Reluctantly, they are making plans individually and independently to make changes in their practice arrangements that may likely lead to limited access to care.

For instance, we asked physicians what the morale is among other physicians whom they know. Eighty percent said it was low or very low. 20% said it was good. We asked physicians about their own morale, and 62% said their own morale was low. We found this in other surveys; physicians are more candid about their colleagues than themselves. We found 77% of physicians were pessimistic about the future of the medical profession. Only 3.1% answered that question as being”very positive.” We found 84% agreed with  the statement;“The medical profession is in decline.”

Other Alarming Metrics

There are other metrics that were worrisome. Almost 60% would not recommend medicine as a career to young people or their children; 34% would not choose to go into medicine again, up from 27% who answered that question in 2008. Physicians are working 6% fewer hours, which means if this  pattern  continues for another 4 years, 44,250 FTEs will be lost from the physician workplace.  Sixteen percent of physicians are seeing fewer patients than in 2008, which would portend 100 million fewer patient visits than in 2008. Physicians spend 22% of their time on non-clinical paperwork – a huge distraction of time from direct patient care. Because of this and other factors, 60% of physicians would retire today if given the opportunity. That’s up from 45% in 2008. What’s worrisome here is that 47% of physicians under 40 years of age say they would retire, if given the opportunity.

Changes in Practice Patterns

Reece: What changes do physicians plan to make in their practices in the next 3 years?

Ray: Half of the physicians said they would continue to practice as they are. The other 50% plan to make these changes: 22% plan to work part time; 13% plan to retire; 10% plan to work fewer hours; 6% to 8% plan to do locum tenens; 6% to 8% plan to do concierge medicine; 5% plan to close their practices to new patients; and almost 10% plan to seek a job within healthcare not related to clinical practice. The thing that is disturbing is that all of these different choices indicate a decline of the medical workforce at a time when physicians are already in short supply. This will result in less access of patients to physicians.

Reece: A prominent concern among physicians is usefulness, expense, and privacy of electronic health records. Did you address EHRs in your survey?

Ray: We did. We asked physicians if they were using EHRs, and, surprisingly, 70% of physicians are. We asked if they had any concerns about privacy. Forty seven percent said they had concerns about privacy. Of the 70% now using EHRs, we asked: How are you doing with these electronic records? Are EHRs lowering costs and improving quality? At this point, physicians said they did not know enough on costs, but on quality, their impressions were split.  About half said they thought EHRs had improved quality, and about half said no, EHRs weren’t worth the effort, or they were too difficult and cumbersome to use.

Impending Crisis

Reece: I foresee a political crisis evolving by 2015. If 30 million new Medicaid recipients become insured in 2014 as envisioned by the health law, and as aging baby boomers enter the Medicare rolls at the rate of 10,000 a day, a process which began in 2011, the factors you mentioned will exacerbate the physician shortage. What’s going to happen when all of these patients go out there and can’t find a doctor?

Closing Practices to Medicaid and Medicare Patients

Ray: You are correct. These are very disturbing issues. I can give you more data to back up what you’re saying. Physicians are closing their practices to Medicaid and Medicare recipients more so than in the past. In 2012, 35% of doctors have closed their practice to either Medicare or Medicaid patients. This is up from 24% in 2008. Physicians are doing this not because they want to discriminate against any type of patient but because low reimbursement threatens the very financial viability of their practices.

That’s not the only issue. There is also a demand for physicians to deliver higher perceived quality at less cost with increased reporting and tracking requirements. This is occurring in an environment with higher potential legal liability and declining  reimbursement. The result is that physicians are opting out of medicine and especially out of private practice.

Organizational Transformation – ACOs and Medical Homes

Reece: Part of the health law are initiatives to create an organizational transformation of doctors into accountable care organizations and into medical homes. What is the physicians’ reaction to these federal initiatives?

Ray: As you are aware, the Affordable Care Act puts a large premium on doctors joining Accountable Care organizations (ACOs). ACOs will force physicians to rethink their practices. ACOs  require them to join larger groups more closely aligned with hospitals, to take on financial risks and  to improve quality. This is quite an upheaval.

Medical homes will also require fundamental practice restructuring. They oblige physicians to aggressively pursue health information technology, may engender higher staffing costs, and involve difficult to implement treatment protocols. Many of the standards  physicians will be evaluated and compensated for  will be subjective and beyond physicians’ control.

We asked physicians if they thought ACOs would increase quality and decrease costs. Only 9% said yes, 62% said no and 28% said they really were not  sure of the purpose and the structure. We asked similar questions about Medical Homes. Only 24% of physicians said yes, 34% to 37% said it would not, and 37% to 38% said they weren’t sure about the purpose and structure of Medical Homes.

These two entities are the thrust of health care reform to change the delivery system to decrease costs and increase quality. The pessimistic physician response makes one wonder if these two new organizations can deliver on what they promise.

Differences Between Physician Types

Reece: What is the difference in mindsets between younger physicians, women physicians, and employed physicians and the traditional older independent predominately male physicians?

Ray: Younger physicians answer the survey in slightly different ways than older physicians, but the direction in which they are thinking is the same. Younger physicians are slightly more optimistic by 2% to 3% about the effectiveness of ACOs. Whether physicians are younger or older, male or female, independent or employed, they generally have the same point of view.

Hospital Employment

Reece: Merritt Hawkins has estimated that within the next decade, hospitals will employ 75% of doctors, up from 50% now. What are the implications of this trend?

Ray: This employment data comes from multiple sources, one of which is Accenture,  which tracks employment of physicians. A decade ago 60% of physicians were independent; By 2013, only 33% will be in independent practice. So there is a huge migration towards employed physicians. In our survey, we asked physicians: Is hospital employment a positive trend that will increase quality and decrease costs? Seventy five percent of physicians disagree this was a positive trend while 25% agreed. Younger physicians and female physicians were slightly more positive; about 68%  disagreed.

About 3/4s of all physicians, regardless of age, gender, or employment, agreed hospital employment is not a positive trend. Only 11% of private practice owners thought this was  a positive development; 88.9% thought it was negative. What about employed physicians? Some  62%  felt it was not a positive thing. Physicians who are becoming employed seek economic security and relief from regulatory, business, and malpractice pressures. We also asked if hospital employment would erode the physician patient relationship, and 72% said yes, while  22% said no.

Reece: Other concerns are that hospital employment will increase physician fees, create potential monopolies, and lead to anti-trust suits.

Ray: That’s true. Even if hospital employment doesn’t become an anti-trust issue, it becomes a market force because hospitals  can negotiate higher rates if they employ large numbers of physicians. When physicians become an employee, they may feel obligated to please their employer or risk jeopardizing their  position. Most physicians want to do the right thing for patients regardless of payer or employer Doing the right thing at the right time may be compromised.

Doctor Ray’s View of the Future

Reece: In your career you’ve been a pediatrician in a group, you’ve been a solo pediatrician, and you’ve been active in the medical association in Georgia and at the national level. Where do you think the health system is headed? Are you optimistic?

Ray: I share the opinion of the physicians in this survey. One , when asked if the profession was in decline, 84% agreed.  Only 16% disagreed.  All demographic groups in this survey agree – young, old, male, female, hospital employees, independents. Two, there has been an erosion of physician autonomy. Three, there has been a marked decline in reimbursement. Four, there has been a spike in regulatory responsibilities and liability. All of these things have escalated after passage of the health reform law.

I also agree with physicians who say they are unsure where  we will be or how we will fit in three years.  Ninety-two percent  of physicians in this survey agreed with that statement. Only 2.7% strongly disagreed. There is tremendous uncertainty, and uncertainty always invites anxiety and lack of confidence.

The Physicians Foundation desires a vibrant,  dedicated, confident, energetic and  enthusiastic workforce. There is a connection between this type of workforce, quality  and satisfaction with access to care. Negative trends are now clearly documented and predictable. We know this from this and previous surveys. We are headed towards a significant problem with access to care. We want patients to receive the right care at the right time from the right professional. This ideal situation is in jeopardy.

Reece: People who read this interview can have access to the entire 127 page survey by going to the physiciansfoundation.org website. The survey is open to the public, policy makers, pundits, and, of course, physicians.

Ray: This survey is about more than physicians grumbling. This is about the future of health care and access to care. Physicians are patients too . We are concerned about the care for our families, which we fear may be deteriorating.

Reece: Thank you, Dr. Ray, for this conversation and your insights.

Tweet:   A survey of 630,000 physicians indiates   physicians suffer from low morale secondary to health reform, and 6 of 10 would quit practice if given the opportunity.

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Doctor Richard L. Reece is a retired pathologist and frequent health care commentator. He is the author of 11 books on health reform. The latest three are Innovation-Driven Health Care (2007), Obama, Doctors, and Health Reform (2009), and The Health Reform Maze (2011). Doctor Reece blogs at Medinnovation blog, where he has composed 2475 blogs over the last six years. He welcomes comments on his blogs.

Hospital and Airplane Safety: The Problem with The Death-Rate Metaphor

Medical errors kill enough people to fill four jumbo jets a week.

Marty Makary, MD, born 1976,   Johns Hopkins surgeon , in “How to Stop Hospitals from Killing Us, “ Wall Street Journal, September 22-23. Wall Street Journal

When you use metaphor, do not mix it up. That is, don’t start by calling something a swordfish and end by calling it an hourglass/

E.B. White (1899-1985), Elements of Style (1959)

September 23, 2012 -  To hear hospital safety critics tell it, the health system is out to kill us.  If only, say critics, the health industry would adopt the practices of the airplane industry, and only if patients were encouraged to report mistakes, killings would decline.

To a limited extent, I am sympathetic with these points of view, as expressed as follows.

·         Donald Berwick, MD (born 1946), administrator of CMS form Jlu 7, 2010 to December 2, 2011), when president of the Institute of Healthcare Improvement, in 2007 launched a campaign “Saving 100,000 Lives”, with these specific suggestions.

1.      Deploying rapid response teams at first sign of patient decline. 

2.      Delivering evidence-based measures to save patients with acute myocardial infarction.

3.      Preventing adverse-drug reactions.

4.      Preventing central-line infections.

5.      Preventing surgical-site infection with correct peri-operative antibiotics.

6.      Preventing ventilator-site infections.

 

·         Marty Makary, MD, Johns Hopkins surgeon, writes in his new book, Unaccountable; What Hospitals Won’t Tell and How Transparency Can Revolutionize Health Care (Bloomsbury Press, Press, 2012), that we could reduce hospital deaths and medical mistakes if every hospital:    

1.      Had an “information dashboard” that would include rates of infection, number of readmissions, surgical complications, number of procedures performed, and lists of patient satisfaction complaints;

2.      Published surveys of comments by doctors nurses, technicians, and other hospital employees about the safety environment of their hospitals;

3.      Installed cameras at hand-washing stations and other critical safety places and made videos available to patients about procedures they are about to have or have undergone;

4.      Made doctor notes “open,” i.e. immediately available , when patients are being interviewed or online to improve compliance with safety standards;

5.      Promoted and encouraged open dialoguew abut medical mistakes with “no more gagging” of doctors, nurses, and others to coer up mistakes.

·         The Obama administration is field-testing a new reporting system encourage patients to report medical mistakes and unsafe practices by medical providers.   As part of this system, patients reporting “mistakes” would answer these queries if a mistake is perceived to have been made.

Patients would report a caregiver did not:

1)      Communicate well with the patient or the patient’s family; 

2)      Didn‘t respect the patient’s race, language, or culture;

3)      didn’t care about the patient;

4)      was too busy;

5)      didn’t spend enough time with the patient;

6)      failed to work with other caregivers; 

7)      were not aware of care received elsewhere.

I find these questions subject, open to various interpretations, and an open invitation to make easier the work of malpractice lawyers.

My Chief Complaint

My chief complatint here is not that various approaches lack value, but tht critics overuse the hospital-death airplane crash and doctor vs. pilots metaphor.

Hospital caregivers and airline pilots are not the same breed of cat, nor are they faced with similar situations.

1.      Hospital employees are for sick, often frail patiens, suffering from often chronic or terminal illnesses, while pilots are carrying a plan laod of motly healthy younger people.

2.      Doctors and other hospital personnel are caring for one patient at a time with complicated individual problems; pilots are responsible for a plane load of 100 to 300 passengers with a simple generic goal- reaching their destination.

3.      Circumstance surrounding individual patients are broad and multifaceted  while passangers tend to have a much narrower set of problems -  luggage, meal and beverage offerings, and troublesome seatmates.

I don't  quibble or question systematic organization teamwork approaches to decreasing hospital death rate, or to making patients aware of or reporting medical mistakes. These approaches are needed, and many are overdue.

Tweet: The Metaphor comparing hospital death rates to preventing death from airline crashes and doctors to pilots is over-used and may not be analogous.

Sources

1.      Marty Makary, MD, “How to Stop Hospitals from Killing Us, “ Wall Street Journal, September 22-23, 2012

 

1.      Robert Pear, “A New System for Patients  to Report Medical Mistakes,’ New York Times, September 23, 2012.

 

Revenge of EHR Nerds

Being a nerd really pays off sometimes.

Ken Jennings (born 1974), computer scientist and holder of longest consecutive wins on  Jeopardy show

September 22, 2012 – It wasn’t supposed to be this way.  Electronic health records (EHRs) were supposed to lower costs by helping document what hospitals and doctors do.   But, alas, according to today’s New York Times,  EHRs do the opposite (Reed Abelson, et al, “Medical Bills Rise as Hospitals Turn Electronic," September 22, 2012). Says the Times, “The move to electronic health records may be adding billions of dollars by enabling hospitals and physicians to bill more by providing the same services.”

How could this be?   How could hospitals be paid to install EHRs be showing a 47% rise in Medicare charges from 2006 to 2010?  How could 1700 doctors with EHRs cost Medicare $100 million more, especially when those practitioners  are family doctors,  general internists, and emergency room physicians?  These doctors, after all, are generally on the lower end of the payment scale for physicians.

Let me tell you how.   Medicare payment codes  are generally lowest for evaluation in office visits.   For years, Medicare has ratcheted down office visit codes,  so much so that the doctor is forced to see a patient every 7 to 10 minutes to make ends meet.  Doctors are paid more if they do a complete evaluation by documenting symptoms,  family history, allergies, and a detailed personal history.  But how is a doctor to do this in such a short period of time? How can he or she do a detailed evaluation and charge for the same in ten minutes or less?

One way is to let the patient do their own histories online from home or from the reception room.

A piece of software, developed by Allen Wenner, MD, a family physician nerd in  South Carolina, is something called “The Instant Medical History.”  This history is a “yes” or “no” clinical algorithm based on the patient’s symptoms,  age, gender, and chief complaint.   On their own time, the patient enters the demographic and clinical data.  Once the patient has entered the data,  the medical history software generates a narrative history,  It is sent to the doctor in the examining room.  

The key word here is “instant” medical history.  Once the doctor has the narrative history in hand,   in an “instant” the doctor can get to the root of the problem, ask relevant questions,  do an exam,  record findings, click a button, and generate a detailed history which commands the optimal code for an office visit.   In the process, the physician can save 6- 8 minutes a patient,  allowing the physician to see 5 or 6 more patients each day.

There are variations off this theme.   Many specialists are hiring medical assistants  or aspiring medical students to  record symptoms, drug histories, allergies, and family histories before seeing the doctor, or by following the doctor around to record findings.  Other doctors are cutting and pasting common symptoms for common diseases seen by specialists – saving time and embroidering the history.  

There is nothing wrong with these nerdy approaches.  One can argue they produce a more  documented history that has  the appearance of a more thorough history and examination.  They also offer medical legal protection and a more accurate diagnosis.  EHR histories are faster and easier and more complete than medical records of the past. But they do not save money. Many EHR companies have incorporated the Instant Medical History in their systems.  According to a survey of 630,000 physicians,  70% of physicians are now using EHRs. EHRs with  embedded patient-generated  histories  may represent  the revenge of the doctor and software nerds.

Tweet:   Electronic records were supposed to save money by completely documenting office visits.  But the more EHRs are used, the more costs rise.