Physician Demoralization - Notable and Quotable – “The Falling Down Professions”

By Alex Williams, January 6, 2007, New York Times, Sunday Styles Section

“As of 2006, nearly 60 percent of doctors polled by the American College of Physician Executives said they had considered getting out of medicine because of low morale, and nearly 70 percent knew someone who already had. “

“Dr. Yul Ejnes, 47, an internist in Cranston, R.I., said he was recently forced by Medicare to fill out requisition forms for a wheelchair-bound patient who needed to replace balding tires. ‘I’m a doctor,’ he said, ‘not Mr. Goodwrench.’ “

“But in the days when a successful career was built on a number of tacitly recognized pillars — outsize pay, long-term security, impressive schooling and authority over grave matters — doctors and lawyers were perched atop them all. “

“Now, those pillars have started to wobble.”

‘The older professions are great, they’re wonderful,’ said Richard Florida, the author of ‘The Rise of the Creative Class: And How It’s Transforming Work, Leisure, Community and Everyday Life’ (Basic Books, 2003). ‘But they’ve lost their allure, their status. And it isn’t about money.’ “

OR at least, it is not all about money. The pay is still good (sometimes very good). Still, something is missing, say many doctors, lawyers and career experts: the old sense of purpose, of respect, of living at the center of American society and embodying its definition of “success.”

“In a culture that prizes risk and outsize reward — where professional heroes are college dropouts with billion-dollar Web sites — some doctors and lawyers feel they have slipped a notch in social status, drifting toward the safe-and-staid realm of dentists and accountants. It’s not just because the professions have changed, but also because the standards of what makes a prestigious career have changed.”

“This decline, Mr. Florida argued, is rooted in a broader shift in definitions of success, essentially, a realignment of the pillars. Especially among young people, professional status is now inextricably linked to ideas of flexibility and creativity, concepts alien to seemingly everyone but art students even a generation.”

“Indeed, applications to law schools and medical schools have declined from recent highs. “

“The number of applicants to medical school, has dipped to 42,000 from 46,000 in 1997, although it has recovered from a low of 33,000 in 2003.”

“ ‘Students are focusing now on starring in their own creations, their own start-up businesses,’ said Trudy Steinfeld, the executive director of the Wasserman Center for Career Development at New York University. “

“ 'There’s a sexiness to starting something cool,’ she said. ‘Now we have people trying to start a Facebook or a MySpace. You might be working like a maniac, but it’s going to pay off in status. You’re going to be famous, providing something people are going to know and use all over the world.’

“Unquestionably, many doctors and lawyers still find the higher calling of their profession — helping people — as well as the prestige and money, worth the hard work. And the stars in either field are still that: commanding the handsome compensation and social cachet. But to others, the daily trudge serves as a constant reminder that the entrepreneur’s autonomy simply can’t be found in law or medicine.”

“Doctors face pressure. Complaints about managed care crimping doctors’ income and authority over medical decisions are nothing new, but the problems are only getting worse, several doctors said. “

“One doctor responding to the American College of Physician Executives survey wrote: ‘I find it necessary about once every month or two to stay in bed for 24 to 48 hours. I do this on short notice when I get the feeling I might punch somebody.’

“Increasing workloads and paperwork might be tolerable if the old feeling of authority were still the same, doctors said. But patients who once might have revered them for their knowledge and skill often arrive at the office armed with a sense of personal expertise, gleaned from a few hours on www.WebMD.com, doctors said, not to mention a disdain for the medical system in general. “

“ ‘If the topic comes up in cocktail party talk, you’ll hear nightmare stories from people as they’ve gone through the system — ‘they gave me the wrong pill,’ et cetera,’ said Dr. Gregg Broffman, 57, a former pediatrician who is now a medical director of a primary care group in Buffalo. ‘In terms of my own self-esteem, it feels like a personal attack.’ “

“EVEN the language of contemporary medicine has eroded the physician’s sense of majesty.”

“ 'What irritates me the most is the use of the term ‘provider,’’ said Dr. Brian A. Meltzer, an internist in Pennington, N.J., who now practices pro bono on the side, but works full time for Johnson & Johnson’s venture capital division. ‘We didn’t go to provider school.’ “

Obama Campaign Promises - Obama and Huckabee Health Proposals

Iowa has spoken, and New Hampshire ooms ahead. This is a good time to take a quick look at the health proposals of Iowa winners.

Governor Huckabee’s ideas are,

1. More emphasis on preventive care (His personal massive weight loss of 100 pounds or so, and Arkansas’ status as a national leader in preventing childhood obesity may offer clues to his thinking here)

2. Health care should remain in private sector, but needs improvement.

3. The system should feature more EMRs in doctors’ offices and hospitals. (who should pay isn’t said).

4. Health care should be portable from state to state.

5. Health insurance premiums for individual should be deductible, just as they are for corporations.

Senator Obama’s proposals are more nuanced but smack of economic populism, i.e. bringing down the big boys in health care, big health plans and big Pharma , and giving a bigger role to government.

1. Offering coverage for all by providing a cost savings of $2500 per family

2. .But not making universal coverage mandatory because doing so would be a wealth transfer from the young to the old, the young being a constituency he seeks to cultivate.

3. Compelling competition among health plans (just how is not clear).


4. Having health plans pay more for care and less for profits and administration.

5. Allowing Americans to buy drugs from abroad and let government negotiate drug prices at home for Medicare and Medicaid.


6. Following the lead of such European countries as Switzerland and Germany by offering universal coverall through a mix of market and government-based care.

7. Requiring parents to buy coverage for their children.


8. Requiring all employers of 15 more to provide health benefits or pay subsidies .

One of Senator Obama’s advisors is David Cutler, Harvard economics professor. He says Obama would “guarantee” universal comprehensive coverage by,

1. Having government pick up tab for expensive illnesses.

2. Focusing on preventive care by requiring coverage of scientifically –based preventive tests.

3. Improving quality by having hospitals and doctors publicly report outcomes and quality measures.

4. Requiring a paperless system.

5. Making generic drugs more available and more of the requirment of care.

6. Ending monopolizations of health plans and drug companies.

There you have it.

Physician Bias =-Doctor Bias

The perfect is the enemy of the good.

Voltaire


To be perfectly blunt, I tire of searches for the perfect doctor - perfectly balanced, perfectly equitable, perfectly consistent. I weary of stories about physician bias against blacks, ethnic groups, the poor, and the uninsured. I dread commentaries saying no bias was intended but must be considered.


“Nobody’s perfect,” goes the cliché, and doctors don’t pretend to be. We don’t change stripes between patients. We evaluate, diagnose, and treat patients we meet.


Part of the attitude that a bias lies under every medical rock dates back to a 2002 Institute of Medicine Report “Unequal Treatment Confronted: Racial and Ethnic Disparities in Health Care.” Of the report, Alan Flieschman, MD, senior VP of New York Academy of Medicine, said this in a 2002 NYT letter to the editor:

Doctors, hospitals and the institutions that represent the medical profession must be held accountable for correcting those parts of this problem that are within their control. Medical racism is unacceptable.

Realizing that preconceived notions about others exist in all of us is critical to eliminating social stereotyping and the resultant disparities in medical services. The overt or unconscious bias that a physician may bring to a patient encounter must be recognized and eliminated.

I concur, in theory. But the crusade against “overt and unconscious bias” can be overdone. Much of this so-called “bias” may simply be a sampling problem
Consider the following, based on three medical journal aritcles, and widely reported in the media.

• The January 2 Hartford Courant ran a story “Drug Bias Seen in ERs.” It says whites are more likely to get narcotics for pain than blacks and other ethnic minorities, and is based on a January 3 JAMA article ( Pletcher, el, “Trends in Opioid Prescribing by Race/Ethnicity for Patients Seeking Care in US Emergency Departments “ The JAMA study indicated narcotics were prescribed for 31% of whites, 28% of Asians, 24% of Hispanics, and 23% of blacks. For blacks, the reporter speculated, doctors feared, presumably due to “social stereotyping, “ that blacks were more likely to be addicts and to feign pain. Maybe the doctors were right. Maybe black addicts visit ERs more often to get fixes because they’re unknown to ER personnel whereas private doctors might be more suspicious of feigned pain.

• The January 3 issues of both the NYT and the WSJ carried articles citing a NEJM article indicating too many American hospitals take more than 2 minutes to respond to sudden cardiac arrest ((Chan, P. et al: “Delayed Times to Defibrillation after in-Hospital Cardiac Arrest, “ NEJM, January 3, 2008). When response times exceeded 2 minutes, survival plunged. Response times were slow when hearts stopped at night or on weekends, in patients with non-cardiac diseases, in hospitals with fewer than 250 beds, units without cardiac monitors, and in blacks. The NYT reporter was careful to point out that racial bias may not have been a factor because blacks tended to be in smaller hospitals. Still, the NEJM authors felt compelled to say,

“The association of black race with delayed defibrillation is not intuitively obvious and raises potential issues of disparities in care. Further studies are warranted to determine whether such variations are due to geographic differences in access to hospitals with more resources (such as more monitored beds) or whether they reflect actual differences in practice patterns according to race.

• The January 3 Boston Globe features “Drug Distribution System Faulted.” The article says doctors distribute more free drug samples to the “wealthy and insured” than to the “poor and uninsured.” The reporter, citing an article in February issue of The Journal of Public Health, is, in my opinion, is subconsciously using the phrases “wealthy and insured” and “poor and uninsured” pejoratively . He implies doctors are systematically biased against the disenfranchised. However, The lead author Sara Cutran, MD, is carefully and correctly points out,

“Doctors are truly trying to target samples to needy patients, but their individual efforts failed to counteract society-wide factors that determine patient care.”

These factors, of course, include the reality that the insured tend to see doctors in their offices, while the uninsured more often go to ERs and hospital clinics, where free samples aren’t usually distributed. The faulty distribution, therefore, is not due to doctor bias, but to society factors beyond doctor control.

To conclude:

Some insist doctors harbor an ingrained bias,
Against blacks, so critics in the main decry us,
I say doctors can only treat
Patients they see or meet,
To say otherwise is overly pious.

Give doctors a break. In this imperfect world, inequality may depend on clinical and social circumstances, not on bias.

U.S. Health Care System, Government vs. Market Reform - Why American Health Care Reform is So Hard

I’ve been writing about American health reform for 30 years. It never gets any easier.


I started in the 1970s when HMOs bloomed in Minnesota, thanks to Paul Ellwood. Ellwood convinced Preside Nixon HMOs were the thing. . In 1973 the HMO act was born. The pace accelerated in 1976 when I attended an 8 week course on Health System Management at Harvard Business School. A single payer system seemed imminent, and Senator Edward Kennedy got government money to support the course so Harvard could meet the major players in the new system.. But reform was not to be. In 2005 I interviewed 42 national authorities for my book Voices of Health Reform. I concluded health care gridlock would continue because reform always geared someone else’s ox.


Health reform is hard for many reasons. We distrust centralized government. We believe in equal opportunity not equal results. We think the majority rules even though minorities may suffer. We see freedom of choice and access as God-given rights. No “socialized medicine,” rationing or queuing for us. We’re not a cruel people. We just don’t believe government is the answer. Markets and self reliance are.


We’re a vast continental nation with vast regional differences, but our reform ideas tend to be half-vast. We have a mixed population of 300 million. Our people include 31 million recent immigrants with different cultural expectations. This creates barriers and confusion. We have a history of individualism. Our Wild-West mentality creates the illusion that all things are soluble as long as we move to the horizon and seek new frontiers of cure.


We all hold strong ideas of what health care should be, especially when someone else pays for it. Given this sense of entitlement, we expect, even demand, the health care we think we need. Damn the expense.


We yearn for a political savior, but there is no savior. The problem is bigger than politics. It’s being hooked on technology, behaving as we please, rushing to satiate to relieve anxiety and stress, riding rather than walking, believing vitamins, immune system builders, herbs, hormones, and other nostrums will do the trick, and, if all else fails, turning to specialists for a quick fix.


We see the body as a machine. If the machine’s face or frontal knobs sag, lift them; if pipes plug, bypass them or put in Drano; if joints wear out, replace them; if organs fail, cannibalize other machines for substitutes. Stress body owner’s manuals, artificial hearts and parts, and mechanical devices. We can’t replace one organ , but we’ve got Al (Algorithm) and Art (Artificial Intelligence) working on it.


We’re opportunists. Lift ourselves by our own bootstraps. Talk of safety nets, as if life were a high-wire act, but don’t dig too deep in our own pockets to pay taxes to weave new nets or to sew up holes in old ones.


We’re capitalists. Solve problems by letting markets reign. Let Big Management and Big Ideas solve social problems. In the end, blame Big Government. But distrust Big Government. As a conservative society, we suspect no nation can support a robust growing economic and a generous welfare state at the same time. We cite Europe as an example. Health costs for Europe’s aging peoples are growing as fast or even faster than ours. Their economic growth has been half ours over the last 25 years. Their unemployment is twice ours over the same period.


These are some of the reasons health reform is so hard. Meanwhile, until reform comes, we’re living longer. Deaths from cancer, heart disease, and stroke, and our cholesterols, are dropping. Things could be better, but we’re getting healthier every day even without reform. So don’t despair. Hang in there. Americans and their doctors are doing something right.

Consumer-driven care, Herzlinger - Remaking American Health Care, Part 2, The Consumer-Driven Solution

In my blog before last, I described how George Halvorson, Kaiser CEO, would remake health care. That blog drew mixed opinions. Some top-down corporate control was bad. Others said it was about time doctors engaged in systematic improvement programs from on high.

Halvorson advocated a national system-wide data-driven revolution comparing how well doctors and hospitals perform, focusing on improving care for major chronic diseases, then allowing payers to bid on who performs best in terms of costs and outcomes. You can read details of his proposal in Health Reform Now! (Wiley, 2007).


At the end of my blog, I asked how you, America’s practitioners, thought of Halvorson’s approach.


Now I would like to ask how you react to another proposal, this one by Regina Herzlinger, Professor of Business Administration at Harvard Business School and author of Who Killed Health Care? (McGraw-Hill, 2007)..


Here’s what she said in an August Wall Street Journal piece “Where Are the Innovators in Health Care?”


“Luckily there is a solution, but there is only one: consumer-driven health care. Let’s take back our $2.2 trillion from the entrepreneur-suppressing status quo and allow consumers to reward those entrepreneurs who lower costs by improving health. Until we control our own health-care system, the entrepreneurs who could reform it – and it make our lives better – will continue to look elsewhere for opportunities . Who can blame them?”


She is referring to the 20 or so doctors enrolled in her “Innovating in Health Care” course at Harvard Business School. She says thy’re “ruefully driven to earn MBAs once they realize they innovate better as an entrepreneur than as a doctor.”


In “Who Killed Health Care? she argues health insurers, general hospitals, employers, the U.S. Congress, and academics have “killed” health care through a complex web of rules and regulations. What is needed, she says, a consumer-driven health-care system that will unlock those shackles to bring about a much-needed entrepreneurial revolution that will lower costs, improve care, and expand choice.


Do you agree?

Clinical Innovations - Five Health Care Innovations: Shine Your Light in Different Places

Well, 2008 is here. It’s time to shine the light of innovation in different places, to do things differently, to look at medical practice in a new light.

In the 1980s, the Eveready, the company that makes those inexpensive red lamps and metal flashlights, then sold mostly to men in hardware stores, was in trouble. Ralston bought Eveready. A Ralston executive suggested Eveready change the color of lamps and flashlights from red to pink, light blue, and lime green and sell them to women in supermarkets. Sales took off. Same product, same light, different colors, different places.


For doctors, the moral of this tale is four fold:


• Bring in people from outside for new ideas.


• Place your services in different places.


• Paint your services in a different light.


• Think of where your patients’ convenience


Venture outside your practice box. Use your same training and expertise. Shine light of That same knowledge in different places. Here are a few thoughts that have worked in the past and may work in the future.


1. Create and own your own retail clinic. Many medical groups are doing this as an extension of their practice or in partnership with retail outlets. Entrepreneurial companies are marketing franchises for physician-downed retail outlets. Rushed consumers, short on time and money, will appreciate it.


2. Think about approaching companies to set up worksite clinics. This is already happening. Primary care practitioners run these clinics, offer preventive services to employees, prescribe generic drugs, and create their own specialty referral networks. Employers will save money, and employees love the convenience.


3. Consider partnering with hospitals to set up a Big MACC (Multispecialty Ambulatory Care Centers), also called Big Boxes, in convenient suburban or rural settings, with ample parking and with shared receptionists, laboratory, x-ray and imaging, and pharmaceutical services. Place your practices in these New Big Boxes. Your patients will be impressed with the one-stop-shopping convenience.


4. Brainstorm about getting into the chronic disease game. It’s a known fact five diseases – diabetes, depression, asthma, depression, coronary artery disease, and congestive heart failure – gobble up 70% of total health costs. You are probably doing this already. But you might consider adding a new wrinkle or two – such as offering home house calls or monitoring electronically patients who are homebound. People want to be treated at home. Make it easy for them.


5. Fill prescriptions in your office. It’s convenient for your patients, cost them less, saves them time and driving, and makes for better compliance. Office prescribing is permissible in 36 states, and software is out there for you to check on drug interactions, prescribe from your office, and build and maintain your inventory. You’re using the same knowledge, you’re prescribing the same drugs, you’re profiting from your knowledge, and you’re making thing easier for your patients. If you find this commercial, unethical, or a conflict or interest, don’t do it. But keep in mind there’s a national movement propelling pharmacists prescribing , and it’s taking off in states like Florida.

Happy New Year!