Human Narratives Versus E-Imperatives – When Computers Get Between Physicians and Patients

June 5, 2011 - The other day I phoned a primary care practice and asked to speak to the doctor. The receptionist asked who I was and why I wanted to speak to him.

I explained I was a doctor, and my wife had just experienced a sudden attack of diplopia. I was worried this diplopia might be a sign of a stroke. I needed advice, and I might want a referral to an ophthalmologist.

She asked,”Do you have insurance? We’ll need your insurance number to enter it ino the computer before you can talk to the doctor.”

I said I was not a patient, I merely wanted to chat with the doctor.

The receptionist said the doctor was busy and could not talk to anyone today. What I had to say was urgent, I said, would take only a minute, and as doctor I could keep the conversation brief and pointed.

She replied, “Don’t pull rank on me. Even if you walk in, we will not honor your request to speak to him.”

“Well, “I said, “Then simply leave a note on his desk.”

“No, “she countered, “I will not do that. He has to record all encounters on his computer. We are a computer-run office, you know. The computer takes priority.”

I complained to the supervisor of personnel at the health system. She said she was having trouble teaching newly hired receptionists and other front-line people about telephone etiquette. She observed that many of her new employees were not adept at talking to people. They were accustomed to texting to communicate. Phone calls distracted them.

The supervisor added that their health system had recently installed an electronic record system. Computer-entry was taking precedence over voice-entries. For the moment, at least, their employees were having a hard time adjusting, productivity was lagging, and receptionists were simply trying to protect the doctor against interruptions.

I do not know if my encounter reflects nationwide problems – bad telephone manners, loss of a sense of urgency, or lack of professional courtesies.

The supervisor and I agreed a seminar might be in order to instruct those at the front desk on how to courteously, expeditiously, rationally handle callers.
One person who conducts such seminars is Susan Keane Baker, who has written a book on the subject, Managing Patient Expectations: The Art of Finding and Keeping Loyal Patients (Jossey-Bass, 1998). Susan may be reached at 203-966-4880 susan@susanbaker.com.

The book maps out how to:

• Identify patient expectations

• Create positive word-of-mouth comments from patients and staff

• Enhance listening skills

• Respond effectively to patient complaints and adverse outcomes

• Build patient loyalty.

Passage of the health reform law in March 2010 may have changed patient expectations. Patients may have been led to expect they would have greater access, and that access would be accompanied by computerization of their records.
Universal computerization has been a struggle for doctors – installation costs average $40.000, staff must be trained in computer skills, productivity of the practice drops initially by 30% or more, EHR companies go out of business, EHRs do not talk to other EHRs, and whole patterns of practicing must be restructured (“For Physicians, Electronic Medical Records Continue To Pose Challenges,” Kaiser Health News, June 4, 2011).

Furthermore, doctor shortages, increased workloads, transferring patient records into digital form, and need for computer entry of all information is a pain. Computers, moreover, can dehumanize the doctor-patient relationship by making needs of the computer more important than needs of patients.

Computers placed physically or figuratively between the patient and the doctor can harm the relationship. Computer communication tends to be flat, impersonal, numeric, and abrupt.

The Obama administration has dedicated $27 billion to $30 billion in its 2010 stimulus bill to develop a nationwide interpretative computer system linking all doctors, hospitals, and other health care facilities, not to mention to creating personal health records for patients.

This is a noble national effort. Almost everyone agrees EHRs ultimately will be the way to go. After all, there can never be too much reliable information. But there can be too much reliance on computer documentation of every human encounter as the only way to communicate. The computer is not always the best gateway between humans. The patient’ story and the tone of their voice can speak volumes.

Something was displaced, missing, or askew in my encounter. It was the narrative. The doctor would have immediately understood without computer intervention.

Could it be that texting, tweeting, face booking, and other computer obsessions, with cell phones and other electronic devices glued to the ear, distract from a smile in your voice, the art of conversation, and good telephone manners?

Why Cognitive Doctors Need To Be Paid More

Preface: On June 3, Kevinmd.com, America's most widely read physician blog, reran this blog of mine.


Everybody has a theory of what’s wrong with American health care and why costs are high.

I have my own theory – talk is cheap. By this, I mean Americans and third party payers are unwilling to pay more for what mere talk is worth.

They do not want to pay more for a visit to the family doctor, other primary care physicians, or a psychiatrist. They pay primary care doctors only 55% of what average specialist makes, and only 30% of what an orthopedic surgeon takes home. A psychiatrist is the lowest paid specialist.

A front page headline in a recent New York Times nails the problem: Talk Doesn’t Pay, So Psychiatry Turns to Drug Therapy.

A psychiatrist can make $150 out of three 15 minute sessions with a patient followed by prescription, but only $90 for a 45 minute talk consultation. A prescription pad has replaced the couch.

A visit to the shrink has become a brief chat, a prescription, and you’re out of there. Many of the nation’s 48,000 psychiatrists no longer provide talk therapy. Instead, it’s a 15 minute session with a prescription adjustment.

The situation is similar for primary care physicians. Only the visit may be even shorter, 10 minutes or less. As Steven Sharfstein, a psychiatrist who serves as president and CEO of the Sheppard Pratt Health System, Maryland’s largest behavioral health system, says of a psychiatrist’s practice, “It’s a practice very reminiscent of primary care. They check up on people, pull out the prescription pad; they order tests.”

Practice becomes all about volume. Treatment becomes a production line.

So, fewer doctors enter primary care and psychiatry. Doctors in these fields switch to other specialties, retire early, or become health care executives. More health policy types bewail the primary care shortage. Increasing numbers of onlookers say we have to re-jigger the payment system by paying “cognitive doctors” more like “proceduralists.” Critics seek to restructure the RUC (Reimbursement Update Committee), in which a specialist-dominated committee appointed by the AMA and slavishly submitted to by Medicare, sets doctors’ fees.

But there’s a huge cultural problem nobody talks about. We’re an action-oriented people. We like strong silent men of action. Talk is cheap, and we’re unwilling to pay more for it.

Americans want action – a prescription, a laboratory test, a CT or MRI, a procedure.

Anything.

Something concrete. Something we can touch, feel, take, ingest, inject, point to, biopsy, grasp, identify, undergo.

Something we can share with friends and family, even if it’s a surgical scar, a pacemaker, a vascular port, a hip or knee prosthesis.

Americans get all the talk we want – from talking heads on radio and TV, from channel news shows, from the Internet, and from bloggers like me.

Other than rewarding talk and recognizing and rewarding cognitive physicians for time spent with them , we should, of course, pursue the big things. ‘

Joe Flower, a health system change guru, suggested five of these things in a recent piece in The Health Care Blog.

1. New business models – retail care, urgicare centers, free (but profitable) fee-for-service clinics, specialty clinics, bundled care organizations, onsite clinics
2. Integrated systems
3. Organizations featuring shared financial risks
4. Building a stronger primary care base
5. Applying management tools – leaner care models, benchmarking , continuous quality improvement, and checklists

I am all for these things. If Joe will forgive me, let these Flowers bloom. But in the meantime, let us pay our thinkers and talkers, our cognitive doctors, more.

Richard Reece is the author of Obama, Doctors, and Health Reform and blogs at medinnovationblog.

Why Accountable Care Organizations May Flounder and Fail

June 3, 2011 - In The Health Care Blog, America’s most widely read commentary on health reform and its consequences, David Dranove, a professor of health industry management at Northwestern University's Kellogg Graduate School of Management, introduces his post “The Sequel of Sequels" by writing:

“I have seen this film before. Folks get all excited about the potential for vertical integration to save our healthcare system, and then the facts emerge.”

“The results of the first major ACO demonstration project are in and unless there is some hidden meaning behind all the data, it looks like ACOs may not be the magic bullet that the Obama administration had hoped."

"The demonstration began under President Bush and the specific payment structure and quality incentive differ somewhat from the ACO rules under the Affordable Care Act, but the main features are the same – give an integrated provider organization a share of the savings if it can hold down Medicare spending while also offering some quality bonuses.”

“Despite the fact that the participants included ten of the nation’s best known physician-led integrated organizations, less than half were able to lower Medicare costs by the final year of the project and only two demonstrated consistent cost savings. And the methods used to achieve savings – nurse call centers and telephone health checkups – are the sorts of thing that don’t exactly require vertical integration.”

The Health Care Blog asked me to comment on professor David Dranove’s blog.

Here is my comment:

“Why Accountable Care Organizations are destined to fail, and may not even get off the ground, is no mystery to me. Why would hospitals and physicians join together to form an organization that requires $11 million to $26 million to form (AHA estimate); that demands an inordinate amount of time, trouble, and grief to negotiate; that is designed, even guaranteed, to decrease reimbursements of hospitals and doctors; that hands over the reins of dispensing “savings” to your competitors and the government, reimbursements CMS may choose to reduce in the future; that subjects you to the risk of being sued by the Department of Justice for monopoly behavior; that requires you to be accountable financially for the behavior and complications of populations of patients before, during, and after hospitalization over whom you have little control; that 94% of members of the Medical Group Association of 400 integrated health organizations, supposedly ideal candidates for ACOs, have said they will choose not to join. Hospitals, doctors, and leaders of integrated health organizations are not dimwitted lemmings anxious to jump off the ACO cliff into an unknown abyss.”

A Review of A Roadmap for Physicians to Health Care Reform, a 73 Page White Paper of The Physicians Foundation

June 3, 2010 – On June 1, The Physicians Foundation, a nonprofit representing practicing physicians in state medical societies, released a 73 page white paper explaining the impact of the health reform law, available at physicianfoundation.org.

The Foundation has existed for eight years. It results from a 2003 settlement of 19 medical societies with a handful of national health plans. It exists to advance the work of practicing physicians and to improve the quality of care in America. Through $28 million in grants and two national surveys of physicians, the Foundation has laid the groundwork to meet these goals.

Milestone

This White Paper is a milestone. It culminates eight years of work. It expresses deep physician frustration, stress, and anxiety, largely gathered through two national surveys completed in 2008 and 2010. It is balanced, comprehensive, realistic, and, above all else, readable.

Organization and Revelations

The White Paper is organized into three parts:

• Health reform’s economic and budget framework

• The 2010 elections and the “reform of reform”

• Health reform provisions and for doctors and physician targets for reform

What does this White Paper reveal? It reveals hard truths about the cost and complexity of health care in America. It gives insight into the workings of the collective physician mind and the stresses on private practice.

It explains why many health reform provisions are so difficult for physicians to implement and indeed may be unworkable in the real world despite good intentions in policy-making circles.

Reform Provisions

These provisions include:

• Government “innovations, “ largely based on organizational restructuring into larger, coordinated groups such as accountable care organizations in which physicians fear losing their autonomy.

• An Independent Payment Advisory Board (IPAB), which many physicians do not regard as “independent.”

• Quality reporting and outcomes research, which many physicians regard as cookbook, protocol-driven, medicine.

• Physician fee adjustments, which means systematic fee reductions, abandoning fee-for-service medicine, and adopting capitated or bundled payments.

• Value-based purchasing for hospitals, which entails paying hospitals and their medical staff for outcomes and “population health,” which may or may not be within the physician’s control.

There are other issues as well, which are discussed from the patient, physician, and national perspectives. The overhanging cloud of possible health law reform repeal is also addressed in depth.

This book’s lead authors include Physician Foundation Officer – Lou Goodman, PhD, President, Tim Norbeck, Chief Executive Officer, and Walker Ray, MD, Vice-President; Kathy Means, manager of Old Creekside Consulting , an independent health care consultancy located in Fredericksburg, Virginia; and Ken Monroe, Chairman and CEO, a leading association management and professional services company.

Two Truths

In my opinion, the White Paper reveals two truths about health reform.

One: The health reform law is a disparate assortment of mandates, public insurance expansions, subsidies, and regulations that affect different groups of Americans, including physicians, in different ways and at different times. Whether one agrees with the law or not, or supports its various provisions, it will leave a permanent mark on how medicine is practiced in America.

Two: Whether health reform succeeds or fails depends on physician support and cooperation and availability of physician services because of the public’s widespread trust in physicians and visceral distrust of current reform policies. Without access to doctors, universal coverage could be meaningless. Physician understanding and reaction to the law are essential for improving care and access in America.

The Impact and Purpose of the Roadmap

According to Lou Goodman, PhD, president of the Physicians Foundation and CEO of the Texas Medical Association, “We believe that no matter what actions Congress takes to amend the ACA, the most direct provisions affecting physicians will endure in some form. The Physicians Foundation commissioned this Roadmap to educate physicians on those core elements, as well as to promote broader understanding of how private practice physicians will be impacted."

Beware of Stereotypes About Physicians and Their Politics

Attempting to get at truth means rejecting stereotypes and clichés.

Harold Evans (1928 - ), British Journalist and Historian

Dave Racer, a conservative Minnesota- based publisher and commentator on Obamacare (www. freemarkethealthcare.com) has asked me to comment on two New York Times May 30 pieces - “Doctors Soften Their Stance on Obama’s Health Overhaul” by Gardiner Harris, and “As Physicians Change, So Do Their Politics” by Tara Parker-Pope in her NYT blog. Her blog drew 97 mixed responses from physicians.

The authors admit there are no national polls on the issue of doctors and their political leanings. They base their opinion that doctors are turning left on what’s happening in Maine, where doctors are withdrawing their opposition or softening their opinion on Obamacare.

I find these this article and the accompanying blog to be an exercise in wishful and stereotypic thinking. According to Wikipedia, “ a stereotype is a popular belief about specific social groups or types of individuals. The concepts of ‘stereotype’ and ‘prejudice’ are often confused with many other different meanings. Stereotypes are standardized and simplified conceptions of groups based on some prior assumptions.(most often untrue).”

Stereotypes about the medical profession include:

• Idealistic medical students and women physicians lean left.

• Pragmatic doctors in private practice lean right.

• Salaried doctors in academic medical centers lean left.

• Young doctors and doctors abandoning private practice to work for hospitals lean left.

There may be an element of truth in these stereotypes, but there are yet to be verified by physician polls. These opinions depend on selective reporting.

For example, the Maine story comes out of a state which leans liberal on social issues and has two RHINO (Republican in Name Only) senators. You will find similar stories in Vermont, which has just voted for a single-payer system); Massachusetts, which has had a “universal” health program for five years; and states on the “left coast,” such as California, Oregon, and Washington State.

These isolated stories do not mean the majority of other states or physicians who practice there embrace liberal policies and politics. With 26 states challenging the individual mandate in court, the converse may be true.

Physician politics depend on the issues involved. I was speaking to a successful ophthalmologist in his office yesterday. He voiced a common opinion among doctors, to wit, “ I think all patients ought to have coverage. Nobody should go bankrupt from using my services. I agree health plans restrictions ought to be curtailed."

Then, I waited for the inevitable But. Sure enough, it came. "But, on the whole, I do not approve of Obamacare’s provisions to cut my pay, to force me to install an EHR, or to join an accountable care organization. Under his plan, quality and access will deteriorate.”

This response reminds me of two comments: One, President Harry Truman’s remark that he had yet to meet a one-handed economist. There is always a caveat,a "but," an “on the other hand” followup; Two, on the observation “When you lose your job, it’s a recession. When you lost your job, it’s a depression.”

In politics, the 18 months before the next presidential election is a lifetime. Who is elected will depend on how much health costs go up over that time frame, how many folks lose their current coverage as health plans pull out of markets, how many Americans remain unemployed, how the current Medicare flap over the Ryan Plan plays out, and how much the economy craters or recovers.

A Dissenter Dissents from Traditional Health Reform Positions

Preface: For the last three years or so, “Buz” Cooper, MD, a professor of internal medicine and a senior fellow at the Leonard Davis Institute of Health Economics at the University of Pennsylvania, has dissented from the world view of The Dartmouth Institute of Health Policy and Clinical Practice.

Susan Dentzer, editor of Health Affairs since 2008 , is a member of the Board at the Dartmouth Institute. She has declined to publish articles by Cooper, who disagrees with the Dartmouth Institute’s fundamental views on health reform - that regional variation of costs for Medicare patients is “unwarranted;“ that bringing these variations into line from the highest to the lowest payers would wring as much as 30% of “waste” out of the health system; and that provisions of more care by primary care physicians and less care by specialists - would save money and improve quality.

Cooper says these arguments are flawed and that poverty and delayed diagnosis, not too few primary care doctors, too many specialists, or provider greed, drive higher health costs and lower care quality. Here are Cooper’s latest thoughts. I will let readers decide if his arguments are persuasive.

Finally from Dartmouth: More is More

Posted on May 27, 2011

http://buzcooper.com

The Dartmouth machine has published a rather astounding new paper about the wonderfulness of primary care. The reason that it’s astounding is that it debunks decades of Dartmouth doubletalk and adds to the growing evidence that patients who receive more medical care have better health outcomes. More is more, just as you would expect. Here’s what the Dartmouth team did.

First, using the conventional approach to measuring physician supply (AMA Masterfile), they counted the number of primary care physicians and found no significant correlation with either Medicare spending or mortality. This directly contradicts earlier claims by Shi & Starfield that areas with more primary care physicians have lower mortality and by Baicker & Chandra that areas with more primary care physicians have lower Medicare spending, both of which are widely quoted. But we now know that neither is true. In fact, they never were.

Like the current study, Shi & Starfield had also failed to find a correlation between mortality and the total supply of primary care physicians, both family practice (FP) and general internal medicine (GIM). The correlation they found was only with FPs, although they called it “primary care.” However, as I’ve explained, this correlation exists because FP training programs (and therefore FPs) are more prevalent in the upper-Midwest, where minorities are sparse, poverty ghettos are rare and mortality rates are low. FP supply has nothing to do with it, and we now know that primary care supply doesn’t correlate with mortality. It never did. Ouch!

The same for Baicker & Chandra’s claim that areas with more primary care physicians have lower adjusted Medicare spending – about 30-40% lower. The current study shows that this isn’t true. In fact, it never really was. Baicker & Chandra’s claim was based on a statistical shell game that I exposed in Health Affairs. They responded that I was wrong, and Susan-the-Editor (and Dartmouth board member) responded with feminine furry, but it turns out that I was right.

As the current Dartmouth study shows, areas with more primary care physicians do not have lower adjusted Medicare spending. Ouch again!

Now for the big story. In addition to using the AMA Masterfile, the Dartmouth team counted primary care physicians a new way. They measured how many primary care services were billed and then converted services into the number of FTE physicians that would, if working full-time, be able to supply them.

But forget about the conversion. Stick with the measure. It’s a good measure. It measures services per beneficiary. The Dartmouth team found that areas with more primary care services also had more total clinical services (primary care plus specialty care), and these areas also had more Medicare spending. It is areas like these that the Dartmouth group previously called “high spending areas,” where patients were no sicker and didn’t get any better despite all of that added spending. This gave rise to the mantra about the unwarranted use of supply sensitive service needlessly consuming 30% of the health care budget.

But the current study found that patients in the high-spending areas were sicker. And despite being sicker, their mortality was lower. Mortality was lower in areas with more physician services and more Medicare spending. More was more. OUCH!

That’s the exact opposite of Elliott Fisher’s conclusion that more care is associated with higher mortality. According to Fisher and colleagues, this added care is not only wasteful. It’s dangerous. Only a few years ago, David Goodman (senior author of the current study) said, ”more physicians will make health care worse.”

And Susan-the-Editor said ”the greater the amount of health care you provide, the more likely it is to kill you,” somewhat awkward syntax but quite damning. And now the Dartmouth team has shown that more health care is associated with lower mortality. Ouch, ouch and ouch again. Three strikes and you’re out.

So how did the new paper spin these observations? It concluded that “a higher level of primary care physician workforce was generally associated with favorable patient outcomes.” Therefore, medical homes, train more, pay more, bla, bla, bla. But the workforce wasn’t measured. All that was measured was primary care services. And primary care services where greater where specialty services were greater, and these areas had more Medicare spending. The real conclusion is not about primary care. It’s about medical care. Medicare beneficiaries who received more medical care had better outcomes, even when they are sicker. MORE was MORE.

In publishing the same conclusion two years ago, I said ”let the simple truth that health care quality is better in states with more physicians, both primary care and specialists, sweep away the myths and permit greater clarity as planners work to solve the crisis in physician supply that now confronts the nation.” Possibly this latest study from Dartmouth will allow us to do just that.

References

1) Hua Chang, Therese Stukel, Ann Flood, David Goodman, “Primary Care Physician Workforce Outcomes and Medicare Beneficiaries’ Health Outcomes, “ JAMA, 305(20), 2096-2104, 2011.

2) B. Starfield and Li Shi, “Contributions of Primary Care to Health System and Health,” Milbank Quarterly, 83(3), 457-502, 2005.


3) K. Baicker and A. Chandra, “Medical Spending, and Beneficiaries’ Quality of Care, Health Affairs, January June,2004.