Let’s talk for a moment about medical education. I went to a work-related party yesterday and rode in the elevator with a dear friend who is my contemporary, and a more senior and highly regarded faculty member known for her work in medical education. Both were afraid for the future of medical education in different ways. My contemporary was concerned that the emphasis on the use of advanced technologies like ultrasound will make residents dependent on these devices and unable to function without them. The more senior doctor was actually concerned that residents weren’t learning technologies adequately, a seemingly opposite opinion.
Then I read a nice post on KevinMD by a medicine intern: http://www.kevinmd.com/blog/2013/12/deep-learning-medical-education.html. In it Dr. Peteet expresses his concern that superficial and strategic learning outweigh deep learning in medicine, and that the residency process emphasizes individual learning of acute illness in a large hospital setting and that the skills of collaboration and teamwork needed in the current medical climate are ignored. That same site, KevinMD, also had posts touting the advantages of technology in the areas of both education and clinical practice, both authors managing to emphasize the removal of the doctor from the hands-on care of the patient. One was a wide-ranging and extremely optimistic evaluation of emerging diagnostic tools in the form of computer algorithms. The other talked about simulators and simulated patients and how awesome and helpful they are.
Look. You want to learn to be a doctor? So go doctor. On people. That’s what doctors used to do. Now you’ve got an office where the patient logs in in the waiting room to their personal data page, prints out an algorithm-generated list of medical priorities. The patient then sticks their hand in another computer and gets their vitals taken. Then they sit in another office and a nurse comes in and repeats all the information the computer has and asks you what your symptoms are. She enters it in her computer, which generates a list of what is wrong with you based on your symptoms from most likely to least likely. Then the med student comes in and repeats it all and enters it in his computer, which he is adept at because he majored in molecular biology and biochemistry. The resident then comes in and tries to do the same again but his beeper keeps going off. Another technician comes in and does an EKG with his little machine. The med student takes his computer (given to him by the medical school) to his simulated patient in his artificial classroom and plays out scenarios involving how to break bad news to this patient or how to do a rectal examination. The student then simulates doing a venipuncture on the simulated patient. The resident sits in the back room updating the computer program that tracks his team’s inpatients and calling radiology because he can’t find the ultrasound machine he must have to do an arterial line on 98-year-old Mrs. Jones. Meanwhile back at the office the actual real patient has not been seen or touched by an actual doctor since his/her arrival.
We have arrived at this utopia in a variety of ways, starting with the way we pick our med students and going all the way through how we organize our private practices. Med students come fully equipped with a knowledge of how to get ahead in an academic situation and are adept at superficial and strategic learning. Those who have a deep and abiding care for real people either don’t get in or don’t get far before that care is beaten out of them by the constant demands of technologies that remove the real people from their care. Residents are used as grunt labor and to fill seats and write orders and chase down X-rays. The intern sits in the lounge entering data in a computer while the attending deals with the gunshot wound.
We doctor real people. Forget the radiology images. Throw out the simulator. Send the practice patient home. Sabotage the robot. Teach caring people how to be caring doctors. Of the patient sitting right in front of us.
I recently read a wonderful article by Jonathan Rauch in the December 2013 issue of the Atlantic Monthly entitled “The Home Remedy for Old Age”. A remarkable doctor named Brad Stuart noticed back in medical school that elderly patients were being treated aggressively for illnesses and had the out-of-the-box thought (at the time) that maybe this wasn’t such a good idea. He has since started a program that treats many elderly patients at home and provides ways for caregivers to avoid hospitalizations. As George Taler MD, of Georgetown University and MedStar Washington Hospital Center says: “Hospitals are hugely dangerous and in-appropriately used. They are a great place to be if you have no choice but to risk your life to get better.” Well put.
One home-based primary care model is called Advanced Illness Management progra (AIM), which I believe is Dr. Stuart’s program. Here each patient has a team of doctors nurses, social workers and therapists who get together once a week to discuss the patient and decide if a home visit would be beneficial and to adjust care as the patient declines. They provide a phone number that caregivers and family members can call instead of 911. Advocates say that such programs save Medicare (most of the elderly are covered by the government) money, and systems like the Veterans Administration have seen results that back this up. This cost savings is because Medicare pays for hospitalizations, not home care or social workers or home doctor visits. The ACA, which penalizes hospitals for readmissions and has grants available to hospitals testing new care models, has made a start in making these home-based primary care models financially viable, but most still operate at a loss.
So this is great! I’m all for it. That’s the way I want to be treated when I’m frail. Along with cabernet and chocolate chip cookies.
I was brought up short while reading the Atlantic article when I realized who the good Dr. Brad Stuart worked for: Sutter. Uh Oh. That rings some sort of bell doesn’t it? The New York Times just did a big piece on exorbitant hospital prices and which network do you think showed up as the worst offender?
“Sutter Health, California Pacific Medical Center’s parent company, operates more than two dozen community hospitals in Northern California, almost all in middle-class or high-income neighborhoods. Its clout has helped California Pacific Medical Center, the state’s largest private nonprofit hospital, also earn the highest net income in California.” http://www.nytimes.com/2013/12/03/health/as-hospital-costs-soar-single-stitch-tops-500.html?ref=health&_r=0. The NYT cites exorbitant charges like $36 for a tylenol with codeine pill or $137 for a bag of IV fluid. We’ve all heard stuff like this before.
Yeah. Hmm… But ok, maybe Sutter uses it’s overcharging to pay for money-losing enterprises like AIM. Well, it outsourced it’s dialysis services (poorly reimbursed) and tried to convert a hospital it had acquired in a poor community into an out-patient clinic. So it looks like at least in these two cases it tries to get rid of money-losing enterprises. But maybe Sutter uses all it’s money to do some sort of separate charity work. Well, one of it’s main hospitals, California Pacific, made $200 million dollars net in 2011. It spent $16 million on charity work. But maybe Sutter needs to upgrade it’s facilities and that’s what they use all that money for. The NYT: ”California Pacific, Sutter’s main campus, is in upscale Pacific Heights. It has just broken ground on a $2.7 billion renovation, which includes a new flagship hospital. Though the project was initiated to meet new state earthquake standards, the facility is designed as a sleek glass and marble structure with all private rooms, underground parking and roof gardens with flowers and bees “to enhance the quality of the healing environment,” according to California Pacific Medical Center’s website. Its Facebook page has called it “the coolest hospital in San Francisco, possibly the country and even the world.” Oh. Hmm… But ok, maybe Sutter has more than the usual number of people it has to pay. After all, 28 of it’s top officials earn more than a million dollars a year. The CEO earns $5 million.
So if Sutter is so expensive and so money-grubbing and so selfish, why is it pioneering AIM and actually expanding it? You will not believe this. It got a $13 million dollar innovation grant, a GRANT, to expand AIM. The fancy new hospital, which Sutter is supposedly trying to keep people out of with AIM, and the CEO’s fancy salary will not be shortchanged. Thank goodness for the ACA.
The other day I got a letter from Doctor Sherman. ”Is it time for you to schedule your next pap test?” Well geeze doc I don’t know, you’re the doctor. Oh, I’m told a pap test can find cancer of the cervix at an early stage. Good to know. Who are you again, Dr. Sherman? Oh you’re an MD, MBA, MS. Thank goodness I thought you had no credentials since you clearly can’t keep track of the last time I had a Pap test. Dr. Sherman then goes on to quote “leading health experts” about the current screening recommendations for cervical cancer. Good to know. He even includes a flyer on Chlamydia and HPV, which causes me to think that maybe Dr. Sherman knows something I don’t… But here’s how I know Dr. Sherman really knows me and my cervix: ”If you are not due to schedule your Pap test within the next few months, or do not need one due to previous surgery or a health condition, we apologize for this reminder. Oh OK. Dr. Sherman apologizes if he’s somehow forgotten that he removed my cervix.
Dr. Sherman is not my doctor. I love my doctor, she’s a dear friend, and if I needed a test she’d call me and tell me to get myself in to the office this minute or else. Dr. Michael S. Sherman is the Senior Vice President and Chief Medical Officer my health insurance company. I will sell bags of sand to Bedouins if Dr. Michael S. Sherman gives two hoots about my cervix. Why this sudden concern for my wellbeing?
I actually don’t know the answer to this. Certainly screening for cancer prevents some of the expense associated with getting and treating the cancer itself. So maybe the company is trying to save money. But nobody is sending me loving letters about my overdue mammogram. And for a long time insurance companies didn’t want to pay for contraceptives, in the mistaken hope that no one would have sex I guess, since pills are less expensive than babies. Maybe said insurance company is getting ready to financially penalize my doctor for something I have or haven’t done. That’s a real possibility. I’ll have to ask my (real) doctor who does care about me and actually takes care of me about that because I’m sure Dr. Sherman is not concerned for his own paycheck.
Maybe there’s some new initiative I don’t know about, or new law, or maybe women in Boston are rising up against the tyranny of their cervixes (cervici?) and not getting tested and now cervical cancer has run amok on Beacon street. No idea. I do know that my insurance company is there, or should be there, to pay for my catastrophic health needs and help with the routine ones, NOT to act as my doctor or any part of my calendar or conscience. Whether or not I’ve had any test or procedure should really be between myself and my doctor but it’s not. It’s between myself, my doctor, and Dr. Insurance Company. It’s very irritating. Especially the Chlamydia flyer.
I promise I will say nothing about Obamacare. I will say nothing about insurance, cancellation thereof, or anything about the Republicans God bless their sorry souls. I do have to speak out just a little about the new cholesterol guidelines that have made some headlines in the last few days. All I can say is: thank God for Harlan Krumholz. Voice of reason and measured statement. He doesn’t know this, but I used to work with him back when I was a cardiac nurse at Yale-New Haven Hospital. I have it on good authority that his residents remember him too! He is an excellent and well-known cardiologist and not a bad writer either. The kerfuffle about the new cholesterol guidelines was very reasonably explained by Dr. Krumholz in the NYT on November 12 as the following:
1. The guidelines have moved away from achieving target cholesterol levels. (That is, it’s not a competition…)
2. Know your risk. (The online calculator…)
3. Use medications proven to reduce risk. (Drugs…)
OK, so let’s start with number one. Here is what Dr. Krumholz says:
“The new guidelines recognize that FOR PATIENTS WHO HAVE EXHAUSTED LIFESTYLE EFFORTS (capitals my addition) and are considering drug therapy, the question is not whether the drug makes your lab tests better, but whether it lowers your risk of heart disease.”
Oh man! Don’t take away our target numbers! Weight, amount needed to retire, how many cars we own, how many levels we can dial up on ours spin bikes, who has the most toys, we need the numbers! No, we don’t. We want to be healthy as long as possible and enjoy our later years. None other than the American Heart Association is telling you to relax. Exercise, don’t smoke, take your statin if you must, but relax. Stress increases your risk of heart attack.
The second point – here is where the problem lies. I was all excited about this online calculator (another number woo hoo!). I jumped on to compare my far superior low number to my husbands and gloat. I’m female, white, I (used to) exercise, not overweight, don’t smoke, under 50, not diabetic. Maybe it’s not working. Maybe I don’t understand. Maybe my browser is out of date. I don’t know. I got an 8% risk. Really? OMG I need a statin stat! It turns out the calculator may be flawed, as Dr. Paul Ridker and Dr. Nancy Cook have pointed out to the guideline makers, and apparently in a commentary in The Lancet that you have to pay $31.50 for the privilege of reading. Dr. Krumholz again comes to our rescue:
“However, I believe that only you (his italics) can determine what constitutes a high enough risk that it is worth it to you to be treated with drugs. Such a decision depends on how you feel about your risk of heart disease and stroke and how you feel about taking drugs – and their risks and benefits.”
Relax. Seriously. Exercise, don’t smoke, take your statin if you must, don’t stress. And stay away from that calculator.
The third point – drugs. There are a lot of cholesterol-lowering drugs out there. Big business. These drugs might lower your lab number (your number!). Other than statins (Lipitor etc.) they have not been shown to actually do what you really want, which is to lower risk. But I need a number! No, you don’t. Relax. Exercise, don’t smoke, take your statin if you must, don’t stress. The American Heart Association, the American College of Cardiology, and my old friend Dr. Harlan Krumholz are telling you.
The good folks at The Health Care Blog kindly pointed out a post on MOC that they asked me to comment on. MOC, for those blissfully ignorant of this recent regulatory development, stands for Maintenance of Certification. In Anesthesia it’s called MOCA for obvious reasons. Dr. Lois Margaret Nora, head of the American Board of Medical Specialties, invited constructive feedback on this process, which is mandatory for everyone certified after 2000, at least in Anesthesia. What happens to the old guys certified before 2000? I guess their skills never decline and their knowledge is forever renewing automatically through a chip implanted in their elderly brains.
MOC is actually a good idea. You might be surprised to hear this coming from me. It is. Skills and knowledge decline over time. That’s what CME’s (Continuing Medical Education) credits used to be for. Let’s put off for the moment consideration of the considerable time, effort and money each physician must expend on this 10 year process every 10 years. Let’s look at what’s really required. Here’s what the ABA (American Board of Anesthesiology) website says:
“Each MOCA cycle is a 10-year period that includes continuing assessment of Professional Standing (medical licensure), ongoing Lifelong Learning and Self-Assessment, a decennial assessment of Cognitive Expertise, and periodic assessments of Practice Performance. MOCA is an opportunity for physicians to improve their skills in six general competencies: Medical Knowledge; Patient Care; Practice-Based Learning and Improvement; Professionalism; Interpersonal and Communication Skills; and Systems-Based Practice.”
There are four parts to MOCA: 1. Maintenance of Licensure (MOL), which has it’s set of requirements separate from MOC. 2. Lifelong Learning and Self-Assessment, translated = CME’s! But you cannot apply more than 60 credits a year and over the 10 years 90 must be “self-assessment” and 20 must be “patient safety” credits. 3. Cognitive Examination = a very long multiple choice test that costs, get this, $2,100. Yep. Two thousand big ones. 4. Practice Performance Assessment and Improvement, which you can do with an online module. Very effective. But wait! Look what else you can do!
“We are pleased to announce that participating in MOCA in 2013 can qualify ABA diplomates for a bonus incentive payment if they also participate in the Physician Quality Reporting System (PQRS). MOCA participants will receive an additional 0.5% incentive payment (MOC:PQRS incentive) based on their estimated Medicare Part B Physician Fee Schedule allowed payments for Centers for Medicare and Medicaid Services (CMS). This bonus is in addition to the 0.5% incentive payment allowed for participation in PQRS only. CMS will be offering the MOC:PQRS incentive in 2013 and 2014 as defined by the Affordable Care Act. The MOC:PQRS incentive is not currently defined beyond 2014.”
Ah. Now we get down to it. I don’t even know what most of that means but two things catch the eye: CMS and PQRS. CMS is of course the Centers for Medicare and Medicaid Services, and PQRS is the Patient Quality Reporting System. Government regulatory agencies. The federal government has figured out a way to make doctor’s requirements for MOC translate into data points for itself. This is no surprise. Not only will CMS want data, it will use that data to generate data about whether or not MOC increases quality of care. And how will it define quality? The same way it does now. Meaningful Use. Criteria that are easily measured and have little to do with actual quality of the care given to any one patient.
Want to improve quality of care and maintenance of the skill set and knowledge needed to be a good anesthesiologist?
1. Provide doctors with more time with patients and less time on MOC paperwork
2. Develop an open-access and curated central location for all significant recent clinical research
3. Provide time for “professional development” like my pre-schooler’s teachers do. And no, I don’t mean the grand rounds where the guy researching natriuretic peptide puts of slides of the Krebs cycle for an hour.
4. Provide MEANINGFUL ways doctors can improve their skills. Why not provide “mini residencies”? If a doctor needs practice on fiberoptic intubations, give him a month- or week-long intensive airway “rotation” where he gets to intubate everything hard and spends time with the ENT guys who do this in the office every day. Or schedule the ORs in such a way that the poor slob who does cataracts and knee scopes all day every day gets a chance to do some thoracic cases and practice lines and double-lumen tubes.
If all this is too technical, that’s because it is for us anesthesiologists too. Skills can be lost in the slotting of doctors into specialty groups. No amount of simulation or on-line courses or grand-round CME’s will be as effective as these measures in making sure everyone knows what they are doing for the best interests of every patient every time.
Thank you to all of my followers who read and commented on my last post. I would like to expand a little bit on the subject of Duty. People have very different definitions of what their duty is in any given situation. In the case of the military, duty may be rigidly defined by hierarchy. In parenting, duty to your children is sort of a given part of procreation, but within parenting there are very different opinions about what that duty entails. Being “On Duty” may mean no more than being at work or “on the job”. Duty can also mean a tax or other monetary obligation.
In medicine the idea of duty has a significant meaning, both medically and legally. Most physicians understand that once they have accepted a patient it is their duty to care for that patient to the best of their ability, to take responsibility for what happens to the patient, or at the very least to provide them with access to other doctors who can care for them if the original physician cannot. Legally the determination of duty is an important one. Here is what one legal dictionary says about medical duty:
“…a more basic legal question involving medical care is the affirmative duty, if any, to provide medical treatment. The historical rule is that a physician has no duty to accept a patient, regardless of the severity of the illness. A physician’s relationship with a patient was understood to be a voluntary, contracted one. Once the relationship was established, the physician was under a legal obligation to provide medical treatment and was a fiduciary in this respect. (A fiduciary is a person with a duty to act primarily for the benefit of another.)”
This fiduciary bit is very important. In order to successfully prosecute a malpractice claim against someone the plaintiff must demonstrate the legal duty of the doctor to the plaintiff. No duty, no settlement. So even if a doctor never gets sued and has nothing but purely altruistic motives in all cases, the concept of duty is still relevant and an operating principle under which that doctor works. Why is this relevant to the issue I brought up in my last post, about physicians reporting other physicians? People who have been harmed and not informed talk about how their doctor didn’t talk to them, or they wouldn’t admit the error, or they failed to provide information, etc etc. It is absolutely true that the doctor, YOUR doctor, the one with fiduciary responsibility, must and should report/explain any errors or mistakes to the patient involved. No question. In a perfect world, everyone would always report the mistakes of everyone else without fear of retribution so we can all learn from the errors and improve our care and our systems. But doctors are human, and as such they have a very strong instinct for self-preservation, just like everyone else does.
If the patient upon whom the error occurred is not YOUR patient, ie. you have not entered into a legal contract with that patient to provide standard of care, it is very difficult to expect you to go out on a limb. Not only are you accusing a colleague of error, you are accusing him or her of failure in their legal duty to their patient. There are very few humans who would take kindly to that, in any field. Yes it would be great if all errors were reported, and yes the patient is the most important part of the equation, and yes in a perfect world doctors have nothing but all patients’ safety in mind at all times. Given that medical culture virtually guarantees that blowing the whistle on a colleague is likely to be more painful for the whistle-blower than for the colleague, reporting other doctor’s errors is very unlikely to occur. I’m not saying it’s right. I’m just saying it is.
Oh boy. Propublica has really gotten into it now. This non-profit investigative reporting agency, which does some great in-depth work, really has the medical error bone in it’s teeth and isn’t letting go. It’s new interest is in doctors not reporting errors committed by OTHER doctors. Here’s the link: http://www.propublica.org/article/why-doctors-stay-mum-about-mistakes-their-colleagues-make?utm_source=et&utm_medium=email&utm_campaign=dailynewsletter
There are several scenarios at issue here. It is true that everyone at an institution knows who the “good” surgeons are and who the “bad” ones are. Everyone knows who the skilled anesthesiologists are and who is clueless. Same for nurses, same for every level of every specialty. ”Good” and “Bad” are hard to define, however. I’ll use surgeons as an example but it could be any specialty. I could say a surgeon is really good because he’s fast and confident and doesn’t have a lot of complications. I could say a surgeon is bad if they are slow or hesitating or if they have to all in other doctors for help. I don’t do surgery. I can tell if something isn’t going well but not necessarily the reason for it. I don’t have the technical expertise to say exactly WHY this surgeon is a “bad” surgeon. I just have a gut feeling that he/she is unsure of him/herself and that I would not personally go to that person for my surgery. Everyone knows, and everyone rolls their eyes at each other when the bad surgeon does cases, but no one is going to report this surgeon to anyone. There are too many variables. Maybe I don’t understand the technical difficulties. Maybe this surgeon is just out of training. Maybe they were poorly taught. They’ve been hired by the department of surgery so presumably some sort of vetting process has gone on. Maybe you can’t put a finger on a specific error. Or you aren’t really sure if it was an error. Other surgeons don’t want to remove the bad one from the call rotation since it makes more work for them. As long as nothing really bad happens, no one is going to say anything. Ideally, the chairman of the department should be involved enough in clinical practice to hear the way the winds blow and do his own investigation but that is generally not done. A word from anyone would likely cause way more pain for the reporter than the doctor or even the patient.
Egregious errors are generally recognized by all and reported to the patient by the surgeon who made the error. In these cases there is no doubt and it would be a very rare doctor who didn’t report his own obvious error. Although even that is not necessarily true. A doctor could be absolutely sure in his/her own mind that the thing that went wrong was NOT their fault. It could have been circumstance, the physical state of the patient, the available assistance, erroneous information given to them by someone else, etc. Excuses yes, but sometimes absolutely true. In these cases it is often the courts who make the determination of blame.
There is also the professionalism and hierarchy of medicine, which is very necessary but also impedes communication. Very few doctors are going to report the error of another, even if they are absolutely sure the error was done and the patient was harmed. There are several reasons for this. Sympathy: It could have been me. Protection: I know what a lawsuit is like and don’t want to involve myself or my colleague in one. Ass-covering: I don’t want others to think badly of me as a snitch. Rationalization: Yeah but it was a hard case and there were other factors. Job security: I don’t want to lose my job by calling out a superior or colleague. If you look at these reasons you will see that these things are true in any profession. Doctors are not doing anything that any human wouldn’t do in any field when faced with this problem. The issue for doctors is that sometimes people get hurt.
One more thing. The NEJM article about this ( https://www.documentcloud.org/documents/813486-talking-with-patients-about-other-clinicians.html ) is written by a lot of really smart guys in clinical practice and ethics and worth a read by patients as well. One thing they point out is that we can learn from our mistakes. That’s true, but the culture of medicine and malpractice is much more likely to focus on harm and blame than education and learning. It’s unlikely a mistake is going to be reported and then everyone says “Oh, thank you for pointing that out, we all learned so much from it.”