Well, the cat is out of the bag now. All this time we’ve been told that Internal Medicine is a dying art, you can’t make a living at it, payments to physicians are too low, etc. Now the New York Times is telling me that Internal Medicine is fifth on the list of best-paid doctors! How can this be?
Here’s what has happened: Medicare has released the names and specialties of all the doctors it has paid in 2012. That’s a lot of data. It’s, well, Big Data. It’s data on two things: 1) doctors; 2) money. The healthcare reform debate in a nutshell. So this will likely get a lot of press. I haven’t seen the actual numbers yet, and I’m told it will take many weeks to go through all of it. Since nobody pays me to write, I’ll have to keep my day job, and thus will have to leave the number crunching to others.
Thankfully, the New York Times has come to my rescue. (http://www.nytimes.com/2014/04/09/business/sliver-of-medicare-doctors-get-big-share-of-payouts.html?hp&_r=0). According to the NYT, 880,000 practitioners and 77 billion dollars are covered in the report. Twenty-five percent of that 77 billion seems to have gone to two percent of doctors: those in opthalmology, oncology, and cardiology. Internal medicine is right behind, wouldn’t you know. The article actually has a chart that they named “The best-paid 2 percent of doctors”. Yep. Those family doctors are really raking it in.
The paper singles out a specific opthalmology procedure as a prominent, and, it implies, therefore suspect, reason for big payouts. In fact, the paper had to be asked (nicely) not to release the names of the actual doctors with the highest billing records, or to contact them, until all the data is released to the public. I suspect a couple of eye-doctors are going to have a really bad day today. The opthalmology data is a good illustration of how Big Data can be Limited Data. And how it can be interpreted a number of ways. The NYT is implying that because eye doctors’ billing is so high, and so much higher than other specialties, there must be some something criminal going on. Either eye doctors are committing fraud, or they are doing unnecessary procedures, or they are using drugs that are too expensive. The doctors must be wrong.
But the data doesn’t say that at all. All it says it that Medicare, which sets it’s reimbursement rates at levels mandated by Congress, not doctors, pays more money to treat people with eye diseases than it does other diseases. That’s it. It says nothing about a doctor’s practice at all. Nothing.
Let’s take a couple of examples. Opthalmology is a sub-specialized field. A doctor who does cataracts doesn’t do Lasik, or he does Lasik but he doesn’t handle macular degeneration, etc. A lot of specialties are getting like this. Now, say a few doctors have specialized in this one procedure the NYT is all upset about. Other doctors send their patients to these guys. All of their practices becomes doing this procedure. Because it’s their specialty. So they bill Medicare for the procedure. Medicare pays out what it decided to pay for this procedure. How is this the doctor’s fault? (By the way, funny story. There’s a Lasik advertisement on the internet page with this article.)
Another example. Say you are an oncologist. You treat a lot of blood cancers, leukemia and such. Other doctors send you their patients if they have leukemia. There are a lot of types of leukemia, many of which are very expensive to treat and some which actually become chronic. You bill Medicare for your treatments. Medicare pays back what it decided to pay for these treatments. It costs a lot to treat leukemia. That’s what the data says. That’s all it says. It says nothing about quality of care, patient population, number of patients, or disease complexity. It says nothing about variability in office visit time or the level of co-existing disease in a specific doctor’s patient population.
I am all for transparency. I think having this data out there is fine, as long as we understand what we are getting. And I’m not sure we do. Specific doctors are going to be targeted for a lot of scrutiny because of this report. Maybe they deserve to, maybe they don’t. Fraud and over-treatment do exist. But this data is far from able to tell the whole story.
I was super surprised and honored today when I saw that Dr. Karen Sibert had mentioned me in a tweet. She is an anesthesiologist and blogger, and all her posts are fantastic. She wrote a piece on pain management and opioid addiction and drug regulation that is so good, so complete, I wouldn’t dare try to re-invent her wheel. Check it out!
Very interesting question from a med student reader the other day: How do I choose what specialty to go into? Her particular decision was worded differently, but the general idea of the query is the same: how can I possibly know what it’s going to be like to be this or that kind of doctor? It’s a great question. After all, you have to choose during the third year of medical school because of the lengthy match process. (For those of you who don’t know what the match is, I’ll rant on that another day.) Plus, once you pick you’re going to spend the next 3-10 years training in that specialty. It really sucks when after all that you realize you chose wrong.
Some people just know. “I’ve wanted to be a pediatrician since I was 5, my mom is a pediatrician, my grandfather is a pediatrician, I was Doc McStuffins as a child, I loooooove kids…” Great. Awesome. Those people are lucky, and usually right. Others have it narrowed down to, at least, adults vs. kids, medicine vs. surgery, out-patient vs. in-patient, etc. Those people are less lucky, and sometimes right. For the rest of us, all we have to go on is what we see in the third year of medical school, when real clinical rotations get going. Remember, I was a nurse before I went to med school. I was a cardiac nurse. I wanted to become a cardiologist. I thought I knew exactly what I was getting into. I was so wrong. So, as someone who has chosen wrong more than once in her life, I herewith give you a list of things to consider so you don’t do what I did.
1. DO NOT LET A BAD ROTATION INFLUENCE YOU. I can’t emphasize this enough. For a medical student, the experience she has during clinical rotations has more to do with the residents and their treatment of her than anything else. For example, I had a horrible surgical rotation. The residents were stressed and thus either mean or dismissive of students, who are generally not useful and can be a significant added burden. No responsibility or accountability was given to the students, so I could disappear all day and show up for rounds in the evening and nobody would notice or care. I felt hesitant to ask to scrub in and nobody insisted that I do so. Med students in that rotation were not valued. And I could feel that. On the other hand, in medicine everyone was super nice and let me do stuff and ate lunch with me and generally tolerated my presence. So I went into medicine, which was a terrible decision. Please don’t take any of it personally or dismiss a specialty out of hand because some miserable resident was a jerk to you.
2. FIND THE BORING PART. What is it that the attending in each specialty does repeatedly? Because I guarantee you there is at least one thing that each doctor in every specialty does over and over every day. Happiness in a specialty is going to depend in part on how well you tolerate this repetition. Examples: Don’t become a pediatrician if you are bored to death treating ear infections. Even if you love kids. Don’t become a general surgeon if, after doing three appendectomies you’re ready to shoot yourself if you have to do another. Even if you love appendices. There’s a boring part, I guarantee it. Find it.
3. DON’T MAKE LIFESTYLE YOUR MAIN CRITERIA. This one is sort of counter to what people are aiming for these days, but I’ll tell you why I say it. It relates to #2. If you love the lifestyle of dermatology but can’t stand rashes, even the 9-5 office hours and lack of call will not redeem days filled with rashes. If you like that anesthesiologists get a lot of vacation time (we do) but can’t stand sitting in the OR all day, no amount of fabulous days at Disney World is going to make up for what you have to do when you’re not on vacation.
4. FORGET #1. PAY ATTENTION TO HOW YOU FEEL. By this I mean observe yourself in each rotation. Are you cold, hungry, and sleepy all the time? Not a good specialty for you, even if you think you would like it. You’re bored, don’t waste your time. Are you on call every other night and can’t wait to get back to it every day? Better choice. Does the work induce “flow”? That is, do you look up at the end of a day and go “That was fast!”? Good choice. Don’t find excuses for how you feel if you have your heart set on a specialty. Just because you thought you would like it doesn’t mean your body and mind aren’t telling you “no way”.
5. BEWARE OF THE NOVELTY FACTOR. You might think OB is awesome because you’ve never seen a baby born before. You might find cardiac surgery totally cool because you’ve never seen someone stick a hose in a ventricle. These things are awesome, but they better be awesome 15 years from now. Even if you love a specialty, residency will make you practice that specialty so much it won’t be fun anymore. You have to be able to sustain your passion through that.
File this one under the “duh” heading. A study out of Europe has found that patients do better with more educated nurses and lower nurse-patient ratios. Here’s the link: http://www.nytimes.com/2014/03/31/world/europe/nurse-education-level-affects-death-rates-study-says.html.
This is what the researchers did: they reviewed charts and nursing employment files at 300 hospitals across 9 countries. All patients 50 years and older who had surgery for general, orthopedic, or vascular problems were included. So, retrospective, but very large sample size – 422,730 patients. There were two main findings:
1. For every 10% increase in the proportion of nurses with bachelor’s degrees, there was a 7% drop in post-surgical mortality.
2. For every 1 patient increase in the nurse-patient ratio, mortality rose 7%.
The NYT article suggests that the reasons for these findings are matters up for debate. No, they’re not. As I’ve said many times, you don’t go to a hospital for a doctor. You go because you need a nurse. The better educated your nurse is, and the few patients he/she has, the better care you will get. Period. The quality of the doctors, physical plant, janitorial staff, candy-stripers, or CEO doesn’t matter.
Here are some reasons for the findings in the Lancet study. Say you are an 80-year-old woman and you come in for an hip fracture. I’ve used this little old lady before, and she will be me someday. You are old but you have all your wits about you, and then some. In order for you to make it out of the hospital alive, and to still be alive 6 months later, you need some specific things from your nurse: adequate pain management, good food, plenty of fluids and rest, someone to look at your wound and dress it carefully, someone to force you to get out of bed, good physical therapy, adequate referrals for rehabilitation, an advocate and liaison with the surgical staff, and someone who knows what to do if something goes wrong. The more your nurse understands your condition and the underlying physiology, the more these tasks will be correctly accomplished. I am not impugning nurses who are not bachelor’s trained; many of them make up in experience what they lack in education. But for new nurses, a bachelor’s is going to provide an head-start.
How can your nurse do all of these things for you and for 7 others? She can’t, of course. In my opinion, nurse-patient ratios are one of the most important determinants of patient outcomes. Lower ratios are more expensive, it’s true. But remember, you go to the hospital because you need a nurse. You want patient safety and high quality? Provide an adequate number of well-educated nurses. It really is as simple as that.
Remember the scene in the movie Knocked Up, where the obstetrician is telling Allison she can’t have an epidural? Greatest scene ever. I know for a fact that at least three of my most loyal and beloved readers won’t get this cultural reference, so I’ll quote it for you:
Setting: Labor room, Allison (Katherine Heigle) about to have a baby, Seth Rogen’s character, the father, is there, along with the nurse, Deb, and the obstetrician, played by Ken Jeong, who is actually a real doctor.
Allison:”Oh this really hurts.”
Jeong: “I see we’re well on our way.”
Allison: “I want the… I want the epidural. Okay?”
Rogen: “Give it to her now.”
Jeong: “Ok Allison. We’re past the point of an epidural. Okay? The cervix is fully dilated.”
Allison: “No seriously, I want an epidural…”
Jeong: “We can’t give you the epidural.”
Allsion: “I’ll make sure it doesn’t come out! I’ll stop pushing!’
Jeong: “We’re gonna just have to do this the all-natural way, okay? The way you wanted to do it.”
Allison: “This is messed up. Something’s wrong in there.”
Jeong. “Oh, no, no. I mean, granted, gynecology’s only a hobby of mine, but it sounds to me like she’s crowning. Is that right, Deb?”
Actually, there a few scenes in the movie in which Ken Jeong’s character hilariously says things that doctors would love to say on occasion but never do. They are variations on the theme of “Who’s the doctor here?” This post is not a yearning for the old, paternalistic way medicine used to be practiced, but every time I see these scenes I remember similar discussions with patients who are trying to play doctor.
This rant started because a colleague pointed out a piece by Tom Nichols at The Federalist entitled “The Death of Expertise”. (Thanks Jess Geerling!) http://thefederalist.com/2014/01/17/the-death-of-expertise/. Here’s how he introduces the topic:
“I fear we are witnessing the “death of expertise”: a Google-fueled, Wikipedia-based, blog-sodden collapse of any division between professionals and laymen, students and teachers, knowers and wonderers – in other words, between those of any achievement in an area and those with none at all. By this, I do not mean the death of actual expertise, the knowledge of specific things that sets some people apart from others in various areas. There will always be doctors, lawyers, engineers, and other specialists in various fields. Rather, what I fear has died is any acknowledgement of expertise as anything that should alter our thoughts or change the way we live.”
I’ll ignore the blog-sodden comment. Here’s the thing. Information is readily available. Access to the greatest minds in every field is more accessible than it’s ever been. Information, however, even from thought leaders, is useless unless it is processed appropriately in the right context. For example, imagine that I, arguably an “expert” in the field of anesthesia, decide to go consult a lawyer on a possible real estate purchase. This lawyer would presumably be an “expert” in the field of real estate law. I could play my visit two ways: I could go to her (it’s a her. It’s my blog.) and say “Here’s this building I was thinking of investing in, but it has several zoning regulations, what do you think…” and then do what she says. Which is what I would do, since I know zilch about real estate. Or, I could go to her and say “I’ve spent all day on the internet and I’ve discovered that in zone 3 in this state the statute of limitations on blah blah…” If she then patiently explains zoning laws to me, I could come back with “Are you sure, because realestaterus.com says that according to article 33 of amendment 501 of the zoning regulation…”. But I’m not going to do that, right? Because she is the expert, and I am not. It doesn’t mean I’m inferior to her, or somehow in her debt, or that I should feel bad about myself because I don’t know anything about zoning. Nor should I feel attacked or threatened by her superior education and skill in law. I subjugate myself to her in this particular area.
Patients are in a difficult spot. They feel vulnerable, threatened, fearful of pain and unfamiliar circumstances. Especially in anesthesia, which is a black box to most folks. In medicine, patients must subjugate themselves, within reason, to an expert. So many people feel threatened by this. The source of this feeling is distrust. I’ll admit to feeling the same way about my mechanic. But I know less about cars than I know about real estate law. I can, and should, look at the information that’s available that I can understand, but ultimately I must trust. May we doctors be forever worthy of yours.
Here’s one for the philosophers: Sometimes You Aren’t Where You Are. Or rather, you aren’t where you think you are. Or you’re not where other people think you are. Or you are, but not really.
This existential state of existence doesn’t only happen in The Matrix. It happens in Hospitals, The Matrix for people who don’t look like Carrie Ann Moss. As Ann Carrns discusses in the NYT on March 18, beware of the green and red pills known as “admission” and “observation”. You think if you spend the night in the hospital you’re admitted, right? Someone gave you a ticket. You’re in. But no. Turns out if you might very well not be admitted at all, only on observation. Standing room only, if you will. Wow. Lots of mixed metaphors here.
Why should you, the mere mortal, care about what they call your existence? In the normal world it makes no difference, but in the Matrix of the Hospital and Medicare, it makes a huge difference. This is because if you are on “observation” status, Medicare won’t cover some stuff that it will cover if you’re “admitted”. Here’s what Ms. Carrns says: (http://www.nytimes.com/2014/03/19/your-money/when-a-hospital-stay-is-not-a-stay.html?src=me&_r=0)
“Regardless of length, observation stays do not count toward Medicare’s requirement that to be eligible for subsequent rehabilitation services at a nursing home, a patient must have a hospital stay of three consecutive days — three “midnights,” specifically. Otherwise, rehabilitation care may not be covered, making it an out-of-pocket expense.”
OK. So say you are 80 years old. You fall and break a couple of bones. One break is deemed non-operable, maybe a couple of vertebral fractures that don’t effect your spinal cord. The other gets fixed. The ER doctor puts you on “observation” status, figuring you’ll only be in the hospital for a few hours, a day max. You spend three nights in the hospital, waiting for surgery. The OR board is really busy, the orthopedic surgeon has a bar mitzvah, whatever. It takes three days. But you are old, and three days in bed is more than enough to debilitate you, plus your back is killing you. You tell your friendly social worker that you’d like to go to rehab for a few days. She will say sure, give me your credit card number. And you will ask why, since you have Medicare. And the friendly social worker will say “Well, you weren’t admitted.” And you will say “I sure the #$%#@ was!” And she will say “Nope. You were observation. Doesn’t count. Unless you have Medicare Part B.” So you will say “There’s more than one Part?” And she will say “Medicare Part A will cover your inpatient stay. Medicare Part B will cover your outpatient care. Except for laboratory tests, X-rays, and EKGs”. And you will say “Wait, I’m not an outpatient”. And she will say “Yes, you are, you’re observation status”. And you will say “Well, change my friggin status to ‘admitted’”. And she will say “Need a doctor’s order”. Or something like that. Then you will have to get congressional approval for a status change.
You could ask for clarification, but this is what you’ll get (courtesy of Ms. Carrns):
“While the payment for any single Part B service cannot be more than the inpatient deductible, the total of all payments for Part B services may be higher, according to the Families and Healthcare Project of the United Hospital Fund. Prescription drugs are not covered, either. And for those who have chosen not to have Medicare’s Part B coverage, the bills could be quite large. “Each charge is separate,” said Carol Levine, the project’s director, “and it adds up.”
Mhmm. Clear as mud. So why wasn’t your 80-year-old self told about your status as “observation”? Turns out there’s no rule that says anyone has to tell you. Even the Oracle can’t help you with this one.
My parents have always made their own bread, a skill I have never been able to master. The other day my dad was showing off this beautiful loaf of bread he had made, and I asked him how he did it. He said “I don’t know. I followed the recipe and then added more flour until it looked right.” Huh. So the recipe was wrong? “Well, not really. It just needed more flour.”
As I was reading our dear leader Brad Wright’s policy wonk piece from March 12 I clicked on John Goodman’s piece on personalized medicine and it occurred to me that my father’s approach to bread baking is a good analogy for how doctors confront protocols and guidelines. Goodman has a great blog, by the way, over at the National Center for Policy Analysis.
Let’s start with the recipe itself. You think you want to make, say, a pie. You don’t know what kind of pie, just “pie”. But you’re an experienced baker, you’ve been baking for 20 years. You look in the index and find the directions for “pie”. You follow the directions exactly. You end up with something that looks like pie. But it’s not quite right, it doesn’t fit exactly. There’s no filling. You haven’t decided how to personalize the pie, make it yours. According to our analogy, the baker is the doctor. He’s very experienced, and has been practicing medicine for a long time. He sees a patient whom he decides has, say, diabetes. He looks in the index of his protocol manual, as he has been told to do by the administrators of his EMR, and follows the directions for “diabetes” exactly. But the patient doesn’t get better. The doctor hasn’t found out what kind of person his patient with diabetes is, so he can tailor the recommendations to the patient, that is, he can personalize it.
To extend the analogy, say this baker makes his pie according to the directions but because of his experience, knows a few ingredients are missing, so he adds them. Like my dad, an experienced bread-maker, adding flour. The results are much better, and he is able to charge more for his superior bread. But the doctor does this for his diabetes patient, and the patient’s insurance company calls him saying it won’t pay for the added items. They aren’t in the recipe.
Now someone comes to the baker and says: “Baker I ate your pie and I got sick. What did you put in it?” The baker replies that he followed the recipe, but when pressed admits he added a few things, but nothing that could make the pie-eater sick. The pie-eater doesn’t believe him but the worst that he does is no longer buy pie from the baker. The patient comes to the doctor and says: “Doctor I did what you said but I got sick. What did you do?” The doctor says he followed protocol, but when pressed admits he added a few things, but only things that would improve the patient’s care. Doctor is sued for 10 million dollars. Conversely, a person buys a pie and says to the baker: “This pie tastes terrible. What happened?” And the baker answers that someone got sick from a pie he made with additions, even though it wasn’t his fault, so now he just follows the recipe. The patient says to the doctor: “This treatment isn’t working for me, what happened?” And the doctor says: “I got sued for personalizing care, so now I just follow protocol.”
Tired of this analogy? Me too. Here is the problem with cook-book medicine. You’ll come out with something that looks like quality care, but doesn’t really satisfy anyone. It’s nice to have guidelines, so you know in general how things are done by other doctors and experts in the field, but if you don’t have the freedom to use judgement gained by experience to adjust care to the patient at hand, the end product doesn’t work. I guess my point in all this is that quality care cannot be legislated and measured with strict guidelines. Quality health care is like good pie; you know it when you see it, and you leave it to the professionals.