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If only they had a Walmart!

Funny/sad/irritating/out-of-context quote of the day:

“We have no malls and no Walmart.  Recruitment is nearly impossible.”

These astonishing statements were made by Elizabeth Nelson, a nurse practitioner in Nebraska.  She was not talking about teenage summer jobs.  She was not talking about professional Walmart greeters, addicts of cheap stuff made in China who want an employee discount, or people who really really like Cinnabon.   She was talking about doctors.

The funny/sad part is the thought that anyone, doctor, plumber, SAHM or astronaut, would consider the presence of a Walmart to be the defining element of a great zip code.  I don’t think Ms. Nelson really meant this.  I think she was pointing out that there’s not a whole lot of, well, anything, in Nebraska.  Nebraskans presumably like it that way.

Here’s the irritating part: The rest of the paragraph:

The doctor shortage remains. The hospital, Brown County Hospital in Ainsworth, Neb., has been searching for a doctor since the spring of 2012. http://nyti.ms/1HFm62F

Brown County Hospital has no doctor.  None.  Someone from South Dakota comes once a month to do paperwork and see patients.  So, Ms. Nelson has been providing the care in the emergency room at Brown County Hospital.  If she gets in real trouble she goes online and speaks to the doctor in South Dakota.

So, seeing this problem, Nebraska passed a law in March that said that nurse practitioners no longer need physician oversight to practice independently.  They’re doing it anyway, out of necessity.  The Nebraska Medical Society and the AMA predictably opposed this legislation, as they have in a half-a-dozen other largely rural states that have passed similar laws.  According to the New York Times, Dr. Robert Wah, the president of the A.M.A., said nurses practicing independently would “further compartmentalize and fragment health care,” which he argued should be collaborative, with “the physician at the head of the team.”  OK, fine, Dr. Wah.  If you believe that, then why don’t you help send doctors out there?  If the AMA wants so badly to prevent NPs from practicing independently, and believe me it does, mostly for turf reasons, where is the political advocacy for a reasonable cost of medical school, better tuition repayment, and increased medicaid reimbursements?  Is Dr. Wah willing to go be the head of the physician team at Brown County Hospital?  No.  Neither he nor any other doctor is.

Instead of funding another study to “prove” that NPs cannot practice primary care as well as physicians, fund a primary care physician.  In Nebraska.  Preferably one that doesn’t like Walmart.

 

Step up, pain doctors!

Fifteen months ago, the Federal Drug Enforcement Agency, or DEA for short, began an investigation in four states: Alabama, Arkansas, Louisiana, and Mississippi.  The DEA was looking for illegal drug trafficking, as they do.  But they were looking for prescription drug dealers, not Columbian drug cartels.  And they found them.  They are doctors.

Forty-eight people were arrested on Wednesday, seven of them doctors.  DEA agents went undercover and told doctors that their elbows hurt.  No exam, no X-ray, no history.  Just a prescription.  The agents secretly videotaped them urging their patients to overstate their pain.

In an era of diminishing trust in physicians, this is not OK.  Actually, in any era this is not OK.  This is not, never has been, never will be, OK.  I’m sure the American Academy of Pain Management will back me up on this.

“Getting them the care they need is a major challenge.  The D.E.A. tends to seize their medical records, so they have nothing to bring to the next doctor. And when they say who their previous doctor was, many providers don’t want to touch them for fear that they’re not legitimate.”

That, according to the New York Times, is Dr. Bob Twillman, the executive director of the American Academy of Pain Management, speaking about how patients with legitimate pain complaints could be caught up and harmed in this investigation.  Dr. Twillman is not a medical doctor, by the way.  He has a PhD in Clinical Psychology and Oh if that’s not blindingly ironic.  According to the AAPM, Dr. Twillman is responsible for federal and state pain policy developments.  He advocates for “those supporting an integrative approach to managing pain”.  He’s even Chair of the Prescription Monitoring Program Advisory Committee in Kansas.  A guy who can’t even write prescriptions.

Oh, but wait.  There’s another national Pain organization.  The American Academy of Pain Medicine.  Also, confusingly, AAPM.  Their website front page doesn’t say anything about Wednesday’s events.  It talks a lot about a 71-page National Pain Strategy, which is good…I guess?  Is the AAPM doing anything to mitigate this problem of physicians becoming drug dealers?  Well, they have Continuing Medical Education programs…

The program encourages multispecialty exchange of information concerning scientific advances in the field of Pain Medicine and its application to clinical practice. Providing quality pain care is a universal competency to providing quality medical care and as such, content areas must reflect the identified learning needs of physicians specializing in the treatment of pain, as well as providing quality pain continuing medical education to the physician community at large. AAPM CME program includes activities designed to improve knowledge in the major domains of Pain Medicine, improve competence in evidenced-based, pain treatment modalities (integrative and interventional), and provide applicable tools for mitigating risks, assessing, and managing the medico-legal aspects of Pain Medicine. http://www.painmed.org/education/

Not so helpful.  Well, who’s in charge of this AAPM?  A guy named Bill McCarberg, a real doctor this time.  A primary care doctor.  He wants the focus of his organization to be on, well, primary care.

Primary care is my background and my year as president of the AAPM will be structured to help define, organize and shape our relationship with the primary practitioner, the provider who is tasked with helping the vast majority of pain patients. http://www.painmed.org/membercenter/presidents-message/

The major advocacy organizations for pain management shouldn’t be drafting Pain Strategies, teaching doctors about the medico-legal aspects of anything, or dealing with primary care.  They should be loudly and aggressively denouncing the kind of behavior the DEA found over the last year, and in prior years as well.  Dr. Twillman shouldn’t be weakly suggesting that maybe such DEA raids might possibly be hurting some real patients.  He should be shouting to the hilltops that this sort of behavior is unacceptable and will not be tolerated.  Dr. McCarberg should be jumping on this with both feet.

Since doctors seem unable to police themselves, the Federal Department of Health and Human Services is going to try to do it for us.  Here is, in part what HHS wants to do:

Teaching medical professionals how and when to prescribe opioids by working with lawmakers on bipartisan legislation requiring specific training for safe opioid prescribing and establishing new opioid prescribing guidelines for chronic pain. http://www.hhs.gov/news/press/2015pres/03/20150326a.html

Lawmakers teaching medical professionals how and when to prescribe opioids.

Step up, pain doctors.  Make it clear that this is not what you do, not who you are, and not what you believe in.  Because to the world, it kinda looks like you don’t care.

Step In.

Allow me to wax philosophical.

I have a violin performance coming up in a couple of weeks.  It’s not a big deal but my debilitating performance anxiety makes it seem so.  I have had to work just as hard on performance as I have on scales and Bach.  In my quest I came across a newsletter written by Jeff Nelsen, a well-known and very successful french horn player and leader of a series of workshops, articles, and audio files entitled Fearless Performance.  I found this image in one of Jeff’s articles (http://www.jeffnelsen.com/blogs/fearless-conversations):

The Magic Line.  The idea here is that you work really hard, spurred on by a healthy fear of failure that compels you to the practice room, but then during the performance you drop the fear and just share what you’ve learned so far.  The line is the green room, the waiting in the wings before you walk onstage.  It’s where you go from preparing to performing.

I picture the Magic Line to be at knee height, for some reason.  And because my stage fright is so severe and starts so early (like now) my Magic Line is more like a wide Magic Zone.  Picture a horizontal, knee-height shimmering force field like Spock might have encountered in the early days of Star Trek.  When I am practicing pieces I know I will NOT be performing my Magic Zone is nowhere to be seen.  When I am practicing something I WILL have to eventually play for someone, my zone hovers beside me, nudging sideways on my knee.  That is, I am outside the zone but I know it is there and it feels dangerous.  It feels solid and sharp.  Historically, when my Zone shows up I run.

But what if I did something different?  What if, instead of running away, I step INTO the zone, just along the edge?  If I agree to a performance, however far away in time it might be, I have stepped into my Magic Zone.  If I do that, I’ll be scared and I might jump back out.  I do that a lot.  But what if I don’t?  What if I stand firmly in the Zone?  I might find that the Zone is not solid but completely painless and, in fact, it isn’t harmful at all.  In fact, I might find I can live with in the Zone quite peacefully.  There’s no danger here, I might find.  I don’t have to fear.  In order to find this out I have to STEP IN.  Take the risk.  Play the concert.

We as doctors must do a similar thing.  We spend many years in preparation for our performance of medicine.  In fact, we continue to prepare all the time, that’s why it is called “practicing medicine”.  We study and work with a healthy fear of not being able to treat our patients as they deserve.  But then we stand outside the exam room door.  Our Magic Line.  There is always a little bit of tension before we open the door.  What will we find?  What will this patient need from me?  Am I adequate to the task?  Will the patient like me?  We have to drop everything we’re afraid of, all the problems of our day, and step in to our performance space, our exam room, to share what we have learned.  For some of us the Magic Line is a Zone.  Maybe my anxiety over what patients I will encounter or if I will be able to help them starts when I get up in the morning, or the night before.  If I’m a surgeon maybe the Zone starts when I book a patient for surgery.

We could run away.  We could pretend we are somewhere else, distract ourselves with paperwork, computers, prescription pads.   We could protect ourselves from the Zone by not committing to our relationships with our patients.  But then we bring our fears over the Magic Line and don’t perform as well.  And our patients aren’t helped as much.

Drop the fear.  Step In.  Share what you have learned.

 

If I had a million dollars…

I haven’t had much to say on this blog recently, largely because nothing in the news has irritated me enough to employ my (arguably) formidable powers of ridicule.  Then my husband saved the day by bringing home a letter.  It reads, in part:

I am writing to inform you that Massachusetts General Laws Chapter 112, section 8 requires all fully licensed Physicians who practice in Boston to register with the Office of the City Clerk.  The City of Boston Code, Chapter 18, section 1-16 (22) establishes a fee of $100 for a submission in compliance with this state law.

There follows an official-looking form with a whole bunch of “herewith”s and “tendered”s, to be signed (with check or money order payable to The Office of The City Clerk) by the physician and the Clerk of the City of Boston.

Of course, all physicians in Boston are already registered.  By the Massachusetts Board of Registration in Medicine.  Apparently Boston has just seceded from Massachusetts and the news hasn’t made The Globe yet.  Or the Board has lost the $500 checks from all the physicians in Massachusetts last year and can’t afford a computer system, in which it would be easy to type in “Boston” and get a list of all the physicians who practice in Boston.  There’s 31,000 doctors in Massachusetts according to the Kaiser Family Foundation.  Should be enough for a decent used Dell or something.  Strangely, a quick Google search doesn’t reveal the number of doctors in Boston, but if you assume a third of the total number, that’s about 10,000 doctors.

I’m looking around the city for some big expensive public works project that costs a million dollars, or some official whose salary just added a couple of digits.

Oh, wait.  Boston 2024?

Public schools should follow the ABA’s example.

Humans are social creatures who naturally evaluate where they stand in relation to those around them.  I have no idea how this evaluation process evolved, but at some point we noticed that some cavemen brought more food to the cave than others.  The idea was born that some people are better hunters than others.  We’ve been trying to decide who is “better” ever since.

The origin of the word test comes from Middle English, and referred to a vessel in which metals were assayed.  That is, the test determined what kind of metal was present in the vessel.  So a test functioned as an identifier, similar to the way certain medical tests identify specific bacteria.  Today most people, when they hear they are being tested, don’t think about the test as just a source of information.  People think of testing in terms of evaluation or comparison, a judgement about some aspect of their knowledge or abilities.  Someone is better and someone else is worse.

Here is how Merriam-Webster defines test:

1. A critical examination, observation, or evaluation.
2. The procedure of submitting a statement to such conditions or operations as will lead to its proof or disproof or to its acceptance or rejection.
3. A basis for evaluation.
4. An ordeal or oath required as proof of conformity with a set of beliefs.
5. A procedure, reaction, or reagent used to identify or characterize a substance or constituent.
6. Something (as a series of questions or exercises) for measuring the skill, knowledge, intelligence, capacities, or aptitudes of an individual or group.
Notice the terms “critical”, “ordeal”, “measuring”, “evaluation”.
We have tests for everything.  And people are getting sick of tests. Observe the growing backlash against public school testing in New York (http://nyti.ms/18c2jrq).  Observe the questions arising about medical testing (http://www.boston.com/dailydose/2012/05/21/psa-screening-for-prostate-cancer-gets-thumbs-down-from-federal-panel/ip80Gu1FRujF8B7mTGfNEJ/story.html).  Observe the pushback from physicians over maintenance of certification exams (http://www.anesthesiologynews.com/ViewArticle.aspx?d=Commentary&d_id=449&i=January+2015&i_id=1138&a_id=29115).
Some tests are good, right?  A blood test to identify HIV is good.  Quizzing yourself after reading a difficult passage in a textbook is a good test.  Covering up the multiplication tables and seeing how much of it you can do by memory is a good test.  Testing the gem in your engagement ring to make sure it’s diamond and not cubic zirconium is a good test.  What makes a good test?  The Center for Public Education says that test should be “valid, reliable, and free of cultural bias”.  Essentially, a good test reliably measures what you want to measure, and, presumably, doesn’t measure what you don’t want to measure.
Let’s take an example.  The PSA test evaluates the blood for a prostate-specific antigen that, in high amounts, can be an indicator of prostate cancer.  So it measures PSA.  That’s all it does.  It does not measure how much time a man has left, or mortality rate, or rate of prostate cancer growth, or what the man will eventually die of.  In short, it gives you a number that you can’t use.  People think a PSA will tell you if you will die of prostate cancer.  For that you’d need a good test.  Like a crystal ball.
Here’s another example.  Common Core tests kids as early as third grade.  The problem with these tests is not that you don’t get useful information.  It is that the information you get is not what you want to measure.  The test is supposed to measure knowledge but instead tests memorization.  It is supposed to measure learning but measures test-taking ability.  And actually it isn’t supposed to measure knowledge or learning, but teacher quality.  But the test is not administered to teachers, so the test not only doesn’t measure what you want it to but tests the wrong subjects.  The result is that students and parents think the test measures the intellect and worth of the student, and school districts think the test measures the intellect and worth of the teacher.  The same problems exist for the maintenance of certification (MOC) exams in anesthesia and other specialties.  The tests are time-consuming and expensive and measure memorization and test-taking skills that have nothing to do with quality care.
By some unbelievable miracle, the American Board of Anesthesiology has just announced that they are getting rid of the MOC tests, largely in response to vocal backlash by physicians.  Hopefully a similar outcry from a growing number of parents can effect a similar change in the public schools.  It would take a miracle.

Would You Like Fries With That?

Glancing through the latest issue of  Anesthesiology News, the independent newsletter for anesthesiologists, I was yawning through subjects like Enhanced Recovery After Surgery, aspirin for cardiac surgery, and stellate ganglion blocks for PTSD (?!) when I turned to page 30 and there, luminous on their glossy paper, two articles about “customer value”.  Here’s how one of them starts:

“Like all workers, anesthesiologists must determine the best way to serve their ‘customers’ – the hospital, surgeons, patients and bill payors.” (Crist, C.  Marketing 101 for Anesthesiologists: show your value. Anesthesiology News, 41(4), April 2015, p30).

(The italics around the word customers was not added by me.)

“Anesthesiologists should follow age-old marketing advice: Identify customer needs, develop products to meet those needs, and communicate those products to the consumer.”

(The need for marketing might have to do with the ongoing CRNA-MD war being fought between the ASA and the AANA.  Maybe.)

“Show that you can get it done.  Be a hard worker, facilitator and collaborator.”

The authors suggest that instead of sitting by our anesthesia machines we should be helping the surgeon tie his gown, answer phones for the nurses, and open sterile packaging for the scrub techs.  This is how we prove our value to our customers, the surgeons and OR nurses.  Sort of a generally nice, helpful guy.  Like a waiter.  This kind of behavior is, incidentally, what is recommended to medical students to prove that their presence in the OR is not just a hindrance and/or nuisance.

Then, on the very same page, a lawyer by the name of Mark Weiss tells us that our real value is measured by our ability to create an “experience monopoly”.  The EM, or E +Phe+PQenv = strength of unique experience, is “providing such a valuable experience to patients, referral sources and facilities that they deem you their preferred partner, one that they can’t see themselves doing without.” (Weiss, M.  Do you make this mistake concerning customer value? Anesthesiology News, 41(4), April 2015, p30-31).

Mr. Weiss points out that people have preferred dry cleaners or restaurants because of the personal and environmental touches that give customers a good experience and thus keep them coming back.  In medicine, this lawyer suggests, an EM has three components: expertise, physical environment, and relationship environment.  And expertise is the least important.

“Of course, the goal is for you to increase the level of performance within your medical group across each of the components.  Note especially that you must focus on the human experience and environmental factors – all physicians understand the importance of medical expertise, yet that expertise alone, and certainly, that expertise tamped down by the impact of a poor environment and an even poorer experience is worthless in terms of creating relationships with patients, referral sources and facilities that over a career will prove extremely valuable.”

Expertise worthless, waiterly obsequiousness priceless.  Got it.

So I’ve got my order book and my pen, my apron, my black running shoes, and a big wide grin.  I went to waiter school, and I’m ready to serve.  But there’s a problem.  Nobody in my restaurant wants the same thing.  Everyone wants it their way.  If I make suggestions based on my experience with the food I’m told to stay out of it and bring me what is requested.  One guy says he wants cheap food and doesn’t care much about quality.  Another customer says quality is his highest value, and you “can’t put a price on quality, am I right?”  The lady at table 8 insists on putting ketchup on her tacos even though I know it is not standard of care for tacos and might even be harmful to her.  But I am a waiter, here to please, so I bring the ketchup.  Soon after, the cook comes to me complaining that I am overusing ketchup for unnecessary and frivolous uses and must refuse ketchup for all tacos in the future.  My boss tells me to hurry up with my orders, then gives me three more tables.  Now the food is coming out quickly, but the dishes aren’t being cleared and the aesthetic experience in the restaurant is tarnished.  I’m still smiling, but I’m now I’m confused.  Why did I go to waiter school if no one takes my advice?  Why is the guy who wants cheap food sitting with the oil baron for whom price is no object?  How can I please the lady who wants ketchup on her tacos, and who will give me a good or bad evaluation in the form of a tip, and the cook who considers ketchup on tacos to be wasteful at best and malpractice at worst?  And where’s the bus boy?

 

Internal Motivation

Everyone is very excited about Congress’s elimination of the annual CYA known as The Doc Fix.  For a refresher go to the excellent piece at The Health Care Blog by Steven Findlay (http://thehealthcareblog.com/blog/2015/04/08/sgr-rip-hopefully/).  Also in that legislation was an increasing push toward paying doctors for a group of patients, instead of by individual or by service, and giving monetary rewards to doctors who have better quality metrics.  This is supposed to save money by taking away the doctor’s incentive to see more patients and order more tests.  It is also supposed to increase quality by tipping the doctors, as I’ve discussed before.

OK, so I have a primary care doctor.  I am healthy, I eat right, I don’t smoke, I drink moderately (most of the time), I (used to) exercise.  Most men and women in my particular demographic do all of these things as well.  I have access to quality food, a gym membership, and health insurance.  Say my doctor participates in the proposed arrangement: she gets paid for a block of patients and, if those patients do well, she gets a bonus.  I love my PMD, but she would be getting a bonus for doing NOTHING.  I haven’t seen her in at least 5 years. The annual physical has been largely discredited, I haven’t reached the age-related screening test juggernaut, and I have the freedom to do everything I can to be healthy.

Let’s say I am not healthy.  I’m overweight, in my 50’s, I have a bad knee and had a heart attack last year.  My blood pressure is high and I quit smoking, but not soon enough.  Maybe I live in a low-income neighborhood and healthy food is not readily available.  I can’t exercise because my knee is bad, and also because I’m working two jobs, one during the day and one at night.  Let’s say my PMD has been seeing me once a month, has given me blood pressure medication, sent me to the office nutritionist and the social worker, checked my blood sugar and cholesterol, ordered my mammogram and colonoscopy, and kept the office open on Saturdays so I can actually make an appointment.  Despite these interventions I’m still overweight, my blood pressure is still high (because I can’t afford the co-pay), I haven’t had my screening tests (because I work two jobs and those guys don’t work weekends).  Now my PMD, who has worked her butt off for me, gets no bonus.

Health care administrators seem to be operating under the assumption that doctors won’t do good work without monetary incentives.  They also assume that people’s health depends on the good work of doctors.  They further assume that the quality indicators they have chosen actually indicate quality, and finally, that doctors have full control over their quality numbers.

But Shirie, you say, you are always complaining and moaning about how broken the system is.  How about you give us an alternative?  Not everyone can be an arrogant one percenter like you.

Provide health care for all patients who want it, change malpractice laws, and salary everyone.  Give every doctor a salary commensurate with the amount of money and time doctors spend in training so that they can support their student loans, their office overhead, and a moderate lifestyle.  So doctors go to school, graduate, and get good jobs.  If said doctors want to make more money they either a) quit and go into banking, or b) earn bonuses by taking care of sicker patients, or underserved populations, or the poor.  This solution offers the following advantages:

1. Doctors have good jobs that they don’t have to stress over.  Each patient gets the time they need and there are no production pressures. Quality rises as a result.

2. All patients have access to health care, so there are no uninsured folks waiting until their diseases are really bad before seeking help.  On the other hand, people who don’t choose to take charge of their health don’t penalize their doctors as a result.

3. Bonuses earned are for useful work, not data points.

4. Tests and medications are not ordered on-demand or because of fears about litigation.

5. All the overhead and CEO salaries for private insurance companies goes away.

But Shirie, you say, you arrogant one-percenter socialist, won’t that make doctors lazy, since they have no incentive to do a good job?  They can just while away their days because they get paid regardless.  Well, isn’t that what all the members of the US Congress are doing most of the time?  My kids’ kindergarten teacher gets a salary.  Why wouldn’t she do the same?  My mailman gets a salary.  What prevents him from wrinkling and/or soaking my mail and delivering it days late?  There is the threat of being fired, of course, but there is also the possibility that the teacher and the mailman like what they do and care about doing it well.  Why do we assume that doctors, or anyone else, will do a terrible job unless we incentivize and/or punish them?  We are not toddlers.  Most of us have an internal motivation to be good at what we do.  We just need to be given the right environment in which to do it.

 

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