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Practice vs. Performance

It is one of the most boring truisms on the planet: “Practice makes perfect.”  It is also one of the most misleading.  Practice merely ingrains certain patterns after deciding on the best course of action after constant criticism and problem-solving.  Performance requires that the body forget the work required to ingrain the pattern and let the pattern happen.  Performance requires that we drop all criticism and technical considerations.  These two activities are vastly different.

The transition from practice to performance, it turns out, is a matter of belief.  I was thinking about this today after reading Seth Godin’s blog.  Godin is a fantastic management and leadership expert who also happens to know a lot about performance.  Here’s what he said: http://sethgodin.typepad.com/seths_blog/2016/06/taking-notes-vs-taking-belief.html

Is there anything easier than listening to a lecture or reading a book and taking notes?  And is there anything more difficult than setting aside our preconceptions and the resistance and acting ‘as if’, being open to belief, at least for a moment?

Practicing is like taking notes.  You are trying to ingrain patterns in the brain.  At some point you have to decide that the ingraining process is complete and just go take the test.  You have to trust your preparation.

Another writer I really like is James Clear, a fitness expert and all-around wise man when it comes to making real change.  Here is a bit of one of the central tenents of his philosophy: http://jamesclear.com/identity-based-habits

Changing your beliefs isn’t nearly as hard as you might think. There are two steps. 1. Decide the type of person you want to be. 2. Prove it to yourself with small wins.

Here are some examples of what I’m talking about.

Suppose you are a patient whose doctor has told you that you need to make some lifestyle change for the good of your health.  You go and read every book ever written about this change, talk to five different experts, and draw up a fool-proof plan that you have memorized.  None of these things is worth anything unless you decide “I am the kind of person who integrates this life-style change into his everyday life.”  You have to take the knowledge (practice) and turn it into belief (performance).

Say you are a nurse who is trying to decide whether or not to go to medical school.  You read all the books. (Actually there really aren’t any on this subject although I’m working on one.  I haven’t quite gotten to the stage of believing I’m the kind of person who can write a book.)  You talk to all the experts.  You consult with people who have made the transition.  You decide medical school is indeed the best choice for you for all of the right reasons (a life-time project in itself).  None of this makes any difference unless you decide “I am the kind of person who can successfully complete medical school.”  Knowledge, and choice, into belief.

Or perhaps the contrary.  You decide that you are happy in nursing.  You don’t want to change.  You’ve done the research and made your choice.  Fine.  Same thing.  You’ve done the work, now commit to and believe in the choice you’ve made.

Maybe you are a young person from a foreign country and you would like to live and work in the United States.  You research your (legal) options, talk to friends who have been to the US, interview people who have done the job you’re interested in.  You’re not going anywhere unless you decide “I am the kind of person who can move thousands of miles from my family in pursuit of new experiences.”  Choice into belief.

Say you play a musical instrument and you want to get a good orchestra job.  You practice for 20 years, put in your focused 10,000 hours.  None of those hours count unless you can stop the self-evaluation you have been perfecting for 10,000 hours and trust that those hours have ingrained the necessary patterns and that, at the moment of performance, no more self-evaluation is needed.  You just play.

If you’ve done the work, just play.

Prove It

I was recently honored by a request to write a piece for the journal Outpatient Surgery.  Having duly provided a pithy and witty ditty about the Veteran’s Administration MD vs CRNA kerfuffle, the editor dutifully came back at me with an edit.  He said:  “Can you give a specific example of how the broad knowledge of medicine gives MD anesthesiologists an advantage?” or something to that effect.  Hmmm… trying to stir the pot, I thought.  Controversial?  You want controversial?  I thought.  So I sent out an email/text/tweet to my colleagues specifically asking for examples of how the broader knowledge of medicine gave them an advantage when it came to the safe practice of anesthesia.  Here are some of the responses I got (my friends will likely cease to be my friends after I post this):

“They’re [CRNAs, I assume] often pretty cocky and it’s usually because ignorance is bliss.”

“Just doesn’t demonstrate a solid foundation in the basics of physiology or pharmacology.”

“They often can’t think outside the box.”

“Physiology, pathology, pharmacology, anatomy is just not there.  I think it’s a depth of knowledge and problem solving skills.  Everything they know is very superficial.”

“Pathophysiology.  That’s why we make the plan.  They can complete it very competently, but don’t have the extent of knowledge regarding all conditions to make the safest plan for the patient.”

Of all these responses, the last is the only one that comes even close to a specific reason for the existence of the MD anesthesiologist.

Please don’t misunderstand – I truly believe that the presence of an MD in the supervision of the administration of anesthesia is very important.  But, friends, we need to be very specific and persuasive.  Simply saying “it’s not safe” and “we know better” isn’t going to sway administrators who see cost savings instead of patient savings.  We can’t just say we’re worth our price.  We have to prove it.

MACRA – doubling down on acronyms.

The Centers for Medicare and Medicaid Services (CMS) has felt your regulatory pain, apparently. They have watched you flounder in the muddy waters of ICD-10 and Meaningful Use.  They have agonized with you over Quality Indicators.  So, in an effort to “streamline” the “quality” metrics, and thus get a better handle on who is a good doctor and who is not, our wise legislators have come up a new, equally muddy law with the somewhat apocalyptic name MACRA.
MACRA stands for Medicare Access and Children’s Health Insurance Program Re-authorization Act of 2015.  Here is how CMS describes it: (https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/MACRA-MIPS-and-APMs/NPRM-QPP-Fact-Sheet.pdf)
“Currently, Medicare measures the value and quality of care provided by doctors and other clinicians through a patchwork of programs, including the Physician Quality Reporting System [PQRS], the Value Modifier Program, and the Medicare Electronic Health Record Incentive Program [meaningful use].  Through the law, Congress streamlined and improved these programs into one new Merit-based Incentive Payment System (MIPS).
So MACRA created MIPS.  And QPP  (Quality Payment Program).  Oh, wait.  MACRA created QPP.  MIPS is a pathway under QPP.  The other pathway is APM (Alternative Payment Models).  Clearly.  Try to keep up, will ya?
Here’s CMS again:
The MACRA makes three important changes to how Medicare pays those who give care to Medicare beneficiaries. These changes create a Quality Payment Program (QPP):
  • Ending the Sustainable Growth Rate (SGR) formula for determining Medicare payments for health care providers’ services.
  • Making a new framework for rewarding health care providers for giving better care not more just more care.
  • Combining our existing quality reporting programs into one new system.

These proposed changes, which we’ve named the Quality Payment Program, replace a patchwork system of Medicare reporting programs with a flexible system that allows you to choose from two paths that link quality to payments: the Merit-Based Incentive Payment System (MIPS) and Advanced Alternative Payment Models.

CMS continues:

Consistent with the goals of the law, the proposed rule would improve the relevance and depth of Medicare’s value and quality-based payments and increase clinician flexibility by allowing clinicians to choose measures and activities appropriate to the type of care they provide.

Wait, what?  There’s about 100 things wrong with this sentence.  MACRA does absolutely nothing to improve the relevance of the government’s “quality” indicators.  The indicators are, for the most part, completely irrelevant to actual quality. The metrics are simply percentages of people who received a certain treatment or test deemed appropriate by large organizations like the AMA.  Such percentages have little to do with the actual quality of the interaction between doctor and patient.   And the flexibility mentioned is merely the flexibility to choose between MIPS and APM.  Which isn’t really a flexibility since APM billing pays more.

Clinicians who take a further step towards care transformation – participating to a sufficient extent in Advanced Alternative Payment Models – would be exempt from MIPS payment adjustments and would quality for a 5 percent Medicare Part B incentive payments.

What is and Advanced Alternative Payment Model?  Bundled payments, meaning Accountable Care Organizations.  Remember those?  Lump payments to a group of doctors, money that they keep if they spend less than the lump payment, but that they’re on the hook for if they spend more.  CMS wants to funnel everyone into a bundled payment model.  Not super flexible, those CMS folks.

OK, one last thing and then I’ll quit bugging you.  Here’s the breakdown of the scoring for the incentive payment system:

10% – cost
50% – quality – based on six metrics
15% – clinical practice improvement (systems improvement, not personal improvement, I assume). 90 options to choose from!
25% – Use of EHR

To prove you’re a good doctor, you better use that EHR to document those quality metrics!  Otherwise, CMS might take away your lunch money.

No papers? No problem!

An immigration issue has come to my attention that I thought I would weigh in on.   I wrote a piece awhile back in support of Foreign Medical Graduates (FMGs) that bent a bunch of people over at KevinMD out of shape.  I guess that makes me an expert in all things foreign and medical-ly, because I was recently contacted by a reporter (Hi Alicia!) who wanted to know what I thought about admitting children of undocumented immigrants (themselves also undocumented if they were children when they came here) to medical school.  Apparently there are at least 60 medical schools in the country that are doing this.

I am not a believer in penalizing children for the sins of the parents.  Ever.  There are tons of good reasons and very few bad ones for granting children of undocumented immigrants the right to health care, education, and the same opportunities other kids have.  (I know!  Bless my bloody little liberal heart!)  The argument is made that denying such privileges further documental (documentary?) misbehavior on the part of people who want to come to this country to help their kids do better than they are.  How’s that working out so far?  The Department of Homeland Security says the population of undocumented immigrants grows by 275,000 each year (www.dhs.gov).  Denying resources to kids who arguably need them most perpetuates the poverty of their families and future generations of their families.  They’re coming.  They’re here.  Might as well help the kids, at least.

But wait, you say!  How About Helping Our Own Kids!?!?!  I’m not talking about a free ride through school.  The same chance for federal loans that everybody else gets would be fine.  Oh, did I mention?  Undocumented kids admitted to medical school are not eligible for federal financial aid.  So…not really an opportunity…really.

That political soapbox having been stood upon, let’s look at one of the discussions circulating around the issue of allowing the children of undocumented immigrants to go to an American medical school:  The Doctor Shortage.

Ah, The Doctor Shortage.  By this I assume what is meant is the lack of primary care and other services in poor and underserved neighborhoods and counties in the United States.  Because if you hold your arms out and spin slowly you’re bound to hit two or three doctors here in Boston.  We’re chock-a-block.  The Doctor Shortage problem has been farmed out to foreigners for years.  Everyone thought FMGs would fill this role.  Or People Who Speak The Language Of The Community (translation: black and latino doctors).  Now the undocumented.

Here’s a question for you:  Why the &^%$ would the children of undocumented immigrants be any more likely to go into primary care in their communities, or remote Appalachia, than any well-documented, voting-eligible medical student?  Especially if you deprive them of financial aid?  Out of the goodness of their hearts?  Out of concern for their paperless neighbors?  Maybe some of them.  But staring $200,000 in student loans in the face, especially high-interest private loans, makes plastic surgery a really attractive option, I don’t care who you are.  Also remember that putting anyone, but especially a smart, ethnically or financially challenged person, into the smart-kid, high achieving environment of medical school and residency, is inevitably going to show them the options available to them.  Furthermore, medical school and residency takes up most of people’s 20s.  Maybe a smart, talented immigrant falls in love with neurosurgery and the co-ed (non-immigrant) OB-GYN resident down the hall.  All the good intentions in the world aren’t going to convince this person that what they really want to do is take their beloved and treat colds and high blood pressure in a community in which only one of the couple feels connected.  Life happens while medical school happens.

Medical students, no matter where they come from or what papers they have, don’t go into primary care and/or into underserved communities for two reasons: money and money.  Medical school costs too much and primary care doctors get paid too little. (Well, one other reason – paperwork) I know!  More people getting their feathers up at KevinMD!  A doctor in such a community is making so many multiples more than the people they serve!  Doctors are so greedy!  Let me refer you here: http://www.kevinmd.com/blog/2011/04/real-life-medical-school-debt.html, or here: http://www.cbsnews.com/news/1-million-mistake-becoming-a-doctor/.

Here’s what I would suggest: children of undocumented immigrants are, arguably, lucky to be here and, if they’re smart, eager to grasp the opportunities their parents have attempted to provide them with.  If such a kid wants to go to medical school, great!  Provide him or her with the financial aid available to all kids, but put a binding contingency on it.  All undocumented students have to commit to a certain number of years of work in their communities or in other underserved areas.  And back it up with financial support.  The military already does this – medical students get med school paid for if they commit a certain number of post-residency years to military service.  Such a program also already exists in the private sector.  The National Health Service Corps offers substantial loan repayment for professionals who sign up for a certain number of years of service in an underserved area (https://nhsc.hrsa.gov/loanrepayment/).  The NHSC is, in my opinion, underutilized.

The Doctor Shortage will not be solved by making people who are Not Us do the work.  It will be solved by effective monetary and regulatory policies that make primary care in remote areas a viable and attractive option.

 

 

 

Gambling Man

My thanks to Dr. John Mandrola of  theheart.org/Medscape Cardiology for the idea for this post.  Dr. Mandrola is an interventional cardiologist but I forgive him for that because he also reads the fine print and dares to question the status quo, particularly when it comes to preventive medicine.

An interesting paper came out this month in the on-line medical journal Open Heart (a branch of the British Medical Journal) about one particular area of prevention – heart attack.  The researchers used data from a class of cholesterol drugs called statins, such as Lipitor, which have been shown to have a significant benefit in preventing ischemic heart disease (the study cites evidence that statins can decrease cardiovascular death by 20-30%, a number in some dispute).  You can find the whole thing here: http://openheart.bmj.com/content/3/1/e000343.full#aff-1.

The researchers crunched a bunch of numbers and talked to a bunch of people, and these were the results, in part:

  1. 50 year old smoker with high blood pressure and high cholesterol could have his life extended by up to two years by taking a statin.
  2. An healthy 50 year old who starts preventive treatment with a statin at 50 can see a lifespan gain of a mean of 7 months.
  3. BUT, of 100 of those healthy 50 year old men, 93 will see no life extending benefit at all. The other 7 gain a mean of 99 months.  99 months!
  4. Starting statins later than 50 does not increase the life extending benefit.  Quite the opposite.
  5. Of those healthy 100 50-year-olds, there is no way to tell which ones will be in the group of 7.

But here’s the most interesting part of the study – The researchers went down to the Underground (it’s a UK study) and asked around 400 people a simple question:  “Which would you choose – to take a medication that would guarantee you one extra year of life or to take a medication that gives you a 2% chance of living an extra 10 years?”  Then they extended the question – “How about if the medication gave you a 10% chance of living an extra 10 years?” and so on up to a 50% chance.  As you might expect, as the percent chance of getting the 10 years went up, more people chose the chance option.  But, there was always a significant percentage of people who never took the chance option.

So in a certain sense, taking a primary preventive medication, in this case a statin, is a game of chance.  Do you choose to take the medication in the hope you are one of the 7 or do you opt out based on the probability that you’re not?  How much risk are you willing to assume, all other things being equal?  The answers to these questions varies greatly among individuals.

Of course, there are many other factors that go into the decision to start a medication to prevent an illness you might or might not ever get.  There are considerations about side effects, cost, life-style, quality of life, etc.  However, all or most of those considerations are also subject to probabilities and subjective preferences.  Plus, you could die of something besides heart disease that you didn’t take a drug to prevent (or maybe you did but we all have to die of something and sometimes bad stuff just happens.) The take-home is that medicine is not an exact science and every person is different.  What is an acceptable risk for one is an unacceptable gamble for another.  Here’s what Dr. Mandrola says:

The point of this work is that it brings statistics, probability, and cognitive psychology to the doctor-patient relationship. When it comes to treating people with risk factors, not diseases, embracing uncertainty has always been important. But, now, as technology increasingly measures the human condition and creates more risk factors, comfort with gambling in medical decisions has never been more vital.

 

Humans will be human.

This week the governor of the great state of Massachusetts, my home state, signed into law a bill that puts strict limits on new opioid prescriptions, specifically a limit of a dosage sufficient for 72 hours, among other things.  This of course, is in response to the opioid addiction problem afflicting the country.  Many other states are taking similar measures.

I am of two minds on this.

Such laws are a good idea

First of all, why are these laws targeting doctors?  Well, we’re the source, at least in part, at least at the beginning.  It has become a habit with surgeons to send patients home with 30 percocet after a hysteroscopy, for instance, or a knee scope.  I can’t speak to the habits of other kinds of doctors, but according the the New York Times, primary care doctors prescribe the bulk of opiates in this country, so there’s habits there too for, say, back pain or a sprained ankle. (http://www.nytimes.com/2016/03/17/health/er-pain-pills-opioids-addiction-doctors.html?hp&action=click&pgtype=Homepage&clickSource=story-heading&module=second-column-region&region=top-news&WT.nav=top-news&_r=0).

Why so many pills?  For the same reason I sometimes (well, a lot of times) put pre-packaged snack bags of Goldfish in my kids lunch instead of cutting up fruit or putting baby carrots in sandwich bags.  It is the habit of human nature to go with what is easier.  Escalators vs. stairs, jarred marinara instead of homemade, roller bags vs. the kind you have to carry.  Dishwashers.  Those things guys put on their heads so they can drink beer out of a straw while watching football.  Quicker and easier.  The patient will not call you on the weekend for a refill.  The patient will not ask for more at their next office visit.  It takes a lot longer to tell a patient why they can’t have a drug than just give it to them.  It’s a hassle to explain to the people who do patient satisfactions surveys why Mr. Jones sent in a bad review because his doctor wouldn’t give him what he wanted.

On the other hand, it is generally taught in medical school that pain that doesn’t go away in a timely manner should prompt an investigation into why it hasn’t gone a way.  This is definitely true for acute pain.  If you’ve had your appendix out, 3-5 days of a mild narcotic should get you through the post-op phase.  If you’re still having pain requiring opiates after a week, the doctor will, or should, look for other causes of pain like infection or perforated bowel.  So in the case of acute pain in which the source is clear, Governor Baker’s (Charlie, of Massachusetts) new law makes sense.

Plus, the doctor can tell Mr. Jones it is not her fault – blame the government.

Such laws solve nothing

Studies suggest that giving patients a short course of opioids for acute pain does not lead to addiction.  Here’s Scott Strassels, a pharmacologist writing in the journal Advanced Studies in Pharmaceuticals in 2008.

…several studies have demonstrated very low rates of addiction among patients receiving opioids for acute pain. One chart review of nearly 12,000 hospitalized patients who received opioid medications identified only 4 patients with evidence of iatrogenic [treatment-caused] addiction.” (http://www.utasip.com/files/articlefiles/pdf/2nd%20article.pdf)

Secondly, anyone who has ever met an addict knows that restricting one source of his or her fix only sends the addict to a different source, i.e, the practitioner of the unregulated open drug market also known as your local heroin dealer. If my kid wants chocolate and my answer is no, they’ll go to their dad, the babysitter, the mailman, anyone else, hoping for a different answer.  This is because it is human nature to want chocolate and kids want what they want NOW.  Addicts are no different.  Doctors are not responsible for what people put in their mouths or how they choose to use the pills they are given.

Lastly, drug prescribing restrictions are, or can be, a trifle condescending.  Here’s Dr. Sarah Wakeman, a Massachusetts General Hospital physician who served on Baker’s Opioid Working Group, according to the Boston Globe:

“We prevent diabetes by limiting exposure to foods and beverages. We prevent lung cancer by limiting exposure to tobacco smoke,” she said at the news conference. So the proposed opioid prescription limit will help to minimize excessive exposure to opioids.”

Well, no actually.  We (meaning doctors I assume) don’t limit exposure to foods, we don’t limit exposure to tobacco.  We can recommend that people do these things, but people do what they want.  Opioid addiction is a problem because of behavior, not just opioids.

 

Let go and let God?

I have it on good authority that Christians are nice people.  They are super nice, and super generous.  If you are in certain kinds of trouble, a Christian will do anything to help you.  Prayer chains will stretch miles.  Casseroles will multiply.  Christians know that they are super nice.  In fact, they trust each other with their very lives, or at least the part of the body that rust doth corrupt.  They are, however, a tad judgmental,  particularly with regard to “moral” principles and certain branches of government.  It seems to some Christians that health insurance has become one of these issues.  Health insurance is Business, Government, and Coercion, plus some plans cover abortion and contraceptives. So Christians have come up with their own solution: The Health Care Sharing Ministry.
Here’s how the Ministry works, at least at Samaritan Ministries International:
Each member commits to sending a set “Share” amount each month. These “Shares” are sent directly through the mail from one household to another, to the members with “Needs”. Samaritan Ministries uses a database that randomly matches Shares to Needs, so that the Sharing is coordinated and Shares go to the appropriate members with Needs.
OK, so it is just health insurance but the language is different.  Shares are premiums and Needs are beneficiaries.  At Samaritan Ministries that “Share” is about $400/month.  Some organizations have members sent the money directly to the Needs folks, some have members sent the money to a central location from which it is distributed.  So far, so good.
Here’s the problem: there is no regulation on these groups, and no guarantees.  Here is a quote from the Health Care Sharing Alliance, an advocacy group promoting Health Care Ministries:
There is usually no pool of funds, but even when there is, there is no contract for future benefits and no assessment of risk. In fact, every member of a Health Care Sharing Ministry is responsible for paying his or her own medical bills. The purpose of the Ministry is simply to organize other people who voluntarily choose to help fellow members pay their medical bills in keeping with Biblical commands to “share one another’s burdens.”
(The “share one another’s burdens” comes from Galatians 6:2: “Bear one another’s burdens and so fulfill the law of Christ.”)
Ok, so the health ministries are just putting a human face on beneficiaries.  It feels better to pay into a system in which you know who is getting the benefit.  Especially is you agree with their world view.  Again the Health Care Sharing Alliance:
Insurance executives would think this is crazy — how can you rely on the goodwill of other people for paying bills? Exactly. It makes no sense at all in the world of business. It only makes sense in the Kingdom of God and the world of faithful believers. All others should stick with the insurance model.
Oh.  So relying on goodwill is really only for believers.  Which is just as well, because the Health Care Ministries benefits come with certain caveats.
1. No coverage for preventive services
2. No coverage for mental illness
3. No coverage for pre-existing conditions (sometimes)
4. You can’t sue the organization
5. No coverage for injuries caused by morally questionable behavior, such behavior I assume to be determined by whoever is administering these plans.  So STDs, HIV, out-of-wedlock pregnancies, drunk driving accidents, depression, schizophrenia… you’re out of luck.
So Paul’s letter to the Galatians really says that people who are true believers should share the burdens of other true believers unless the true believer’s behavior is not in keeping with the behavior deemed appropriate by said true believers.
Well that’s kind of unfortunate for Christian teens, who have a pregnancy problem related to lack of contraceptives and abstinence only sex education.  U.S. states whose residents have more conservative religious beliefs tend to have higher rates of teen pregnancy according to a new study in the journal Reproductive Health.  Joseph Strayhorn of Drexel University College of Medicine found “…a strong correlation between statewide conservative religiousness and statewide teen birth rates, even when they accounted for income and abortion rates.” (Bryner, 2009, http://www.wtamu.edu/webres/File/Academics/College%20of%20Education%20and%20Social%20Sciences/Department%20of%20Political%20Science%20and%20Criminal%20Justice/PBJ/2013/3n2/3n2_02MJM.pdf).
It would also be unfortunate for anybody with an unexpected premature infant or surgical complication – Samaritan only covers costs up to $250,000.
Ok, but maybe there are other reasons why Christians are opting out of regular health insurance.  Maybe health insurance is too expensive and these Health Care Ministries are cheaper. Many Christians are in lower income brackets.  The Pew Research center says that 35% of Christian families make less than $30,000 per year, and number that increases to 53% in African-american families.  Abby Goodnough of the New York Times (http://nyti.ms/1LTcSTJ) spoke to one family who had decided on a Ministry option.  The husband is a machinist and the mother is a stay-at-home mom.  They say that their premiums and deductibles are too high.  They would probably be eligible for subsidies under the Affordable Care Act.  They might also get medicare, except they live in Texas, which has chosen not to expand Medicare because it was Obama’s idea and they’re Republicans and most Christians are Republicans and Oh isn’t that interesting.
Sorry.  I digress.
Here’s Ms. Goodnough on the Ministry response to this objection:

Acknowledging that many families can qualify for subsidized insurance policies with free preventive care through the Affordable Care Act, Mr. Lansberry [James Lansberry, executive vice president of Samaritan Ministries International said that most new members were not “joining primarily on price; they are joining primarily on principle.”

On principle.  The same principle that Christian Healthcare Ministries of Ohio invoked when the guys in charge spent $15 million on homes, vehicles and excessive salaries out of the central fund where members had sent payments.

I hate health insurance as much as anybody.  But trusting your money and your life on a principle is dangerous.

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