By Evan Falchuk
The Jobbing Doctor, a primary care doctor in the UK, writes today about the British version of what Americans call “Pay for Performance,” or “P4P.”
He says something I’ve said many times before (like here, here, and here). Which is this: incentives fail because they try to treat medicine as an assembly line process, when it’s not.
But what’s most interesting about his post is that it could have been written by a doctor from anyplace on the planet Earth.
By Evan Falchuk
The American Cancer Society says that men over 50 need to seriously consider whether they really ought to get screened for prostate cancer. According to them, the risks of getting tested may outweigh the benefits of detecting the cancer, especially for younger men. They say it’s a “complex issue,” but they understate how complicated it really is.
Like the recent controversy over breast cancer screening, the new recommendations add to the swirling morass of conflicting messages and priorities around health care in America.
By Evan Falchuk
Japan is completely different from the United States. But it’s exactly the same.
I’m talking about health care, of course.
Japan is a country of about 130 million people, and one of the richest countries on Earth. They enjoy a system of universal health care coverage, and some of the best doctors in the world. But there are problems.
By Evan Falchuk
A new study out of Israel (h/t Robin Grantham via twitter) says that the kind of mood your doctor is in may significantly impact the quality of care you get.
On days the doctors felt positive moods, they spoke more to patients, wrote fewer prescriptions, ordered fewer tests and issued fewer referrals. However, when doctors were in a bad mood, they did the opposite.
Now, I bet this is true in any line of work. If you’re in a bad mood one day you probably aren’t as good at your job as on days you are in a good mood. Ok, well maybe not every line of work.
Still, if being in a bad mood leads to lower quality, higher cost medicine, let’s think about what the work life of a doctor typically looks like.
For starters, they often have to see 30 or 40 patients a day, and spend maybe 20 minutes with each. Private insurers and the government impose on them an increasing amount of administrative work. They’re also increasingly involved in the medical decisions the doctor works so hard to make. Doctors’ incomes aren’t going up, but the cost of their malpractice coverage is. Meanwhile, patients are increasingly demanding and sophisticated, the pace of change in diagnosis and treatment is accelerating.
It’s a set-up that seems exquisitely designed to create high levels of stress, anxiety, fatigue and burn-out, doesn’t it?
Of course, these were precisely the things the Israeli researchers said led to lower quality, higher-cost medicine.
The stress, anxiety, fatigue and burn-out we see, though, are just symptoms of a larger problem. Our system too often deprives doctors of the time and space they need to get to know a patient, think about their problem, consult with colleagues, and offer sound advice. These are the things patients want from their doctors. What’s more, doing these things are a big part of why people become doctors in the first place. Unfortunately, there isn’t much of anything in the health care reform proposals that addresses this deeply fundamental problem, and so it will continue, or get worse.
Which ought to create bit more stress and anxiety for the rest of us.
By Evan Falchuk
“We can no longer afford an overall health care system in which the thought is more is always better, because it’s not.” – Peter Orszag
Could anyone disagree? Not really. Which ought to be the first clue that it’s a meaningless truism. I mean, of course more isn’t always better.
But this hasn’t stopped this truism from becoming one of the most popular refrains in health care reform. Most of the time this is directed at one area: end-of-life care.
The idea is this: Americans spend too much money on heroic, but ultimately futile care at the end of people’s lives. Well-known research out of Dartmouth shows that that huge percentages of health care dollars are spent on end of life care. What’s more, it shows that this kind spending varies by big amounts, depending on which hospital you go to. For example, the federal government spends an average of $85,000 at Johns Hopkins, while spending less than $30,000 at Mayo Clinic. Reformers see the chance to save huge amounts of money by getting rid of these variations. Some say this could save the government a half a trillion dollars over 10 years.
It sounds good.
But here’s something you probably didn’t know: the Dartmouth study only measured spending on patients who died. If the spending saved your life, the researchers didn’t count it.
What the hell?
The New York Times (h/t Kausfiles) reports that some people are trying to take a clearer look at this problem, and conducting research that looks at the living, not just the dead. Those studies show that when you count patients who live, the difference between the most and least expensive hospitals narrows by as much as 44%. Government research that accounts for the fact that sicker patients often end up at more highly skilled hospitals further narrows the gap. Seen in this light, that potential half-trillion dollars evaporates pretty quickly.
This isn’t to suggest that variation doesn’t exist, or that some patients or their families demand care beyond the point where it’s beneficial. But it does show — again — how easy it is to get lured into oversimplifications of the problems in health care.
There are many people in health care who pore over the enormous amounts of data our multi-trillion dollar health care economy generates. They’re looking for patterns, big, systematic problems for which they can devise systematic solutions. But for all their looking, they keep missing the most important lesson of all. Which is that health care is not an assembly line process amenable to one-size fits all solutions. They miss that the answer to the most important question – what is the right way to treat this patient? – is a very unsatisfying: “it depends.” As one of the lead researchers of the Dartmouth study framed it: “Sometimes more medical care is better, but the question is when.”
Getting the right answer to that question isn’t a matter of protocols and financial incentives. Doctors want to get these answers right, regardless of the financial incentives, and so do patients. What is required to do this is a commitment to making sure each and every patient has the time, insight and judgment of their doctor. Yet our system fundamentally undervalues these things, and the reform efforts continue this mindset. If we continue to focus on how much money is spent, rather than whether that money is spent correctly, we will keep making it harder for doctors to get these answers right.
And people will continue to look at data, see puzzling results, and wonder how things ever got that way.
By Evan Falchuk
At the Wall Street Journal’s Health Blog, Jacob Goldstein writes that programs that pay more for better quality care are a “tricky proposition:”
Even if you can figure out what to measure, and how to account for differences between patient populations, you still need to have a decent sample size; anybody can have a bad (or good) day, so you need to measure a large enough number of events to minimize the role of random variation.
But 65% of primary-care docs work in practices that are too small to draw meaningful conclusions about the quality of care they provide (at least if you rely on Medicare data), according to a study published this week in JAMA.
Fair enough. But it begs the question: why would we need to pay doctors more for delivering quality service (whatever that term might mean)?
The hidden assumption in these kinds of programs is that quality problems in health care are caused by bad financial incentives. Since doctors are paid the same regardless of the quality of their work, they don’t care enough about whether they do a good job or not. Pay them extra if they do well, and you’ll see improvements as they try to earn that extra pay.
It might be true if the practice of medicine were like an assembly line. In that kind of work, the goal is to deliver large numbers of standardized products through a series of repetitive, simple tasks. People are good at this kind of work, and can be incentivized to deliver different kinds of outcomes, depending on how you pay them. Want more cars? Pay extra for hitting some production target. Want higher quality manufacturing? Pay extra for lower levels of defects. Robots do this kind of work even better, and you don’t even need to pay them anything at all.
But doctors aren’t robots, and this isn’t what medicine is all about. Of course, this hasn’t stopped the exact opposite from becoming the conventional wisdom about health care.
Costs are too high? Increase throughput and reduce unit costs. Or, in English, make the doctor see more patients and pay him less for each one he sees. Still too high? Get nurses to do some of the work so throughput can be increased even more. Oh, and let’s cut the pay, too. Meanwhile, let’s buy some new computer systems that will make work more efficient. Computer systems always do that. Let’s also come up with some quality measures, like maybe, 1,500 or so, and pay doctors a little extra if they meet some of them.
If it weren’t for all the politics surrounding health care, I think many people would find it amusing that anyone thought this was a very good idea. But it’s the state of the art in reform. And it’s characterized by a fixation on metrics that too often misses the bigger, more important, picture.
So what’s wrong? In health care, we do not have a consensus on what “quality” means. Some say quality should be measured based on outcomes, but even the very best doctor can’t ensure a good outcome. Sometimes the news is bad, and the outcome will be what it will be.
Instead, why aren’t we measuring quality based on what people really want from their doctors – the right diagnosis and treatment? As a patient, I would gladly pay more to go to a doctor who I knew was better at this than her colleagues.
As I’ve noted many times before, the fundamental mistake is prioritizing money over medicine. By focusing on ever more clever ways to design economic incentives, our system undervalues the very things that make it possible for doctors to deliver the right diagnosis and treatment. Things like time with the patient, thinking about his or her problems, consulting with colleagues, and coming up with sound advice.
If we want to remake our health care system, we need to start with the idea that the right diagnosis and treatment is the fundamental goal. Everything else we create should be based on whether it helps serve this goal, above all others.
By Evan Falchuk
Dr. Toni Brayer asks – is it dangerous for doctors to say “sorry?”
In the past, physicians were advised to never admit to a problem or to apologize for clinical errors with the thought that it would lead to more lawsuits. Saying “I’m sorry” might be taken by a lawyer as an admission of guilt and malpractice. Attorneys advised, “Say nothing” but that left patients with unanswered questions and often the feeling that the doctor just didn’t care.
She points out that some 35 states have passed laws that prevent a doctor’s apology from being used against him or her in proving a malpractice claim.
I understand why these kinds of laws may be needed. If you say you’re sorry for something, you are implicitly taking some degree of responsibility for whatever has happened. Plaintiff’s lawyers will use a doctor’s apology to the maximum extent possible to show the doctor knew what they did was wrong.
“Sorry” is, as wise people have observed, the hardest word in the English language. But why is this?
I think people like to think of themselves not as infallible in their actions but as infallible in their intentions. By this I mean, whatever I do, it will be with the right intentions. Even if something goes wrong, it will not be so much my fault so much as a bad twist of fate. Apologizing is, in this sense, a very un-natural thing to do. You haven’t done anything wrong.
But think of it from the perspective of the person who has been harmed by your actions. If you’ve hurt me in some way, I may conclude that the reason it happened wasn’t dumb luck but rather that you were careless, or at the least not concerned enough with my well-being. Your failure to apologize will look to me like my conclusions are right. You can’t even say you’re sorry? You must not care much about me at all.
It’s enough to make someone very angry. And it’s awfully easy for an angry person to find a lawyer who will listen to them. At that point, it’s too late for sorry.
Saying you’re sorry is so hard because it takes so much humility. We have to be willing to accept that not only are we imperfect in our actions, but we can also be imperfect in our intentions. Or at least that others may believe we are imperfect in our intentions. You have to be able to admit that, yes, it’s true, I wasn’t as attentive as I could have been. Or you know, you’re right, I can see why you would think I was being careless, I’m sorry for what I did.
So long as your apology is genuine, timely, and based on a true understanding of the problem you have caused, you will defuse the problem. But your work isn’t done. Apologizing doesn’t fix everything, it just gives you the opportunity to repair your relationship. So, saying sorry is not a cure for problems of medical malpractice, but it might prevent more cases than you think.
Still, there is something very wrong with the notion that we need to pass laws to make it so that an apology isn’t a legally dangerous thing to do. We should not look upon a doctor’s apology as something to be used against him, but rather as a sign of his humility and his caring for his fellow man.
If he has committed malpractice, there will be plenty of facts that can demonstrate it. Whether he acted as a good and caring person in dealing with the aftermath of a bad event ought not be one of them.
By Evan Falchuk
I’ve blogged for a long time (like here, here and here) about how the conventional approach to health care systematically devalues the thinking, processing and deciding aspects of medical decision-making. Among the symptoms of this problem is the limited amount of time doctors are expected to spend with their patients. For example, the latest government data show that the average doctor visit features face time with the doctor of less than 15 minutes.
Now, a new study is out. Some of those talking about it are saying the time problem is being solved.
Really?
According to the study, between 1997 and 2005, the average length of a doctor visit increased significantly. Well, statistically significantly. It went from 18 minutes to 20 minutes 48 seconds.
Does it mean anything? A study by ABC News earlier this year found that the number one complaint patients have about their doctors is the amount of time they get to spend with them. Patients don’t seem to be noticing much of a difference.
Still, the whole thing misses the point. You don’t go to your doctor to spend time with him or her. You go to the doctor to find answers to your medical problems. You go to your doctor because you want him to listen to you, answer your questions, and give you confidence about the next steps in your care. Having limited time with your doctor doesn’t help, but pushing the median to 22 minutes or 24 minutes or whatever isn’t the answer.
The answer lies in fundamentally rethinking our approach to health care. We need to move away from the fixation on units of health care and towards a focus on the needs of the patient. We need to have a profound respect for the doctor-patient relationship, for the time doctors are able to spend thinking about their patients. We need a system that puts these fundamentally qualitative measures of care at the center, and not the assembly-line metrics that have for too long moved health care away from serving the needs of patients and their doctors.
So, I guess it’s a good thing that patients have an extra three minutes of time. But health care shouldn’t be about reducing the rush your doctor is in to an acceptable level. It’s about things that are more fundamental, and more important, to patients and their doctors.
By Evan Falchuk
My post What Really Matters provoked a lot of interesting responses from doctors and others. But especially doctors.
In my post, I said that what patients really want from their doctors are three things: that their doctors pay attention to them; that they answer their questions; and that they give them the confidence that they’re going to do the best they can.
A round-up of the very insightful reactions is below.
By Evan Falchuk
Being sick is bad, and for a million reasons. I think the worst is the feeling of powerlessness. Yes, there are terrific doctors and more new tests and treatments than ever. But your fate depends on factors beyond your ability to control.
Doctors and nurses know this, because they see it every day. But most non-clinicians don’t. So the terrible reality of illness and the helplessness that comes with it is new, and difficult. As a patient, or the family member of one, you look to the doctors in charge to help you make sense of this distressing and unfamiliar situation. In an inherently uncontrollable situation, helping you deal with this is one thing doctors actually can control.
Most doctors are good at this to varying degrees. But too many of them aren’t.
I don’t know why, maybe some people just don’t have the kind of empathetic personality it takes to really help. Or maybe it’s just that it’s hard to be a doctor – you are dealing with a large number of patients and worried family members who may be unreasonably demanding. But it’s no excuse, people in other customer service related professions deal with these kinds of problems every day. And I can’t think of any reason why doctors should be held to a lower standard.
I don’t think it’s hard to define the things that doctors absolutely must be able to do in this regard. I’m not talking about keeping their appointments on time – I can accept that doctors are busy and most of us are willing to put up with the inconvenience of that. And I’m not talking about whether doctors have the skills and experience they need. I’m talking about how doctors are seen by their patients and families, regardless of how well they deliver medical care.
Here are the three things doctors must understand about what patients and their families want from them.
1. You want your doctors to pay attention to you.
Doctors are very busy, so you may only get a few minutes of time with them. Doctors may not realize how immensely valuable those moments are to a patient’s family. And so, too often, in their busy-ness, doctors check pagers or blackberries, or even take calls during these precious moments. There are few things that can make you feel less important than having the doctor you’re looking to for comfort decide that some unknown call or message is more pressing than helping you.
In a business setting, this kind of behavior is just plain rude. It’s that in a medical setting, too, but I think it’s worse. It undermines the relationship of trust the doctor must have with the patient and their family, and needlessly hurts them in a time of great vulnerability.
So, doctors, with respect, stop doing that.
2. You want your doctor to give you answers to the questions you are asking.
I recently observed an experienced and well-regarded doctor dealing with an anxious family member of a patient who had just been re-admitted to that doctor’s care in a hospital. When asked what the plan was for the next 24 hours, the doctor chuckled uncomfortably. I don’t know, he said, it’s just my first day back from vacation so I’m trying to catch up on things. It was a terrible answer, even though it was true.
It would have been much better, and equally honest, to say: “I don’t know yet, but here’s what I am going to do. I will talk to Dr. X and Dr. Y and review result Z and go and see the patient, and then I will call you to let you know.” It’s also an honest answer, but it doesn’t leave the impression that the doctor doesn’t take the patient’s situation, or the family’s anxiety, seriously.
Most patients aren’t unreasonable about this. They know that sometimes, there isn’t an easy answer to the question they are asking. But doctors need to understand that patients and their families usually aren’t looking for the word of God. What they want is just a sense that the doctor understands the situation and has some kind of an answer to the questions being posed.
3. You want your doctor to give you the confidence that they are going to take the best care of you or your loved one that they can.
Most people aren’t asking for miracles. But if a doctor gives the impression that he is distracted, or lacking confidence, or annoyed with you, they are undermining the relationship of trust they need to do their job effectively. I appreciate that some patients and families are demanding, and, at times, unreasonable. But doctors know better than anyone that those behaviors are often just signs of appropriate anxiety with a difficult, upsetting, unfamiliar situation.
So while the situation may be totally routine to you, it’s not to them. Some of the very best doctors, instead of being annoyed at the ignorance of a family or patient, take advantage of their experience to calmly explain what’s going on and what they are going to do.
If you do this well, people will run through walls to support you in any way they can. If you do this badly, they will run through walls to look for another doctor.
So, doctors, please accept my suggestions in the spirit with which they are given. I have great admiration for your profession, your many sacrifices, and your dedication your patients. Please help make sure your standards of service reflect the excellence of your care.
