By Evan Falchuk

You have a right to your medical record.

It’s true – the record of every test and procedure you’ve had done, any films or studies, your doctors notes.  It’s all yours if you ask for it.

But it’s not that simple.

If you’re sick, your “record” is likely in pieces in lots of different places.  Some of it is in paper files and computers in the offices of each of your doctors, or in the clinics where you had a test or procedure.  It’s in multiple computer systems in a hospital, or in a folder in a radiology department, a container in a pathology department, or the computer system of a pharmacy.  Each of these places has their own policy or procedure if you want your record.  There are forms you have to fill out, fees you have to pay, time you have to wait.

So while you have a right to your record, for practical purposes, you’re going to have a very difficult time actually getting it (by the way, this is something our team at Best Doctors does very, very well).

But let’s say you actually get all of your medical records.  Now what?

A national study called OpenNotes, is trying to find out what happens when patients get easy, rapid access to their records – or at least their doctors’ notes.  The early results are mixed.  Some patients say it helps them understand what’s going on.  But some doctors say it leads to extra time with worried patients, adding to doctors’ already heavy case load.   The final results will yield better insight into both of these issues.

But it all reveals a larger issue:  There is a divide between you, your doctor and your medical information.

As your doctor opens up his paper file and logs into his local computer system to reacquaint himself with you, he is looking only at a fragmented piece of your medical history.  He is likely missing valuable pieces of context about you.  Those gaps may not matter very much.  But they might.

All of this is an argument for having electronic medical records, and of course billions of dollars are being spent on this.  But all you have to do is spend time in a hospital or a doctor’s office to know that we are a very, very long way away from making this a reality.  And so as a patient, one of the most important things you can do is exercise your right to get your records.  Make sure you understand what they say, and use every resource at your disposal to make sure you get the care you deserve.

By Evan Falchuk

According to the Annals of Internal Medicine, doctors make the wrong medical decisions surprisingly often.

Using a “mystery patient” technique – in which actors pretended to be patients – researchers found that doctors made errors in complicated cases in 60% to 90% of cases.  Sixty to ninety percent. In uncomplicated cases, they made errors in nearly 30% of cases.

As one study participant put it, “I was shocked.”

The study took place over 3 years, and included more than 100 doctors in six Chicago-area hospitals.  The doctors had agreed to participate in a study on medical decision-making but had no idea that they might see a patient who was actually an actor.  The actors recorded their conversations with the doctors.

The actors used scripted medical situations.  In each case, the actor presented their medical situation, but mentioned “red flags” that should have caused the doctors to pay attention and change their plan of care.  According to the LA Times:

Researchers used the audio recordings and medical records to calculate how often physicians picked up on red flags signifying possible complications and consequently adjusted their plan of care. The failure to do both counted as an error. In contextually complicated encounters, error-free care was provided only 22 percent of the time; in biomedically complicated encounters, the error-free rate was 38 percent.

The researchers called this a “failure to individualize care.”

So what’s going on?

Regular readers here won’t be surprised to hear how one participant explained the failure to pursue these red flags.  Doctors, he said, are under “incredible time pressure and don’t want to go there because it could open up a whole can of worms.”  There’s likely a lot to this explanation. It’s hard to expect even the most gifted clinician, trying to make it through yet another week of a hundred or more patient encounters, to get these difficult decisions right.  Too much of the context of a patient’s care gets lost in the endless churn of patient visits that the health care system imposes on doctors.

I suspect this is enormously frustrating for doctors, although it’s worse for patients.  What the researchers call a failure to “individualize care,” a patient might call “not being paid attention to.”  It’s a dynamic that anyone who’s been ill has probably seen first-hand.

As policymakers talk about comparative effectiveness and electronic medical records and all the rest, they keep repeating the same mistake that brought us to this point.  They fail to understand that doctors need time – time to think, time to reflect, time to consult on their patient’s case.  Time to sit with the patient, time to understand their situation, time to help them make the best decisions.  Time to use their intellect and their training.  Time to make clear to their patient the truth:  that they care, and are here to help.

And so until the time comes when we place the relationship between doctor and patient at the center of everything we do in health care, we’ll continue to see tragic results like those found in this remarkable study.

By Evan Falchuk

Yesterday, the Senate yesterday rejected the so-called “doc fix.”   This means that doctors taking Medicare patients will now get 21% less pay for their work.

How’s that getting involved in politics working out for you guys?

Not so good.

But there’s a larger issue here.  Why do we keep trying to control health care costs by just mandating that less money be spent?

It’s failed for decades.  But like a losing gambler that is convinced that if he just keeps doubling down, he’ll finally come out ahead, people keep trying.  For example, the New York Times reported on a study of the impact of pay cuts to doctors for Medicare patients with lung cancer.

The unexpected result, according to one of the authors:  “Hospitals and doctors [] respond to changes in how they are paid.”  (Really?) In this case, doctors ended up treating more patients to make up for lost income.  Other doctors who didn’t want to increase their case load just decided to leave practice entirely.

As another of the doctors who wrote the study said, when you “squeeze” the system, there is a lot of change, “but not always the one you expect.”

So, why do we keep trying to “squeeze” the system?  It doesn’t work, and has all kinds of bad unintended consequences.  The majority of doctor visits have face-to-face time with the doctor of 15 minutes or less.  A fast-growing body of research shows that the time squeeze on doctors has a serious impact on quality.  Some studies show that 20% of patients get with the wrong diagnosis.  The leading cause?  The mental mistakes people make when they have to make hard decisions with not enough time and not enough information.

Instead of asking where can we cut, we should be asking more important questions.

Things like, how well can a doctor do his job if he goes from seeing 100 patients a week to 150?  How is the quality of care affected if experienced doctors find it better to stop practicing?  What happens if smart young people decide that medicine isn’t an appealing profession anymore?  And, most importantly, how much more expensive is our health care system going to be if we have increasing problems with the quality of care?

So, here is a radical idea:  instead of trying to figure out ways to cut health care costs, let’s think about how to make sure the money we are spending on health care is spent correctly.

Over the next 10 years America is going to spend $30 trillion on health care.  The real challenge is to make sure we spend that $30 trillion wisely.  It needs to be spent to make sure each person has the right care.  If we do this, we will look at health care differently.  We would ask – are there enough doctors?  Do they have enough time to make good decisions?  Are they making the right decisions?  Are patients getting the right care?

There are many people laboring to bring these issues into focus.  Patients, doctors, scientists, hospitals, employers.  But there remains much work to do, and doctors are critical to making this happen.

So, doctors, please, instead of trying to fight losing battles over Medicare reimbursements, fight for a real “doc fix.”  Fight to make sure that the the relationship between you and your patient is at the core of our health care system.  Fight for the ideal that whether each patient gets the right care is the only way to measure whether our system is truly any good.

UPDATE: At the always-interesting ACP Advocate Blog, Bob Doherty notes that the Congress is in the process of fixing this 21% cut in reimbursement (well, as Bob notes, sort of).  It’s worth reading the whole thing because he gives typically excellent insights into how hard it can be to square medicine and politics.

By Evan Falchuk

Some things are just part of the problem in health care.  The company “Medical Justice” is one such thing.  I’ve written about them before.

Medical Justice sees the medical malpractice crisis and devised a solution: muzzle the patients.

It’s as misguided as it is ridiculous.

Medical Justice says doctors need to stop their patients from saying bad things about them.  They charge doctors hundreds — or even thousands of dollars a year — to help do this.

Under one of their programs, they give doctors contracts to use with their patients.  The doctor tells the patient that they must agree to the terms of the contract before the doctor agrees to see them.   Ok, so there are lots of forms that patients need to sign when they go to the doctor.  What makes these so different?

Well, with these, the patient has to agree that they will not make anonymous comments on the web about the doctor.  They also have to agree that if they do make comments that aren’t anonymous they will only do it on sites that meet some “minimum standards of credibility.”  If a patient does these things anyway, they’ve broken the agreement and are now subject to being sued by the doctor.

At least one source reports that Medical Justice has another feature in its agreements:  making patients transfer their copyright over these web postings.  That way, the doctor can then send a DMCA takedown notice and have the criticism removed from the web right away.

It’s quite a modern spin on bedside manner.

Think about what it would be like to be presented with these agreements at the doctor’s office.

You’re there, sick, trying to get help.  But instead of helping you in your time of need, your doctor’s first priority is making sure you don’t say anything on the web about what he does.  Well, unless he likes it.  As a patient, the first thing I would think is, “should I be worried about this guy?”

And this is why what Medical Justice does makes things worse.

Patients are vulnerable, needing help, and looking to their doctor as that one source of certainty in a frightening world.  Patients want to feel that the most important person in the doctor-patient relationship is them, the patient.  But by starting off the relationship with contracts like these what the doctor is clearly saying to the patient is, no, I’m the most important person in this relationship.  It disparages and undermines that sacred relationship between doctor and patient by treating it something like buying a used car.

There are patients who will follow their doctor into the grave if they trust them.  And there are patients who won’t take the best advice in the world from a doctor who they don’t trust.  Doctors who use Medical Justice must realize they are sowing the seeds of distrust.

By Evan Falchuk

I gave a speech yesterday at the Midwest Business Group on Health’s 30th Annual Conference.  The MBGH is one of the country’s leading organizations on health care, and its members include the leading innovators and thought leaders on health care in America.  It was a privilege to present to them.

I spoke about why health care just isn’t a consumer business, in spite of all of the efforts to turn people into health care “consumers.”

Read the text of my remarks below the fold, it was a very interesting day.

At Best Doctors, we have a close up view of what happens to people when they try to find their way through the health care system.  It’s not a pleasant picture.

Health care consumers – if you can call them that – are often lost, confused, frustrated, alone.

There was a time – perhaps – when your doctor could help you work your way through.

Some doctors still can.  But the truth is that time has largely passed.

I want to talk to you today about what it means, then, to be a health care “consumer.”

There are three major barriers to health care “consumerism.”

First, time.

According to the latest National Ambulatory Care Survey the majority of doctor visits feature face to face time with the doctor of 15 minutes or less.

Fifteen minutes.  I think we all know what it is like.

In some ways, health care reform will make this worse.  In Massachusetts, where I am from, we passed a reform that some people think is the model for what just passed nationally.  Today, for the first time, we have waiting lists to see doctors in Massachusetts.  In part, it’s because of newly insured people trying to use the system.  It’s hard to predict what will happen as we add 40 million new people onto the insurance rolls.

The second barrier is this:  patients don’t know what questions to ask.

There is no practical way for a patient, faced with a new illness or even one they’ve had for a while, to get the level of training, experience and judgment that their doctors have.

Dr. Jerome Groopman, from Harvard, wrote a terrific book which you may know.  It’s called How Doctors Think.   In it he says patients have to partner with their doctors, ask them insightful questions, interrupt their normal thought process.  It sounds good, but it’s a very difficult thing to do.

Now, at Best Doctors we help patients do this.  But doctors will tell you that working with patients who are trying, on their own, to make sense of their situation is one of the biggest challenges they face, too.

Patients show up with reams of stuff printed off the internet.  Doctors want to help, but it’s difficult to spend that 15 minutes sifting what’s relevant and what isn’t.  It’s a recipe for frustration and dissatisfaction for both doctor and patient.

And it’s part of the third major barrier: how do you know what doctor to see?

It’s hard to know if a doctor is good or not.  There are lots of ways to ask around and find things out, and people do this all the time.  And of course, we do this at Best Doctors, too.  But you know what I think?  I’m not sure if it’s even the right question.

I mean, if your cancer has been incorrectly diagnosed, what does it matter if you are getting treated by the best surgeon in the world?  The wrong treatment is the wrong treatment.

And so there are consequences of these barriers to consumerism.

There is a growing body of research that isn’t getting the attention it deserves.  It’s being done by doctors you probably haven’t heard of, like Patrick Croskerry and Mark Graber.  They are publishing ground-breaking studies that show that 20% or more of patients end up with the wrong diagnosis.  The leading cause?  Cognitive errors – mistakes in thinking – that happen when doctors make important decisions with limited information and not enough time.

Everyone’s familiar with other studies, that show that half or more of patients don’t get the recommended treatment.  At Best Doctors our data, across millions of people is almost precisely the same.  We see that about 20% of people get the wrong diagnosis and about 60% have something wrong with their treatment.

I believe the problem is the way care is delivered in the United States is broken in ways that are not easy to solve.  And if you’re you’re sick, you don’t have time to wait for the system to change.

Let me tell you a story that gives you an idea of what this is like.

You know the movie the Wizard of Oz.  There’s a scene where Dorothy gets to a fork in the road.

Everyone said, just follow the yellow brick road.  But no one warned her there might be a fork.  When she got to one she had no idea what to do.   The only person she could ask was the scarecrow, but he couldn’t offer much help.

He said he had seen lots of people go by, but he had no idea how to get to the Emerald City.  Still he offered to help.  But he warned Dorothy- look, you need to understand, I don’t have a brain.

Dorothy didn’t have much choice, so she took his help.

It’s like this if you are trying to be a consumer in health care.  You’re going to reach points where you have to make a decision.  Maybe your doctor is great and can help you.  Or maybe you have a family member or friend who is able to help you.  But most people aren’t so lucky, and so they end up trying to get help from whoever happens to be there.  And that’s not good.

Now that’s a Hollywood story.  But let me give you another Hollywood story.

This time, it’s a real one, and it’s about my brother, Brad.  You may have heard of him, or at least his show.  He is the co-creator of the Golden-Globe winning show Glee. But about 2 years ago he almost died.

One day he woke up with numbness on one side of his body.  He went to his doctor who told him he probably hurt himself working out.  When it didn’t get better, he was sent for an MRI.   It brought bad news – there was a malignant tumor in his spinal cord.  He went to see a leading neurosurgeon, who told him how these kinds of tumors are treated.  Radiation first, then a delicate surgery to take out the tumor.  You face a likelihood of being paralyzed from the surgery, he was told, but you have to do it, because otherwise you’ll die.

That scared him, and he called me.  I guess it’s because I’m the President of Best Doctors and don’t have my own TV show.  But we treated him like we do anyone else.  We collected all of his medical information, and we had doctors review it all.

Now, if you ask a neurosurgeon, how do you treat a malignant tumor, he is going to tell you something very much like what my brother’s neurosurgeon told him.  What we do is to say, wait, before we start talking about tumors, let’s make sure that’s what’s really going on.

When our doctors reviewed my brothers records, they found that he – well, we – have a family history of a kind of malformed blood vessel.  It’s possible, with this history, that this is what was showing up on the MRI.  We asked an expert in this kind of thing and he said don’t radiate or operate.  Do a different test to make sure it’s not one of these malformations.

We sent that information to my brother and his doctor, and they did the other test. It proved that he didn’t have a malignant tumor.  The thing in his spinal cord was one of these blood vessels.

Now, he still needed surgery, but it was very different from what was planned.  And in fact if they had radiated this blood vessel, it ran the risk of making it bleed – causing a potential catastrophe while he got completely unnecessary treatment.  The work we did saved his life.

So, when we talk about being a health care consumer, remember Dorothy.  And remember my brother.

Remember that when someone is faced with an illness, they find themselves in a new and unexpected place.

In a situation where they aren’t sure which direction to go, and to whom they can turn.

In a world in which the consequences of their decisions can be very costly to their health, and, as employers, to your pockets.

But as people – and all of us here are people, I need to give you some advice.  If you or someone you love gets sick advocate for them, and for yourself.  Ask questions.  Use every resource are available to you.  Don’t let yourself fall through the cracks.

If you’re here, and you’re listening, for your own sakes, for your families, and for your employees, know that you can make a difference.

By Evan Falchuk

The Wall Street Journal’s Health Blog says that cancer lab tests “aren’t always right.”

They report on reports issued by two professional societies that point out that as many as 20% of a certain kind of test are inaccurate.  According to the Health Blog the problem is the tests “aren’t black and white, and rely on a pathologist’s judgment.”

Now, judgment is a critical factor in most everything in medicine, but perhaps nowhere else are the consequences of incorrect judgment so serious as in pathology.  As Dr. William Osler famously observed: “As is your pathology, so goes your clinical practice.”

But how widespread is this problem?

Published studies show that as many as 50% of pathology errors are due to “misinterpretation.“  Countries outside of the U.S. have been quicker to recognize to this problem, with the British and Canadian authorities trying to deal with major scandals resulting from the terrible harm that can come to patients from these kinds of misinterpretations.

We see these kinds of problems in our work at Best Doctors, too.

In cancer cases, we have learned that it is critical to have pathology re-reviewed at a major teaching hospital in order to make sure that the initial read was correct.  In our data from thousands of U.S. cases over the last 24 months, covering a very wide variety of cancer, we found that 15% of diagnosed cancers had misinterpretations in their pathology results.  In many cases, the correct interpretation led to major changes in the patient’s treatment plan.  These results track closely with the results of published studies on the problem.

Your life may depend on the judgment, and experience, of the pathologist.  If a pathologist has seen your kind of disease 1,000 times, he or she is going to be much more likely to interpret your sample correctly than one who has one seen it only a few times.  The trouble is, you likely have no idea who your pathologist is, what kind of experience they have, how long of a day they had had by the time they got to your sample, or likely anything else about what they did or who they are.

Ask questions.  Don’t be afraid to ask for a second opinion in which your pathology is going to be re-reviewed by someone else.  Your pathologist’s judgment is probably excellent, but if it’s not the consequences can be severe.  Be sure you are completely comfortable with what you’re being told before you do anything.

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.

The Jobbing Doctor talks about a UK program that started in 2004 called the Quality and Outcomes Framework, or “QoF.”   Now, the American “P4P” is a much more catchy name, so score one for American marketing.  But it doesn’t matter what you call it – that which we call a rose would, by any other name smell as sweet.

Or, as in this case, as sour.

According to the Jobbing Doctor, QoF has actually increased costs (or at least doctors’ income- he says it went up 33%) because the government seemed to have underestimated the extent to which doctors were already delivering high quality primary care.  He also notes that because the guidelines are so crude and so focused on certain illnesses, there are incentives to meet targets rather than understanding a patient’s medical condition.  It’s pretty much the opposite of what doctors are taught to do in their training.  And his complaints about QoF sound very similar to complaints from doctors in other countries about the impact of such well-meaning efforts by government and private industry.

Which is the larger point.

As Jobbing Doctor put it so eloquently, measures like these distort the practice of medicine and take it away from what is really important:

The other downside is that ideas like the QoF diminish a profession’s values and judgements, meaning that high quality care is not driven by an internal motivation for doing a good and valuable job well, rather we have to be driven by targets.  Targets are the antithesis of professionalism.

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.

Here’s what I mean.

In recent years there has been a big public effort to get men to educate themselves and get tested for prostate cancer.  For example, Major League Baseball has turned Father’s Day into its own prostate cancer awareness day.  Their central message: the disease is treatable if caught early, so talk to your doctor, and get tested.

To show how important it is to get started with this at the right age, a key spokesperson is 51-year old baseball legend Ozzie Smith.  Ozzie says men as young as 40 need to start thinking about it, and to “take the plunge” by the time they are 50.

Ozzie says men as young as 40 need to start thinking about it, and to “take the plunge” by the time they are 50.  Star slugger Jim Thome, 39, has also been recognized by the player’s union for his work on prostate cancer.  Even President Obama is doing his part.  The 48-year old had a PSA test as part of his physical exam.

Now the American Cancer Society says that most men don’t need to start even talking to their doctor about this until they are 50.  It’s all very confusing.  And when you listen to people like Warren Buffet saying we need to declare a “national emergency” to control health care spending, you might start to wonder other things.  Like, if these screenings cost money, and may not be all that necessary, is someone going to use recommendations like these as an excuse to just stop paying for screenings?  After all, aggressive screening saves only about 6 men out of every 1,000.  What’s six lives in 1,000 when there’s money at stake?

Still, I respect that there is a real medical issue here, and so does the American Cancer Society.  They say that doctors need to spend the time to educate their patients about the risks and benefits of testing and to help their patients make the right decisions for themselves.  This is good, but there’s a bigger problem: time.

According to CNN, Dr. Herbert Lepor, chairman of urology at NYU Langone Medical Center in New York, put it well:

[I]t is impractical to suggest that a primary care physician who has 15 to 20 minutes to spend with a patient fully explain all the pros and cons of screening in the course of an annual physical.”How do you present this to a patient? You can’t possibly spend an hour discussing this,” Lepor said.

During the same 15- or 20-minute physical, the physician also has to discuss issues like blood pressure, diabetes, exercise and diet.

So we come back to the same old problem.  Medicine should be about a doctor and a patient working together to get the best outcome.  They need time with each other to do that.  But our system has different priorities.  It says, health care should be about trying to stop doctors and patients from spending too much money.

It’s a mistake.  And what it means is that all the well-intentioned efforts by people like Ozzie Smith, Jim Thome, President Obama and the American Cancer Society to help people get things right end up lost.

UPDATE: Advocacy groups complain that complex new guidelines are confusing men about prostate cancer screening.

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.

The country is is straining under the twin burdens of an aging population and rising health care costs.  At some point in the next two decades, retirees will outnumber active workers.   Medical expenses per person have almost doubled since the 1990s and continue to rise.   In a country with little immigration and low birth rates, it’s a bad combination.

The government’s response has been to try to limit what it spends on health care.  To simplify the situation, Japanese have a mandatory co-payment of 30% of all medical expenses, with some types of treatments or diagnostic testing not covered at all.  There is talk the financial burden on individuals may increase.  It’s one of the reasons that private insurance policies that give cash payments in the event of illness are especially popular in Japan.

In terms of access to care, there have been other issues.  It can be difficult to see a specific doctor at a specific hospital because of well-meaning efforts to keep every doctor busy.  Some doctors and patients have responded by joining private, membership-only clinics where those with the ability to pay can get VIP access to the doctors they want to see.

More generally, Japan has been suffering from shortages of certain specialists, like obstetrics.  It happened because the government miscalculated the need for these specialists over the last couple of decades.  In the last year, there was a major controversy over a case in which a pregnant woman suffering from a cerebral hemorrhage was rushed to a hospital in an ambulance but was turned away by 7 successive hospitals because of the lack of OB support to help her. She was finally taken in by the 8th hospital and died there — the baby survived. There have been other stories like this, raising questions about both the government’s role in picking the right number of doctors to fund in Japanese medical schools and the way in which hospitals treat patients in need of help.

But in each of these areas – and others – the story is very familiar.  The equitable and affordable distribution of health care services is a problem across the globe.  And so the work we do at Best Doctors to help people is just as needed.  When you’re sick, no matter where you are from, you want to feel confident that you are getting the right care.  I think it’s something we are all entitled to have.  The millions of Japanese with access to Best Doctors are a testament to this.

Yesterday, I had the chance to visit with some of the Best Doctors team in Tokyo, executives and clinicians dedicated to helping people get the right care.  They do extraordinary work, and you can see some of them pictured below.  Over the next few days I’ll be seeing some of the most renowned physicians in Japan — not as a patient! — and will share some of their insights on this fascinating country and medical culture.

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.