By Evan Falchuk

If a web site touted misleading health care information, you’d hope the government would do something about it.  But what do you do when the government is the one feeding the public bad information?

Last week, the Obama administration launched the new Healthcare.gov.

It’s mostly an on-line insurance shopping site.  It is very much a federal government version of sites like eHealthInsurance.com or Massachsetts’ HealthConnector site, which have been around for years.  So when HHS Secretary Kathleen Sebelius, in announcing the new site, claims it gives consumers “unprecedented transparency” into the health care marketplace, you should wonder what she means.

But that’s not the big problem with this site.

Right there in the middle of the top of the page is a big tab that says “Compare Care Quality.”  If you click on it, you are taken to an “interactive web tool” that claims to show you “44 quality measures” about hospitals.  The site says it will help you compare the quality of care hospitals provide.

I decided to look at hospitals in the area where I live, Boston, Massachusetts.  It gives you a list of hospitals in your area, and gives you options to compare hospitals based on medical conditions and surgical procedures.

I decided to compare the Brigham and Women’s Hospital in Boston with the Hallmark Health System in Melrose.  If you don’t know these two facilities, the Brigham is a Harvard teaching hospital, justifiably world-renowned in many areas of care.   The Hallmark Health System is a network of community hospitals, which I suspect most people even in the Boston area aren’t familiar with.

I decided to run my search based on the idea that I was trying to help someone with breast cancer.

The first problem I ran into is this: they don’t have any data on breast cancer.  Actually, they don’t have data for cancer at all.  The only things they can tell you about are chest pain, heart attack, heart failure, chronic lung disease, pneumonia and diabetes in adults.

How about a search on surgical procedures?  Nothing again.  My only option is a “general” search.

Ok, well, I guess it’s a work in progress.  So how do the two hospitals stack up?

They give you a few ways to compare, but the one that I think most pertinent is “outcome of care.”   If you click on that you see that “outcomes” are based purely on how many people died who had a heart attack, heart failure, or pneumonia.  So much for my “general” search (and my cancer patient).

So how do they stack up?  You can’t tell the difference.  Both hospitals are “no better than the national average” in two categories, and “better than the national average” in one.

You get more detailed information – but it only makes things worse.

For example, in death rates for heart attack, the Brigham and the Hallmark hospitals are both “no better than the national average.”  Is that good?  It turns out that that “above average” hospitals are as rare as four leaf clovers – out of 4,569 hospitals in their data set, only 95 are better than average (2%). Only forty-five (1%) are worse than average.  Two-thousand seven hundred and forty four (60%) were “no better than the national average.”

The other 1,685?  They don’t have enough data to figure that out.  The smart money says they’re all “average,” too.

Maybe if I just compare them to other Massachusetts hospitals I will get a clearer picture.  Nope.  Out of 65 hospitals measured in Massachusetts, only nine were better than the national average (14%).  Fifty-one were average (78%), and zero – zero - were worse than average (5 didn’t have enough data).

I know health care in Massachusetts is good -but not a single hospital is below average?

It is deeply misleading to consumers to suggest they inform their health care decisions in any way shape or form by this kind of data.  It’s not that the data is incomplete – it is – it’s that even within the data you can’t tell the difference between a major teaching hospital and a local community hospital.

I’d love to know if the people presenting this as a useful tool for consumers think it really is.  It leaves you knowing less about the differences among hospitals than before you use it.  That’s shameful because the site encourages people facing medical situations to use it for that purpose.  The only thing it is going to do for sure is heighten patients’ anxiety, and make their decision-making more difficult.

Some thoughts for a Friday.

What do you think?

By Evan Falchuk

That’s the headline in today’s Boston Herald. It tells the story of young Michael Sanders, who was born in 2007. Michael went home from the hospital but after a few weeks in which he didn’t seem right, his mom, Denise took him to the doctor.  As the Herald reports:

A seemingly routine doctor’s visit brought devastating news: the baby had a fatal, congenital heart defect and just a few weeks to live.

“They said he would never, ever have a normal functioning heart,” his mother recalled, “and they said nothing could be done to fix it.”

The parents, Chris and Denise, got a second opinion from another doctor that supported the original finding. They didn’t have much choice. They brought hospice workers into their home, and started to make arrangements for Michael’s funeral.

At work, Denise had Best Doctors as an employee benefit. She decided to call and see if there was any hope, or if she really had to face the reality of her awful situation. “I was a little afraid to call at first,” she said, “but then I thought, at least it will confirm what I already know.”

After gathering and reviewing Michael’s records, Best Doctors consulted with Dr. Pedro del Nido, chief of cardiac surgery at Boston Children’s Hospital. Dr. del Nido told them very unexpected news – Michael had been misdiagnosed. In fact, he told them, he could fix Michael’s defect and allow him to live a completely normal life. In May 2008, he had the surgery, which went extremely well.

Today, Chris and Denise brought Michael, now almost 3, to visit us at Best Doctors, along with Michael’s big sister Katie. Michael is a very outgoing and playful 2 year-old. He attends pre-school at his family church, where I’m told Michael was greeted as a hero on his first day of school. The community had rallied around young Michael after he was born and during his surgery and recovery, and so his arrival at pre-school was a milestone in the lives of so many people.

Chris and Denise both told me they don’t know why our paths crossed, Best Doctors and the Sanders family. We are honored that they did. And we are grateful that they came to see us today to share their story, and to give us a chance to meet them and their wonderful son. I know I am also thankful for the many people at Best Doctors that helped Michael through his journey, especially Helen Thomas, one of our member advocates.

It is a freezing cold day today in Boston, but not in the offices of Best Doctors.

Michael, earlier this year in Boston

UPDATE: The local Fox affiliate in Boston is covering this story tonight at 6. And the local NBC affiliate will have it on this evening as well. Video to follow.

UPDATE 2: A complete round-up of media coverage is here.

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

In today’s Booster Shots, Shari Rowan says sometimes patients “shouldn’t hold on to hope.”

She describes research that suggests that patients that have a realistic view of their medical situation do better than those who don’t.  One of the authors of the study said that hope “is an important part of happiness. But there’s a dark side to hope.”

I think she’s talking about just another form of denial.   These are patients – and, often their families – who suffer not only from a disease, but also of the psychology of how they deal with it.  As I wrote at the time:

I remember my father, who is an internist, telling me stories [of] . . .people with obvious, visible effects of a disease, but who weren’t getting any care.  It wasn’t that they had no one paying attention to them – often they had family and friends almost begging them to go and get help.  They just refused to go.

It is a reaction that I think is common to anyone who has suffered from a serious illness.  You don’t want the bad thing to be happening, it’s much easier to deny its existence.  The thinking is: I don’t want to be sick.  If I need medical treatment, then that means I’m sick.  So I will not seek medical treatment.

It’s much worse if the family of the patient is in on it, too, enabling the denial.  And I’m sure it’s devastating to those family members who want to see their loved one get help, but can’t get them to listen.

Misplaced hope is really the same.  Of course, realizing this is not the hard part.  Figuring out when your hope is misplaced is the hard part.  Is it really true that the condition is irreversible?  Sometimes it’s easy to say “yes,” or “no,” but very often the answer is “we don’t know.”

What then?

The struggle – the journey – for a patient or the family of a sick patient is trying to figure this out.  Are you doing more harm than good by fighting to get a better outcome, when you’d be better off just accepting reality?  Or are you doing yourself or your loved one a disservice by giving up when there are things you could do to make their situation better?  And as a family member of a patient, is it all really dependent on you?

— Whatcha got ain’t nothin new. This country’s hard on people, you can’t stop what’s coming, it ain’t all waiting on you. That’s vanity.

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.

By Evan Falchuk

There’s a case for killing Granny?  I guess so, or at least according to Evan Thomas’ article in the most recent Newsweek. Thomas, after sharing the story of his mother’s last days, concludes that death is the key to health care reform:

Until Americans learn to contemplate death as more than a scientific challenge to be overcome, our health care system will remain unfixable.

Does everything need to have a political spin on it nowadays?

But let’s take Thomas’ advice and talk about death.  Not “death panels,” not the politics or the cost of end-of-life care.  Just plain old death.

I was reminded recently of how fragile life is.  It made me remember something I read after our oldest child was born.  I realized that one day she would learn the truth about death.  And I thought how bad that was, and how I wanted to protect her from it.  But then, by chance, I happened across this interesting little saying.

When your children are young, all you think about is that you don’t want them to die.  But when they get older, all they think about is that they don’t want you to die.

It touched me, and it made me think about how my responsibility to protect my children extended even unto and beyond my own death.

It’s a nice philosophical point, but there are very practical things each of us can do to fulfill this responsibility.  Here is my list of just a few of the very important things we all should do to plan for our deaths:

Buy life insurance

If you’re young and in reasonably good health you should be able to buy a term life insurance policy for a few hundred dollars a year.  You should do this so your family can have your earning potential replaced in the event of your death.  Find a good insurance broker and make sure you get coverage that suits your needs.  Even if you have a pre-existing condition (like a chronic illness) a good broker should be able to find you some kind of coverage.  You won’t be able to buy any coverage at all if you become acutely ill, so don’t wait until it’s too late.

Make a will

This is so much more than just planning for your family’s financial future.  For example, if you have children, have you figured out who will take care of them if both you and your spouse die?  There are many important and potentially difficult conversations that go along with this kind of planning – but you’re much better off having them now.  After you die, those left behind will end up fighting out these issues not knowing your wishes.  Find a good lawyer to help you.

Make an advance directive

You need to think about what kind of medical care you want if you become incapacitated and unable to decide on your own.  Do you want to live for 30 years on a ventilator, unconscious?  Do you want to undergo extensive and painful treatments if you don’t have much hope of a meaningful recovery?  Don’t leave your family alone trying to make that decision for you, wondering what you would have wanted. Write down what your wishes are.

Appoint a health care proxy

Pick someone who you trust to make your medical decisions for you if you are unable to do so.  Write it down and make clear what you want that person to do, so if the time comes there isn’t any dispute among your family as to who is in charge.

There are many other things you can do, but to me these are four of what I think are the most important things you can do to prepare for your death.  Maybe some commenters can add some more that I missed.

Now, with all that said and done, I will still disappoint Mr. Thomas.

Why?  Because I still prefer to think of death as a scientific challenge to be overcome.  And you know, I’m glad that many other people feel that way, too.

Especially the people who make medical breakthroughs – I’m really glad they feel that way.

By Evan Falchuk

Everyone’s busy trying to figure out what the President is going to say in his big health care reform speech tonight.  I’m more interested in predicting what he won’t say.

Here is my list of three things the President won’t talk about tonight – but should.

Patients have far too little time with their doctors

Government data show that nearly 60% of doctor visits feature face-to-face contact with the doctor of less than 15 minutes.  But not because most doctors are abusing the system.  It’s because for years government and private insurers have paid less for care, forcing doctors to see more patients just to keep up.  Ironically, it probably ends up making health care more expensive.   Not letting doctors take the time they need with each patient makes care fragmented and uncoordinated.  It creates an increased likelihood that something will be missed, and a greater chance that a bad decision will be made.  It’s why almost everyone knows someone who has been lost in the system, trying to get their doctor’s attention, knowing something was wrong in their care.  Some of us are lucky and avoid tragedy, others are not.  Our system should pay for doctors to spend the time it takes to make sure care is done right.  It’s already happening at some medical centers, but it’s not the norm.  It should be.

Patients are far too uncertain about their medical care

Patients find huge amounts of information on the internet and feel more comfortable than ever taking it to their doctors for an explanation.  It makes the life of a medical professional pretty difficult.  And it makes the life of a patient vying for the doctor’s limited time that much worse.  It’s why patients report, in large numbers, that they feel uncertain about their medical care.  What’s more distressing is that they are often right to worry.  Studies show that 15% or more of patients have their diagnosis missed, delayed or wrong.  Other studies show that the biggest driver of these results are the cognitive errors that happen when you make complicated decisions with fragmented information and restricted time.  If we’re going to have a new entitlement program it ought to be this: everyone is entitled to be sure that their medical decisions are right for them.

The ways we measure quality aren’t very good

Health care quality is conventionally thought of as bringing concepts of high-quality manufacturing processes to medicine.  Just as there is a right way and a wrong way to attach a door to a car, there also is a right way and a wrong way to treat a patient.  And so, government and private quality programs have looked for ways to measure process and to ensure doctors adhere to it.  For example, the federal government has catalogued almost 1,500 “quality measures,” everything from whether your pediatrician told you about using a booster seat in your car, to whether your cardiologist took a specific set of steps before prescribing a certain medication.  But medicine isn’t an assembly line process.  Treating it that way fundamentally undervalues the thinking, processing and deciding aspects of medicine – the things that are so important to you as a patient when you are sick.  While some doctors are starting to sound the alarm, the larger point is this: quality ought to be a question of whether the patient got the right care.

These issues are at the core of the problems we face in American health care.  And while I expect the discussion tonight to be about costs and public plans and exchanges and coverage and compromise, I will be very happy to be wrong.