By Evan Falchuk
Who do you think is likely to be a better doctor:
A board certified graduate of one of the top medical schools in America, or a non-certified doctor trained in a foreign country?
If your answer is “I have absolutely no idea,” then you’re probably spending a lot of time looking at the “report cards” that pass for measures of health care quality. And you’re probably confused.
After a week with business colleagues and doctors in Japan, I leave with three major impressions.
First, no matter how a country’s medical system is organized, there are troubling problems with the rising cost of health care. Second, even in Japan, a culture in which patients are especially respectful of doctors, patients are increasingly questioning decisions of their doctors. And third, the best doctors, all over the world, are deeply dedicated to the science of medicine and the care of their patients.
I’ve lined up the pictures of some of the doctors I saw below and share some of their stories, too.
By Evan Falchuk
You can’t generalize about the medical profession from talking to just one doctor. But there are striking similarities in the ways the world’s best doctors think about medical care. I had the honor to meet such a doctor yesterday, Dr. Takeshi Kawase. He’s Professor and Chairman of the Department of Neurosurgery at the School of Medicine at Keio University in Tokyo, Japan.
Dr. Kawase is a neurosurgeon, who specializes in skull-base surgeries. Interestingly one of his major specialties is operating on patients with the exact same illness my brother dealt with recently.
I learned a lot from my talk with Dr. Kawase. What else would you expect from a talk with a renowned medical professor?
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
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
There’s a lot of action happening in the states around health reform.
Last week, I was honored to be asked to testify to the legislature of the state of Michigan about their effort. Here’s my testimony (scroll to bottom for Q&A portion):
Here’s what the state is trying to do. (more…)
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
In my post yesterday about lessons we can learn from Israel’s health care system I wrote:
So, yes, the focus on health insurance reform will lead to many changes, and more complexity. And some day, years from now, someone will be explaining the American system to an audience, and people will wonder, how did anyone ever create a system such as this?
In response, a friend of mine challenged me: if the system is too complicated, how should we simplify it?
I wish more policy-makers were asking this question.
For me, the answer is clear: Primary care. Time was, your primary care doctor was able to serve as the hub of your medical activity. He or she could spend all the time needed to figure out what was wrong and to coordinate with your specialists. It’s not true anymore. Patients are left on their own trying to navigate the system. In many ways they end up acting almost as their own primary care doctors. Patients try to pick their specialists, find out what to do about their condition, decide on good treatment choices.
It’s a problem that is well reflected in data collected by Best Doctors from people calling for help with that process. Here’s our latest data on why people call:
Primary Reason for Call
Need help deciding among treatments 46%
Symptoms not improving 27%
Don’t understand diagnosis 20%
Skeptical of doctor 8%
It tells quite a striking story. Patients, on their own, end up struggling with some very fundamental questions. You could say that their primary care doctors should resolve these questions. But with typical primary care doctors carrying as many as 5,000 patients and spending 15 minutes or less in each visit, it shouldn’t be surprising that they can’t.
What’s worse is what happens in this environment. Studies – and Best Doctors data – show that 15% or more of patients end up with the wrong diagnosis, and more than half end up making the wrong treatment decisions. The biggest reason? The cognitive errors that happen when you try to make complicated decisions with fragmented information and insufficient time. We estimate that, on average, each time you fix one of these problems you save about $20,000. But sometimes it’s much, much more than that – and I’m talking about more than just money.
You don’t have to believe me, though. An increasingly significant body of research shows that focusing resources on primary care is the best way to address the fundamental cost and quality problems we face in health care. Reformers still aren’t getting it. Pay more money for primary care? The conventional wisdom says that doctors who say this are just trying to make more money for less work. Really? If a primary care doctor spends more time with his patients, he can do a better job figuring out the patient’s diagnosis, guiding them to the right treatment choices, and helping them, as a human being, cope with the difficulties of being sick.
So, if I had to pick just one thing to fix in our health care system, it would be this. Focus on making primary care the fundamental basis for the system. I think it is clear that it would save substantial amounts of money and lead to higher quality medical care. But it would do more than this. As Dr. Robert Centor said recently:
Patients need physicians who spend time with them. Patients need physicians who sit down, look them in the eye and talk. Patients need honesty and empathy.
He’s right. Any health care system, or health care reform, that doesn’t create a stronger doctor-patient relationship, is failing.
By Evan Falchuk
Health care reform has become a deeply political subject. And like other subjects that have become political, wading into them can be perilous.
Take two recent examples from the world of business to see what can happen.
In August, John Mackey, the CEO of the Whole Foods supermarket wrote an editorial in the Wall Street Journal on against the proposed health care reforms. From a policy perspective his views were within the mainstream. But from a political perspective he was sharply to the right of his customer base. The result? Whole Foods was hit with organized protests and boycotts. Mackey had greatly tarnished his personal “brand,” if not that if his company.
Another CEO did something similar just a few days ago.
James Guest, of Consumers Union (which publishes Consumer Reports) decided to run its first TV commercials in 72 years. Why? Guest wanted to take a public a stance in favor of the proposed health care reforms. Not surprisingly, Mr. Guest is starting to see the same kind of thing happen to him as happened to Mackey, just from a different side of the political spectrum. Mr. Guest’s mistake? His organization’s “brand” is that it is a independent, trusted resource. By taking sides on a fundamentally political issue, he has put that reputation at great risk. He’s tarnished the company’s brand, if not his own.
What does this have to do with doctors?
Doctors have a very special expertise and insight into medicine and medical care. They also enjoy a reputation as the most trusted profession in America. But they put that reputation at risk when they take fundamentally political positions – no matter how deeply felt – on an issue like health care reform.
Take, for example, the Rose Garden event the other day at the White House. The President held it to show that doctors support the reforms he does, and asked the dozens of doctors there to wear white lab coats to underscore the point in pictures. A few weeks before, doctors protested in Washington against these plans, also wearing their white coats. Why are they all wearing their white coats? Because they are trying to leverage their trusted “brand” to advocate for their political position.
Now, consider that much of what is in these health care reform proposals are changes to the health insurance market, not health “care.” The proposals are about long-term problems with the federal deficit, the uninsured, and the proper role of federal and state governments in addressing them. Doctors don’t have special expertise in these areas. They are just ordinary Americans with political opinions.
And this is the danger. As one smart blogger put it, “if you have a big megaphone be sure you use it to enhance, not detract from, your brand.” If your brand is trust and independence, it detracts from it to take sides in a political debate. Just ask John Mackey and James Guest.
What would make more sense would be if doctors could come together to support a refocusing of our health reform debate on what’s really important in health care: giving doctors the time and space they need to think about their patients, consult with colleagues, and give good advice. It’s something they uniquely understand, and which too few people realize is at the core of our problems in health care.
So, be careful, doctors. If you let the stain of politics set on your white coat, it will more difficult than you think to get it out.
