Response to Michael Cannon

More on Cannon and the USA Today article from 2007.

I have had trouble responding to Michael Cannon. I knew when I first read his response to my critique of his USA Today Op-Ed (that’s a mouthful to follow) that more should be said. He spent most of his time defending incorrect referencing in his Op-Ed, but there was something more. The more I read, the more I perceived a purposeful selection of data in support of an existing position. I am more familiar with the scientific method which requires the writer to follow the data, including contradictory evidence. Mr. Cannon comes from an ideological perspective to which I cannot relate. Perhaps no response is required for ideologues. After all, what is the purpose of the Cato Institute but to purvey a particular ideology?

I have a libertarian streak, but I am no libertarian. These ideas serve as a reminder that there are limits to what government can and should do. There are limitations to the financial resources of any society. I do not believe that there should be a single payer or that everyone is entitled to every possible medical intervention. But as I dig deeper, my understanding is growing of the ideology which shares these principles.

First let me direct some comments directly to Michael’s defense of the USA Today Op-Ed:

  1. To minimize the number of uninsured is to miss the point that there are vulnerable people in society who need some assistance. The government has a role in improving the quality of life of its citizens by supporting education, defense, law and order, health care and probably other areas as well. To believe the government has no role whatsoever is false, intellectually on the fringe and historically on the road to revolution.
  2. To suggest that all people covered by Medicaid would be better off with private insurance is as ignorant of the lives of the poor as Mariah Carey talking about poor starving kids and flies and death and stuff. Crowd-out as Michael Cannon describes is another name for cherry-picking. To force low-income individuals who are most likely to cost insurers more money is to keep private insurance more profitable for the insurers.
  3. Most medical care is not cost-effective, as measured by macro-level indicators. Since leaving Canada I have learned that no country ever became great by trying to be cost-effective, but rather by achieving its goals. Therein lies my objection to raising the issue of medical cost-effectiveness. The most important variable in cost-effectiveness is defining the goal, so as to know if you are being effective in achieving the goal. It would be cost-effective to focus efforts on coverage of the most vulnerable. It would be cost-effective to stop treating the elderly, the disabled and the mentally retarded. Sometimes we do things because we feel it is important as a reflection of the quality of our society. Economic reasons alone are not good enough to make decisions about health care policy, something I was taught by a health economist from Harvard.

There are some very valid notions being floated regarding health reform, not the least of which are reducing payments to hospitals (which account for 50% of the country’s health care bill), increasing transparency of pricing and increasing consumer control of their own health care money and benefits. These proposals address many problems in health care today, but not the problems of those who need the greatest assistance. At the risk of sounding like a guild monopolist, physicians are better representatives of patients when they cannot speak for themselves than a policy wonk who’s never walked a day in clinic.

The first step in crafting health care policy is articulating a role for government. If you don’t believe there is any role for government in health care, then we have nothing more to talk about and we must agree to disagree. If the goal is a responsible approach to improving the well-being of the population through expanded health coverage while simultaneously improving accountability of the tax dollar, then there is a possibility of discussing the relative merits of various approaches.

USA Today Health Reform Editorial

Here is one Michael Cannon would prefer to forget. The problem with the ideologues is that they learn to reference their papers after they’ve written theM. So often, the articles do not say anything about what is being referenced. This is why I do not often use material from think tanks unless it is clear to me they do not have a political agenda and treat facts respectfully, with reason and an absence of rhetoric. From The Physician Executive in September in 2007. I will never delve this deeply into ideological clap-trap ever again! 

 

Dear readers, I need your help.

As you may know, I am a proponent of a non-dogmatic approach to policy debate and would like to see some truly conservative approaches to health care reform. I despise the tools of rhetoric and the use of formal logical fallacies that characterize the current crop of so-called conservatives.

Yesterday (via InsureBlog), USA today published an op-ed by Michael Cannon of the Cato Institute, an organization which I usually find provocative and challenging, but not thoroughly manipulative nor responsible for shoddy scholarship. I reviewed the articles which Mr. Cannon offers as references and have trouble connecting the articles to the point being made. There are also some logical inconsistencies.

Here is a systematic breakdown of what I found:

1. US Census Bureau. Nothing wrong here, the Bureau’s number may very well bear re-examination since all surveys have strengths and weaknesses. There is no such thing as methodological perfection.

2. Agency for Health Research and Quality: “other recent surveys put the number between 19 million and 36 million” for the uninsured. The link takes us to a MEPS survey (Medicare Expenditure Panel Survey is a running survey of medical expenditures using a representative sample of the entire US population) which does not support Mr. Cannon’s statement. The study delves more deeply into the census bureau’s figures by looking at the duration of being uninsured. The census bureau counts people as uninsured if they have been uninsured for any time n the past 12 months. Since the public health concern is identifying a vulnerable population, this is an entirely valid definition. The MEPS survey states “In 2003, 25.4 percent of the population was uninsured at some point during the year, 18.8 percent was uninsured throughout the first half of the year, and 13.6 percent was uninsured for the entire year.” Even math errors on Mr. Cannon’s part does not explain why he is comparing the proportion of American uninsured for the first half, second half and at any time of the year.

3. The next link is used to support the phrase “As many as 20% of the “uninsured” are eligible for government health programs, so in effect they are insured.” This is the most egregious. It comes from data that many who are eligible for Medicaid do not sign up since 20% of those eligible are not signed up for SCHIP. The statement holds true only if all the uninsured are eligible for some kind of government program, which is inconsistent with a seprate implication, presented with no evidence, that so many of the uninsured are illegal. Moreover, it escapes me how someone who is eligible for a program is still covered if they chose not to sign up. How does this address the vulnerability associated with catastrophic health expenditures? Moreover, the study referred to is a sober and numbing methodological comparison of the MEPS and Census surveys, not one of the many studies which have demonstrated repeatedly that under-utilization appears to be the hallmark of programs like SCHIP.

4. Mr. Cannon uses a study by Bundorf and Pauly to support the statement that as many as 75% of the uninsured can afford insurance. The paper is a fascinating and illuminating look at the effect of different definitions of affordability on the population estimate. While 76% is the high end, 31% is the low end of the estimate. Their findings support a statement much different than Mr. Cannon’s, here I quote from Bundorf and Pauly’s conclusion: “Our results demonstrate that lack of “affordability” is an important barrier, but not the only or the major barrier to obtaining coverage for all, or even most, of the uninsured. […]Omitted variables related to health status are potentially of particular importance. If our measures of health status do not capture characteristics of individuals that result in unusually high premiums (potentially due to risk rating of premiums or denials of coverage in the individual market, for example), we may over estimate the affordability of health insurance for high risks. […]Deciding for whom health insurance is affordable is ultimately a normative decision on the part of policymakers and society. We believe that our definitions, however, offer researchers and policymakers a positive empirical framework with which to begin to evaluate this question by basing the definition of affordability on the behavior of other consumers with similar characteristics, rather than an arbitrarily chosen income threshold.” This is very wise, unlike Mr. Cannon’s inexplicable peripatetic diversion.

5. To support the statement that “many economists can find no evidence that it [expanding coverage] is a cost-effective way to improve health” Mr. Cannon uses a non-peer reviewed piece of secondary literature that is actually an interesting review of the literature with respect to causality between insurance and health. The reviewers observe that if the causal chain fails, it may be either health insurance or health care that may not improve the health of the population. That is an established fact, which is not at issue because we are talking about extending health coverage to vulnerable sub-populations. The poor represent the majority of the uninsured unless you believe the prior misinformation. Perhaps the argument against covering the uninsured is being used as an argument against either government run or universal health insurance.

6. A rapid sequence of references asserting that expanding health coverage will not

a. Improve quality: New England Journal article shows that income is more important than race. The study does not address access to which coverage is most relevant.

b. Reduce disparities: Paper argues that reducing poverty is more important to health than improving health care access.

c. Affect life expectancy: A New York Times article about education being related to longevity.

d. Reduce cheating: A Health Affairs analysis of how health care costs for the uninsured are currently distributed. No mention of how not having a program deters cheating on the aforementioned non-existent program, i.e. Mr. Cannon’s argument is nearly circular.

7. The Kaiser Family Foundation says that the average family of four spends $11,000 a year. Individuals are pegged at $4,000. What the average cost per employee is, I just don’t know. Using one number without the other is not an honest presentation of the problem and I may be a little dense here… what was the point? Health care is expensive? We know that.

8. Several correct citations regarding the number of people covered by employer-sponsored insurance, rise in health insurance premiums, a White House press release, Rudy Guliani’s campaign website and a CBO letter.

Please review what you can (not everyone has full text access to Bundorf & Pauly) and let me know if I have mis-read any of Mr. Cannon’s references. Please note the title of the editorial refers to making Americans care about health care. This is a very promising position. I hunger to hear the argument, but am I just dense, or did he completely skirt around the cost, except a passing mention of average family insurance expenditures? I think there are extremely cogent arguments to be made.

Costco, Fashion and Health

I share a lot with the society in which I live.

Shopping at Costco, you always notice the overstock items run in a small number of sizes. Somebody overestimated the number of items manufactured in a given size. Sometimes it’s easy to find your size, which probably means it was either butt-ugly or mis-priced.

My size is not easy to find. People with 18 inch necks are not usually 34 sleeve. You can find 18/36 and 17/34, but 18/34 just ain’t easy.

I have message for the “shmatta” industry: America is getting fat! I’m not proud of it, but facts is facts and I’m not getting any younger, thinner or hairier on the top of my head. America is getting fat and the population’s obesity no longer looks like a bell curve. Stop making clothes for the ideal of the human form and you will lose less money in unsellable overstock.

One good thing: tomorrow is the day I will start to exercise, knowing I finally found an 18/34 this weekend, just in time for Valentine’s Day.

State Licensure: Quality Assurance or Trade Barrier?

When I moved to Washington from Maryland, it was a difficult transition. The worst part was getting to my new job earlier than anyone thought I could, but then having to sit around and wait for my license. I worked hard trying to familiarize myself with the organization as best I could. But it made me think … this post was written in 2008.

 

It is hard to believe that The Physician Executive has not yet received his new state license. It has been over six weeks, but physician readers will not be surprised. Fortunately, our insurers have already assured us that the moment the license is verifiable online, they will honor charges in his name.

In Maryland, the Board of Physicians says it takes 120 days to obtain a license (it usually goes faster). The last time I looked into California, it was over six months. States that decide they are over-doctored typically take longer than other states. There may be something to that, since I have heard of some primary care physicians having a hard enough time finding work that they are considering leaving California. But to be fair, I don’t know if a couple of anecdotes are worthy of calling it an established trend; I will be watching.

The reason it takes so long is something known as primary source verification. Licensing boards are diligent in verifying every employment situation, every hospital affiliation and every training site. Sometimes they go so far as to verify every locum situation as well. If a physician has worked for a single weekend covering a rural hospital, someone will want to verify it. Even thirty years later.

This needs to be done.

But it generates an awful lot of paperwork.

Since some of my former employers are closed, it creates challenges in identifying the correct individual to provide important verifications. Unsurprisingly, many Canadian residencies are less concerned with American credentialing than I am. My former internship site is apparently renovating and having trouble finding documents for some guy who left the country ten years ago.

Such is life.

The trail is long and I am a bit of a Donabedian groupie, so I don’t have a problem with primary source verification. However, there is an awful lot of overlap. There is the National Practitioner Database and the AMA, which offer some degree of triangulation, even though they are primarily a method of identifying complaints, lawsuits and other problems. Employers also do their own primary source verification, that way employers do not need to stay familiar with their state board’s processes. In one instance, the state board was able to obtain verification and the employer was not. The employer insisted on a signed affidavit.

Then there are the insurers. One company I am familiar with refuses to begin a credentialing process until everything is in the file. Then it takes them four months to review. Then they do not pay for any services provided during the credentialing process. I understand the importance of credentials verification, but this sounds a little like manipulating a process to their financial advantage. Yes, I am talking about you, Amerigroup. (Gratuitous stock advice: consider buying the stock, but never the insurance.)*

I would never advocate the elimination of licensing requirements (if I hear someone quote Milton Friedman on the subject one more time, I will subject them to the merciless ridicule reserved for followers of cults, star energy, homeopathy and other quackery), but there are certainly some implications for a free market in health care. There isn’t one.

We could streamline licensing procedures and credentials verification across the country. The CAQH already has electronic tools to facilitate the credentialing process. It would open up interstate competition in health care. (In a subsidized environment, heath care is driven by practitioners, so the competition is between jurisdictions and employers to attract them, not between practitioners to attract customers.) The problem of mal-distribution of physician resources would likely continue, but there are a very few examples of regulatory incentives to encourage physicians not to settle in cities or suburbs. Physicians flock to nice places to live until they start going belly-up. Or working for MinuteClinics.

As it stands, as a CMO, I am competing with much wealthier jurisdictions and facilities and then faced with an outsized regulatory burden to verify my practitioner’s credentials and facilitate our payer’s verifications. Moreover, the barriers to interstate movement of the medical labor force is at a level that makes me think of protectionist trade barriers.

I hope to see my first patient next week.

*I suppose there should be a disclaimer about the fact that my comment is meant sarcastically and not intended to represent real stock advice etc etc, but I assume that my readers are intelligent enough to figure that out for themselves. Caveat emptor.

The Economics of Mid-Levels

Another old post from The Physician Executive with currency in today’s environment. 

 

I was once a family physician delivering babies in an East Coast big city.

No, I am not a masochist, I was a family practice residency faculty.

Given the intense turf wars caused by an oversupply of competing specialists, it was an unpleasant environment to work. The concentration of specialty providers in big cities and urban areas poses some problems when it comes to costs. Frequently, one looks to mid-levels as a way of addressing problems in health care. Indeed Physician Assistants and Nurse Practitioners have a potentially important role to play in health care, but where?

Jason Shafrin at the Health Economist takes a look at midwives (included in the ranks of nurse practitioners for most of the latter part of the past century.)

I like midlevel providers like nurse practitioners and physician assistants because of their ability to bolster the ranks of primary care, the main engine of cost containment in health care. They can be invaluable in rural areas where it is difficult to entice specialists, even where there is a critical mass of demand for their services.

On the other hand, Jason’s post appears to be looking at midwives as a less costly alternative to obstetricians. A commenter on my site reminded me of Milton Friedman’s assertion that licensing leads to higher costs without assuring quality. In medicine, we have established a complicated and lengthy licensing process in the secure belief that the alternative was the chaos of snake-oil salesman that populated the United States at the turn of the last century. In other words, there was a compelling societal reason to limit and license people delivering health care.

I’m not sure what we accomplish by looking at mid levels as alternatives to established specialty providers. Moreover, specialists and midwives are equally maldistributed, being over-represented in metropolitan areas, where competition finds a way of increasing costs. Yes, health care acts strangely and higher concentrations of specialists tends to increase costs rather than reduce prices as one would expect.

On the other hand, finding an incentive to better distribute physicians may be a subtle way of improving physician incomes and health outcomes and reduce costs.

I want to make it clear once again, this is not a tirade against nurses or midwives. Nurses have saved my backside too often not to be collaborative and old school midwives working in labor and delivery taught me everything I know about delivering a baby.

I am questioning how we make policy in the face of a web of data and mess of potential starting points from which to approach the data.

Christmas and Change

I wrote this 6 years ago. It is oddly suited today, because the more we learn, the more we discover to learn. The better I get, the worse I was.

 

Merry Christmas. Christianity was seen by Bertrand Russel as an excuse for mediocrity. I think this perception can arise from Christianity’s insistence on the potential for change.

Christianity is (or at least should be) about forgiveness and redemption above all. That means no matter how inadequate we are, how erroneous our ways, how mediocre our performance, there is always the opportunity for improvement. This position can sometimes seem to excuse past mediocrity, perhaps even celebrate it and reward it.

I was an awkward child, and a certain social awkwardness has penetrated into my adult life. But I am getting better. I have made many mistakes and continue making them. But I need to be free of the baggage of past errors in order to progress. For this reason perhaps, Christianity seems so ready and willing to forgive everything, in heaven if not on earth.

There can be no redemption without guilt. There can be no change without mediocrity. They are the catalysts for change.

Have a warm and happy day.

A Splintered House

This is the text of a speech I gave to the Clark County Medical Society’s New Physician Reception in 2013.

Thank you to our sponsors and guests, to the Board of the CCMS and especially to each of you for coming. To all the new physicians; welcome to Clark County and to the medical society. I want to take a few minutes tonight and talk to you about our medical society and its history, my personal spin on what has happened to medicine in the 72 years since CCMS got started and how the House of Medicine became splintered. I would also like to talk a little about what our future might look like under the current and coming reality. Life is changing quickly for physicians these days.

“Clark County Medical Service Corporation” was established in 1941. The articles of incorporation, written under the name “Clark County Medical Society, Inc.”, were signed by Clyde B. Hutt, MD, as President and L.E. Hockett, MD as Secretary/Treasurer and were approved and filed on December 3, 1942. The constitution and by-laws of 1942 were amended on May 6, 1947 and adopted by membership on May 4, 1948. The bylaws have stood unamended since the last review and overhaul accomplished in 1991. They have withstood the test of time.

Medicine was simpler back in 1941. The bulk of CCMS membership knew each other. The largest group in town was the Vancouver Clinic and it had four doctors: a GP, a surgeon, a pediatrician and an OBGYN. If you wanted to hang a shingle, you may have wanted to meet the local docs so they could tell patients about you and maybe put in a good word for you at local merchants and businesses or maybe the bank. The county medical society was a way to let people know what your special interests and skills were and this was the way you got most of your referrals.

No I am not going to wax sentimental about the golden age of medicine. County medical societies had a dark side: they were exclusive and closed old-boys clubs that enforced standards of behavior in a manner that would be frowned upon today. They focused too much on their own interests and not enough on the health of the people they served. Keeping an eye on the money worked well for the US medical societies, and their parent organizations all the way up to the AMA, until the first turf wars erupted. I don’t need to belabor strife within the House of Medicine.

At the turn of the last century, there was a tug of war in the House of Medicine regarding the need for specialization: Some thought that generalism was necessary to understand the whole person, others thought that specialism was the way of increasing the relevance of physicians and to provide the best possible care for individuals. This was all derived from scientific medicine and the notion prevalent in an industrial society that there was more value in specializing.  Sir William Osler, perhaps the largest historical proponent of scientific medicine was ambivalent about the notion: “[Specialization]’” he said and I am quoting here, “must then be associated with large views on the relation of the problem, and a knowledge of its status elsewhere; otherwise it may land him in the slough of a specialism so narrow that it has depth and no breadth, or he may be led to make what he believes to be important discoveries, but which have long been current coin in other lands. It is sad to think that the day of the great polymathic student is at an end; that we may, perhaps, never again see a Scaliger, a Haller, or a Humboldt—men who took the whole field of [human] knowledge for their domain and viewed it as from a pinnacle. “

One of the earliest specialty societies was the American Academy of Pediatrics, hatched about 15 miles from here at an AMA meeting in 1930. In 1933, dermatology, OB-GYN, ophthalmology and ENT were the founding members of the ABMS. 1941 marked the year that the CCMS was founded and that Anesthesia became America’s 15th recognized specialty. Today we have splintered into between 130 and 157 specialties and sub specialties depending on how you count them and nearly as many specialty societies.

I think that is the word that best represents the House of Medicine today: splintered.

But somehow I think that people with an MD or a DO degree after their name may share certain characteristics more than a similar day-to-day existence within their own narrow silos of specialty and employment.

Somehow I think that people whose primary role is to help patients navigate our current morass of regulation, government, insurance, corporations, pharmaceuticals, manufacturers of various gadgets and medical technologies from titanium hips to scribe-friendly keyboard operated EHRs… somehow these people who bear the primary responsibility for trying at least to improve the health of well-being of their patients (and by consequence our community) have more in common than their differences would suggest.

When I first got to Clark County 4 years ago, I set about charting a course to understand how I could personally influence the course of events impacting my life. I have a MPH,  so I was interested in my role as an advocate for patients and how I could impact the epidemiological measures of health. I looked at what my specialty society was doing in the local community. I found the impact was driven by individuals, many of whom were involved with the local residency. The point is that my specialty association’s largest impact was being felt at the national level and had recently hired a lobbyist at the state. At the local level it was not any association, it was the individuals. I think this is probably true for each of our specialty associations. We can do at least as well locally.

So I believe that medicine has a role in improving the health of our communities. It may follow that when we band together and work towards that purpose, we may have better chances of success. It’s a subject for another day, but medicine has a role. It must have a role if the industry is to remain relevant as a social good, otherwise, we might as well all quit and become bankers, because that’s where the real money is.

Don’t get me wrong, I proudly carry the flag of my specialty society, but the fact is that all our specialty societies are somehow vaguely inadequate to the grass roots tasks. Its not just primary care, but all aspects of medicine that are at work in this town, from the anesthesiologist and the gynecological oncologist and the cytogenetic geneticist. We have more impact as a House of Medicine united in this one common mission that we agree on than worrying about turf wars.

And the impact is felt community by community. A truism in epidemiology is that you need large numbers to detect small changes, but it tells you nothing about what happens to individuals. And communities are made up of individuals, states are made up of communities and nations are built on states. It all starts where you live and work and being concerned for the health of your neighbors and the people around you. The health of Clark County depends in a small way on each one of you. The health of Clark County needs you to speak for it and for its concerns.

One aspect that has helped the health of Clark County has been the role of CUP. CCMS has advocated and will continue to advocate on behalf of this local non-profit community-based health plan both because it works for the community’s health and because it is a significant employer. We were concerned with toxic byproducts of a recycling plant and successfully shot it down. At the state, with other medical societies, we helped overturn the rule that emergency rooms wouldn’t be paid if their services were retrospectively judged not to be emergencies. Physicians got involved to work with the DOH and saved them more money than they envisioned by their prior plan. We also fought the B&O tax which no longer applies to physicians in WA. We are now looking at the impact of a coal terminal on our coast as well as the trains have along the route, so we are supporting studies to clarify the impact and publicize our concerns. At the state we have also supported public health nurses working on STD’s and providing the related questions and answers assistance, reproductive equity in the state and pushed for medical staff reviews that are not quite so abusive of physicians.

Only here in Clark County can you speak out about our lack of availability of fresh food in a wasteland of fast food. Only in Clark County can you do something about obesity in your community. Only in Clark County can you set up community forums to counter the vaccine objectors’ propaganda that makes us so vulnerable to epidemics IN THIS COUNTY!

I hope you each continue to support the county medical society, I hope you get involved, speak up, be a light for others to follow, be obnoxious if you want, just speak!!! And tell you colleagues about the society. You need to take responsibility for your own “belonging” to a group you believe in. And if the AMA or WSMA or even CCMS does something you disagree with, remember that your voice counts. Without that voice, it’s not surprising the organizations do things that don’t meet with your approval. You won’t win every battle in a democracy, but you will win some/ You will make a difference.

Argument for Big Pharma

Not a big fan of big pharma. Not a big fan of big insurance. Come to think of it, I’m not a big fan of anything big: government, hospitals, or anything else for that matter. This bias is evident in this post from The Physician Executive.

 

Peter Pitts appears to be a very intelligent person. As a former head of the FDA, he knew how to find the money and took off to run the Center for Medicine in the Public Interest, generally recognized as a front for Big Pharma. I like reading his posts, for the same reason I like reading the Cato; I am always looking for good arguments on the side of any position.

So I came across this interesting article suggesting that we need to stop insurance companies from switching people to generics all the time. This was published the same day that Wal-Mart added terbinafine, once $300 a month, to it’s $4 generic list.

As a clinician, my frustration is that insurance companies, or more specifically the pharmacy benefit managers, forcing patients to change meds. They insist that a certain medication in a given class is not covered and the patient must change to a different drug in the same class. It’s like don’t take amoxicillin, you have to take penicillin. Alternatively, the physician can somehow demonstrate or certify an adverse reaction or lack of effect before they authorize going back to the original drug. I already know drug A doesn’t work, from experience on the previous insurance. The insurance requires that we try Drug A again, before they reimburse for Drug B, which the patient has been taking for a long time.

I understand the complications of dealing with expanded formularies and the inefficiencies of having to stock so many similar drugs. I also understand the value of the discounts available when you order in bulk.

I just don’t think it’s a good idea to swap chemical entities because I have a healthy respect for the risks of consuming anything on a regular and ongoing basis. Once you have a functional and safe regimen, it is unwise to change.

Here’s the bone I’m going to throw to Big Pharma; sometimes a softer argument makes a greater effect than one so strident, the bias encourages the reader to discard it without a thought.

Finding a match in your doctor.

From The Physician Executive in 2007, but I could have written it last week.

CNN had an article on how to fire your doctor.

I agree. Sometimes it’s about chemistry. Some patients and I are like oil and vinegar, others like fire and gasoline. I have always invited these patients to seek care elsewhere with no hard feelings.

Somewhere in the corporate transition, this message got lost. My previous employer almost had a hissy fit.

The alternative is an unhappy patient who doesn’t trust their doctor, who doesn’t really like their patient but is seeing them begrudgingly out of some kind of moral obligation.

If that isn’t a recipe for a lawsuit, I don’t know what is.

Each physician-patient relationship is different. You are looking for a match. This applies to the patient, but is also good practice for the organization.

Health Care: The Blind Men and the Elephant

From The Physician Executive in August of 2007.

In health care, management and policy are a couple of steps removed from patient care. Physicians and other health care workers have insights that sometimes fall on deaf ears. But this is the era of Babel in health care; I don’t believe we have a common language yet, so we can actually understand what each of us are saying.

Health policy is a large enough field that, as in medicine, specialties are starting to emerge. When I speak with health policy types and health economists, they often see the world through the glasses of their area of interest. I know of an economist who specializes in transplant allocation. Another health economist is a state secretary of health (how rare is it that government hires a real specialist for any post, instead of a politician?) Some people are dedicated to providing care for the poor, other would like to preserve choices and options, which are usually relevant to the wealthiest and most privileged.

These different perspectives yield emphasis by turns on primary care or specialties, ambulatory or hospital care, cognitive versus procedural practitioners… Health wonks are like blind men trying to figure out what an elephant looks like.

Biological organisms are not mechanical, and this has an impact in various aspects of the health system. I recall an Operations Manager who couldn’t understand why the clinical staff didn’t follow medical guidelines the same way his computer staff created patient files. (This represents the mis-application of Six-Sigma to the wrong level of outcomes.) One of the most dynamic classroom discussion I experienced was when a bunch of mid-career professionals tossed around my assertion that “protocols” and “guidelines” are not the same thing. We settled on protocols for processes and guidelines for diagnosis or treatment. It’s too bad that medicine cannot be based entirely on empirical evidence, as an epidemiologist (I think) commenter to this blog asserts.

The complexity of people as biological and social organisms leaves us with so many unknowns, I am amazed at how much information we have that is actually actionable. But health care remains governed by careful judgment informed by some data, to help navigate the unknowns.

Experience can be a fickle teacher. So much of our perceptions are shaped by personal experiences, and then confirmed by the consequent bias. If we have a bad experience a physician, we are looking for confirmation in any trace of behavior of every subsequent interaction. So outliers can begin to distort our opinion of things: the greedy doctor, the uncaring insurance company, the bean-counting administrator, the abusive patient or the ignorant bureaucrat… These people exist for sure, but the vast majority are working stiffs who show up for work and try to do the best they can before getting home to their families and an over-leveraged mortgage.

In all this, it is the emotional context of health care that is the most ignored. The fear and despair that physicians and nurses see is forgotten in epidemiologists’ regressions, economists’ differentials and executives’ spreadsheets. No, the golden age of medicine is gone and good riddance, but something else this way comes and we don’t yet know what it looks like. Let’s just make sure it works for the middle: the normal patients, health care workers and administrators who show up every day and stay for every shift, no matter how terrible the things they see.