A Pandemic of Silence: Hospital Managers Intimidate and Punish Coronavirus Whistle-Blowers

Under cover of a pandemic, managers and executives of hospitals, hospital systems, and other organizations that provide direct patient care are trying to silence health care professionals who point out leadership's failings.  We have seen a distressing parade of whistle-blowers intimidated and punished.

On March 25, an article in Medscape stated the basic problem.Per an anonymous orthopedic surgeon:

'It’s very clear; no one is allowed to speak for the institution or of the institution,' he said in an interview. 'We get a daily warning about being very prudent about posts on personal accounts. They’ve talked about this with respect to various issues: case numbers, case severity, testing availability, [and] PPEs.'

This clearly is not rare.

The silencing of physicians by hospitals about PPE shortages and other COVID-19 issues has become widespread, said Nisha Mehta, MD, a physician advocate and community leader who writes about PPE on social media. Physicians are being warned not to speak or post publicly about their COVID-19 experiences, including PPE shortages, case specifics, and the percentage of full hospital beds, Dr. Mehta said in an interview. In some cases, physicians who have posted have been forced to take down the posts or have faced retribution for speaking out, she said.

'There’s definitely a big fear among physicians, particularly employed physicians, in terms of what the consequences may be for telling their stories,' Dr. Mehta said. 'I find that counterproductive. I understand not inducing panic, but these are real stories that are important for people to understand so they do stay home and increase the systemic pressure to get sufficient PPE, so that we can preserve our health care workforce for a problem that is going to get worse before it gets better.'

Here is our round-up of specific cases, in the order that they came to light

Three Cases, Two Anonymous of the Silencing of Health Care Professionals who Blew the Whistle about Coronavirus Safety Issues

The Medscape article included:

an Indiana hospitalist who took to social media to ask for masks for hospitals in his area says he was immediately reprimanded by his management after the posts came to light.

Another frontline physician who works at a large New York hospital, said staff have been cautioned not to talk with the media and to be careful what they post on social media regarding COVID-19. The general rule is that only information approved by administrators can be shared

The Medscape article also detailed this case:

 [a] nurse, Lauri Mazurkiewicz, sent an email to staffers at Northwestern Memorial Hospital stating the surgical masks provided by the hospital were less effective against airborne particles than were N95 masks, according to a lawsuit filed March 23 in Cook County Circuit Court. Ms. Mazurkiewicz was terminated the next day in retaliation for her email, the lawsuit alleges.

In the short time since that article was published, more specific, and egregious examples have appeared

Emergency Physician Employed by TeamHealth, Owned by Private Equity Firm Blackstone, Fired at the Behest of PeaceHealth for "Inciting Public Fear"

Perhaps the best documented case is that of Dr Ming Lin.  As reported by the Seattle Times on March 29, 2020,

Dr. Ming Lin worked at PeaceHealth St. Joseph Medical Center for 17 years until he was removed on Friday by TeamHealth, a national staffing firm under contract to provide the hospital’s emergency department personnel. Lin became a national avatar for frustrated health care professionals during the COVID-19 outbreak by speaking up in the press and on social media with pleas for more medical supplies and stronger standards to protect health care workers combating the virus.

On March 16, Lin posted a letter on Facebook he’d sent to PeaceHealth St. Joseph’s chief medical officer, outlining how the hospital was mismanaging patient COVID-19 testing and exposing health care personnel and patients to unnecessary risks. He decried the hospital’s internal bureaucracy that prevented some doctors from ordering coronavirus tests, including a 'ludicrous' requirement that a flu test be completed before providing patients coronavirus screenings. Lin also criticized the hospital’s lack of a triage tent outside the emergency room to screen and test patients, to limit exposure of other patients and staff to potential infection.

'PeaceHealth is so far behind when it comes to protecting patients and the community, but even worse when it comes to protecting the staff,' Lin’s letter said.

The hospital's immediate response was to ask Dr Lin to "retract" or "recant" what he said.  When he refused, first

TeamHealth said Lin technically was not fired and remains employed by the company, but will no longer work at PeaceHealth St. Joseph Medical Center. A PeaceHealth St. Joseph spokesman on Friday confirmed Lin’s termination but declined to comment further because Lin was not directly employed by the hospital.

Note that:

TeamHealth was acquired by the Blackstone Group, a private equity firm, in 2016 for $6 billion. Since then, the company came under fire for a pattern of suing uninsured and low-income patients who were unable to pay their medical bills, but discontinued the practice after it gained public attention in the news.

An April 6, 2020 article in the Seattle Times disclosed the hospital's rationale for firing Dr Lin

Richard DeCarlo, chief operating officer of PeaceHealth, which operates Bellingham’s St. Joseph Medical Center, likened Lin’s public warnings about workplace coronavirus concerns to 'yelling fire in a crowded theater.'

that is,

allegedly inciting public fear by criticizing the hospital’s emergency precautions.

thus begging the question of what it was the public might fear.  Perhaps he was afraid they would fear going to his hospital, thus suppressing its revenues?

Note further that Mr DeCarlo, according to his official PeaceHealth biography, has no apparent experience of expertise in medicine, health care, or public health. The CEO apparently is a registered dietitian with no recent experience in medicine, health care, or public health.


NYU Langone Health Threatens to Fire Physicians who Talk to Press Without Authorization

The Wall Street Journal  reported on March 31, 2020 that after the head of the Department of Emergency Medicine at NYU Langone sent a message to physicians implying that they should consider withholding ventilators from some critically ill patients, the physicians

also got got a reminder not to speak to news reporters without permission from NYU Langone's Office of Communications and Marketing.

Kathy Lewis, executive vice president for communications and marketing, said in an email that NYU Langone's longstanding policy required faculty, residents and staff to forward all media inquiries to her.

'Anyone who does not adhere to this policy, or who speaks or disseminates information to the media without explicit permission of the Office of Communication and Marketing, will be subject to disciplinary action, including termination,' Ms Lewis wrote.

A blog post from the Foundation for Individual Rights in Education (FIRE) decried this threat to health care professionals' free speech about pandemic preparedness stated:

free speech and academic freedom do not become less important during a crisis, and that it’s critical that faculty members — many of them serving on the front lines of the pandemic — be able to share information with the broader public.

'It is precisely in times of crisis that it is most important that lines of communication to the public be open,' said Robert Shibley, FIRE’s executive director. 'These faculty members are there because they’re the experts. Inhibiting their ability to communicate important information about COVID-19 presents enormous risks.'

Consider also the source of the threat.  Note that according to her official bio,

Kathy Lewis, executive vice president for communications and marketing, is responsible for the advancement of NYU Langone Health’s unique brand identity as one of the nation’s premier centers for excellence in clinical care, biomedical research, and medical education.

Furthermore, Ms Lewis' qualifications to threaten physicians with termination appear to be limited to:

a BA from Montclair State University and an MA from Seton Hall University.

So the implication is that even in the midst of a deadly pandemic, the managers running NYU Langone think upholding the organization's brand identity comes before transparency and honest communication.

Note that this is not the first time Langone has put its brand identity ahead of transparency about disaster preparedness.  Back in 2012, after the medical center suffered a blackout and other problems due to super-storm Sandy, its board chairman, Mr Kenneth Langone, whose name the medical center carries, vociferously tried to avoid institutional accountability for poor disaster planning (look here.)  Mr Langone, a founder of Home Depot, who as described here had previously boasted

I am a fat cat, I'm not ashamed

is a big booster of President Trump (look here).

Other New York Hospitals Warn Health Care Professionals Not to Talk to Journalists

On April 1, 2020, Politico reported

As hospitals across New York City are filling up with patients gasping for air, health care executives are slapping gag orders on their workers to control the narrative amid the coronavirus pandemic.

Specific instances were:

Northwell Health recently sent medical professionals an email informing them all interviews with news media must first be cleared through the public relations department, a hospital employee told POLITICO.

Also,

Mount Sinai distributed its own set of guidelines discouraging speaking to the press and dictating social media policies as more health care professionals stepped forward to report problems in their hospitals. The guidance coincided with images shared on social media of employees wearing trash bags over their regular gear — an alarming picture from inside one of New York City’s premier and deep-pocketed health systems that has shaped public opinion of the shortage of personal protective equipment.

The email did not contain any reference to the ongoing pandemic or disciplinary action that could be taken, though some employees said the threat is present.

'I am very afraid I would be fired for [sharing the guidance with a reporter], which just makes me think they are more afraid of their image than actually having the patients cared for,' said one employee, who requested anonymity for fear of retaliation. 'I am a valuable asset, yet the fact that I am speaking up for my patients, colleagues and myself would have me terminated is not okay. It is an injustice that they overrule us with fear.'

A more recent New York Times article, from April 9, 2020, added:

'Do not respond or speak to any reporters, as well as current or former employees, regarding a pending news story,' wrote David A. Feinberg, the chief marketing and communications officer at the Mount Sinai Health System, in an email to all faculty and students on March 26.

In response,

health care workers on a coronavirus task force at Mount Sinai said they are demanding 'zero tolerance of employer retaliation or threats against those who are speaking up,' in a letter distributed among staffers and obtained by POLITICO.

Finally,

Eleven medical professionals across various health systems in New York City told POLITICO they signed nondisclosure agreements, had contracts that stipulated they not speak with the press without consent from their employer or feared losing their jobs if they spoke out publicly.

Mississippi Physicians Fired After Speaking Out

Health care professionals outside of states with the highest current coronavirus prevalence are not necessarily protected from punishment if they speak out.  On April 5, 2020, Mississippi Today reported:

An Oxford doctor is one of at least two Mississippi physicians claiming they were terminated for speaking out about their employers’ safety measures during the coronavirus pandemic.

Dr. Samantha Houston says she lost her job of four years at Baptist Memorial Hospital-North in late March for 'disruptive' behavior. In the weeks prior, Houston, a hospitalist, used Facebook to organize a local donation drive for masks and baby monitors so that hospital staff could cut down on face-to-face interactions with patients.

Houston, 34, also says she sent several emails to colleagues raising concerns about the availability of personal protective equipment, or PPE, for some workers.

'Every idea I had was just shut down and dismissed, and I just got very frustrated,' Houston told Mississippi Today. 'I just feel like they were not advocating for our safety, and that was what was so frustrating for me. And it really wasn’t even my safety. I felt safe enough because I had an N95 mask and I was able to get in there, but I felt like the nurses were not as safe.'

Also

Dr. Jennifer Bryan, who chairs the Mississippi State Medical Association board of trustees, told Mississippi Today that she knows of at least one other doctor in the state who was also fired for advocating for stronger safety measures.

A Los Angeles and Another New York Health Professional Punished

An article in the New York Times, April 9, 2020 included:

'They’re very protective of their reputation in the community,' said Jhonna Porter, a nurse who was suspended from West Hills Hospital in Los Angeles after raising safety concerns in a private Facebook group and publicly on her own page, including appeals for equipment. 'If anything seems like it might make them look bad, they’re going to stomp on it quick.'

And,

A doctor at Lincoln Medical and Mental Health Center in the Bronx, Deena Elkafrawi, was reprimanded after the British publication Metro quoted her as saying, 'I am scared that going to work could kill me,' according to the Committee of Interns and Residents, a national association that represented her.

Reactions to Silencing Health Care Professionals

Physicians Societies

Two physicians' societies have condemned hospital managers threatening or punishing health care professionals who spoke out about problems with hospitals' responses to the coronavirus pandemic. Per an April 4, 2020 Medscape article,

'Physicians have a professional and ethical responsibility and need to be able to speak out on these types of issues,' Robert McLean, MD, president of the American College of Physicians, told Medscape Medical News

The ACP is one of several professional organizations that have come out against attempts to silence physicians in recent days. Earlier this week, the ACP released a statement supporting physicians who shared concerns about their workplace conditions and lack of adequate PPE, while also rebuking attempts by hospital systems to silence clinician complaints or activism.

'We as a college felt the need to speak out about that and indicate that this is completely wrong,' said McLean. 'Physicians who are speaking out to make people aware of issues of public health and of public health concern should not be at risk of having their employment terminated or otherwise disciplined.'

According to the ACP's ethics policy, physicians who are able should speak out about public health issues for their safety and the safety of their patients, he said. 'The benefit to patients is that problems are identified and not swept under the rug.'

On Wednesday, the American Medical Association (AMA) also put out a short statement in support of physicians' right to advocate for their patients in the current climate:

'In recent weeks, as physicians have battled the COVID-19 pandemic, the question of when and how to express concern about conditions and safety has become a flashpoint for physicians and their hospital employers.'

The hospital managers trade association responded by minimizing the problem.

When contacted by Medscape Medical News to comment on these reports, the American Hospital Association (AHA) referred to a letter sent by AHA President and CEO Richard Pollack on March 27 to the consumer advocacy group Public Citizen, in response to a complaint filed by the group on behalf of themselves and 54 other organizations.

'Outside of the anecdotal reports you shared, the AHA has not heard any reports of hospitals or health systems restricting the free speech of physicians, nurses, or others regarding the conditions related to COVID-19,' the letter reads.

I wonder if the AHA is now aware of all the cases listed above?

Frontline Health Care Professionals

An April 9, 2020, article in StatNews discussed widespread anger among health care professionals over responses to coronavirus from health care leaders, including local and national government leaders, but also hospital leadership.  In particular,

Among the physicians, there’s a growing fear that they’ll face repercussions if they speak out.

Specifically,

'The thought of being fired right now, when my patients need me the most, is even more terrifying than the idea of potentially getting ill from Covid-19,' the Los Angeles primary care physician said.

Whistleblower International Network

The Whistleblower International Network (WIN) wrote a protest letter saying the coronavirus pandemic has led to "the largest attack on whistleblower in the world."

Coronavirus whistleblowers have been exposing inadequate health system capacity and delivery, public procurement problems, violations of health and safety and labor law, inequitable and ill-prepared global supply chains, unfair competition practices and market abuses, and large-scale violations of personal privacy rights. Employers and public authorities have responded to many of the doctors, scientists, and other frontline workers who told the truth by firing them. In countries like the US, UK, and Italy, such termination of employment is illegal whistleblower retaliation, but that hasn’t stopped employers. Other countries such as China, India, and Poland, employees don’t have any whistleblower rights on paper at all. In either scenario, employer retaliation chills others from engaging in public interest speech, which serves the overall mission of preventing the truth from getting to the community. The act of keeping the truth from the public during a pandemic is gross negligence, which is the deliberate and reckless disregard for the safety and reasonable treatment of others. Every time a whistleblower is retaliated against, the public’s rights are being trampled on too. Indeed, we are all victims in the wake of the largest attack on whistleblowers in the world.

The letter concluded:

Suppressing the truth is a clear and present danger to public health and safety that could turn the pandemic into a modern Black Plague. Employers and governments are silencing their early warning systems, but the effect is trans-national. The outrage must be as well.

Why Are Hospital Managers So Quick to Silence Health Care Professionals?

Thus threats against physicians and other health care professionals who blow the whistle about patient care and safety issues, and dangers to health care professionals in the era of the coronavirus pandemic are likely to continue. 

In medicine and health care, there is a long and sorry history of management trying to silence whistle-blowers who might put the leadership in a bad light.  As noted in the March 25 Medscape article,

John Mandrola, MD, a Louisville, Ky.–based cardiologist who has written about the recent muzzling of frontline physicians with respect to the coronavirus, said he is not surprised that some hospitals are preventing physicians from sharing their experience

'Before C19, in many hospital systems, there was a culture of fear amongst employed clinicians,' he said. 'Employed clinicians see other employed physicians being terminated for speaking frankly about problems. It takes scant few of these cases to create a culture of silence.'

We have been posting about problems with management and governance in health care for a long time.  Some of these problems seem to be grossly manifest in cases in which whistleblowers were threatened or punished to inspire silence, and may explain why the practice continues even in a time of pandemic.

Managerialism

In some cases above, the executives threatening to silence health care professionals were themselves not health care professionals, and seemed to have no direct medical, health care, or public health care experience. In two cases, executives in charge of  communications or marketing intimidated professionals to secure their silence. This implicates managerialism as a source of the problem.

Per an article from the June, 2015 issue of the Medical Journal of Australia (look here):
- businesses of all types are now largely run by generic managers, trained in management but not necessarily knowledgeable about the details of the particular firm's business
- this change was motivated by neoliberalism (also known as economism or market fundamentalism)
- managerialism now affects all kinds of organizations, including health care, educational and scientific organizations
- managerialism makes short-term revenue the first priority of all organizations
- managerialism undermines the health care mission and the values of health care professionals

Such generic managers, who have sworn no oaths to put patient care ahead of all other concerns, may have few qualms about silencing whistle-blowers to protect their organizations' and their own reputations. 

Putting Revenue Ahead of Patients' and Health Care Professionals' Safety

In several cases, hospital management seemed more concerned about loss of patients and revenue resulting from degradation of their hospitals' brand identity or reputation than about patients' and professionals' safety.

As noted above, managers of hospitals are increasingly from business, not health care backgrounds.  Whatever their background, they seem more likely to be influenced by currently fashionable management dogma.  A dominant dogma in management is that pursuit of shareholder value comes before all else.  Even though many, but not all hospitals are still ostensibly non-profit, many hospital managers have likely been influenced by this dogma.  As we posted here, quoting Lazonick:

in 1983, two financial economists, Eugene Fama of the University of Chicago and Michael Jensen of the University of Rochester, co-authored two articles in the Journal of Law and Economics which extolled corporate honchos who focused on 'maximizing shareholder value' — by which they meant using corporate resources to boost stock prices, however short the time-frame. In 1985 Jensen landed a higher profile pulpit at Harvard Business School. Soon, shareholder-value ideology became the mantra of thousands of MBA students who were unleashed in the corporate world.

Lazonick added:

When the shareholder-value mantra becomes the main focus, executives concentrate on avoiding taxes for the sake of higher profits, and they don’t think twice about permanently axing workers. They increase distributions of corporate cash to shareholders in the forms of dividends and, even more prominently, stock buybacks. When a corporation becomes financialized, the top executives no longer concern themselves with investing in the productive capabilities of employees, the foundation for rising living standards for all. They become focused instead on generating financial profits

So many hospital managers may have no qualms about punishing whistle-blowers to protect their organizations' revenues.


What Needs to Be Done?

In the short run, we must do all we can to protect health care professional whistleblowers, as suggested by the Whistleblower International Network above.

In the long run, hopefully assuming there is one, we further need to address the systemic features of our dysfunctional health care system that enabled the rise of leaders who are happy to silence health care professionals to preserve their organizations' reputations and revenue, no matter what.  We need leaders who put patient's and the public's health ahead of all else, and who understand and uphold health care professionals' values.  We need hospitals, hospital systems, and other organizations that provide direct patient care that are not responsible for producing profits for their owners or shareholders.

Challenging the meme that [yes, there are all these drastic flaws and problems - BUT] ... EHRs improve patient safety

One of the most persistent memes in healthcare IT is that, for all their deficits, bugs, flaws, interferences in care, and so forth, these systems "improve patient safety."

I find the meme remarkable.

37 medical societies can issue a complaint letter about how EHR systems interfere in care and pose patient risk (http://hcrenewal.blogspot.com/2015/01/meaningful-use-not-so-meaningul.html).  The Joint Commission can issue a detailed Sentinel Event Alert outlining the myriad ways that these systems "introduce new kinds of risks into an already complex health care environment where both technical and social factors must be considered" (http://www.jointcommission.org/assets/1/18/SEA_54.pdf).

ECRI Institute can, year-after-year, report health IT as among the top ten technology risks in healthcare (2015 list at https://www.ecri.org/press/Pages/ECRI-Institute-Announces-Top-10-Health-Technology-Hazards-for-2015.aspx).

This writer can casually aggregate quite a few examples of EHR flaws, risks and harms without really trying very hard (http://hcrenewal.blogspot.com/search/label/glitch).  Some of these include incidents where EHR flaws could have or did affect thousands, a feat nearly impossible with paper (http://hcrenewal.blogspot.com/2011/11/lifespan-rhode-island-yet-another.html).

Outages that make all records unavailable can occur with regularity (e.g., http://hcrenewal.blogspot.com/2015/05/another-day-another-ehr-outage-medstar.html).

The ECRI Institute in its "Deep Dive" analysis can gather voluntary reports of 171 IT mishaps in just 9 weeks from 36 hospitals capable of causing harm, with 8 injuries and 3 possible deaths resulting (http://hcrenewal.blogspot.com/2013/02/peering-underneath-icebergs-water-level.html).

Medical malpractice insurers can reveal an increasing number of medical malpractice cases (and injury) involve EHRs (e.g., http://hcrenewal.blogspot.com/2014/02/patient-safety-quality-healthcare.html, also http://cci.drexel.edu/faculty/ssilverstein/cases/?loc=cases&sloc=norcal, also http://www.msms.org/AboutMSMS/News/tabid/178/ID/2595/System-Dangers-How-EHRs-Can-Contribute-to-Medical-Malpractice-Claims.aspx).

Yet, the "BUT" phrase seems to reliably appear in articles about these flaws:

"BUT" EHRs improve safety.

Of course the comparator in such statements is the paper record.

For instance, in the June 11, 2015 Politico report "Why Health Care IT Is Still on Life Support" (http://www.politico.com/magazine/story/2015/06/electronic-medical-records-doctors-118881.html), Arthur Allen sums up the problems very well such as:

• In surveys, doctors describe the EHR as the biggest cause of job burnout—worse than long hours, billing and other nuisances.  [Burnout is not exactly contributory to patient safety - ed.]
• One frequent complaint is mental strain.
• The doctors can’t tell one patient from another in the absence of idiosyncratic impressions. The memorable rash or symptom a patient reported is buried in screen after screen of seemingly trivial data [what I've called "legible gibberish" on this blog - ed.] In an ER or ICU, with time of the essence, this can become a critical safety problem.
• EHRs are inevitably listed among the 10 top safety concerns for doctors because they introduce new kinds of errors.
• “All the clicking saps intellectual power and concentration and blocks normal conversation."
•  “The computerization of medicine will surely be that long-awaited ‘disruptive innovation,’” but “today it’s often just plain disruptive: of the doctor-patient relationship, of clinicians’ professional interactions and work flow, and of the way we measure and try to improve things.”

Yet with all of the above, the following familiar claim is made about these systems:

• Overall, EHRs are probably improving patient safety—they have replaced illegible medical scrawl with typing, for instance.

At least the word "probably" was used.  Not to single out this article, as the refrain seems commonplace.

I opine in any case that the advantages of occasional handwriting illegibility problem resolved by EHRs are quite thoroughly nullified by critical data being "buried in screen after screen of seemingly trivial data" and other information-clouding issues related to EHR outputs.  See for instance "Two weeks, two reams" at http://hcrenewal.blogspot.com/2011/02/electronic-medical-records-two-weeks.html.

(Missing in this report, like most others on EHR problems such as the May 2015 American College of Physicians report "Frustrations with EHRs rampant as development slows" (http://www.acpinternist.org/archives/2015/05/EHRs.htm) are mentions of patient harm and deaths.  That topic seems verboten.)

In view of all the above, let me state this clearly:

With the increasing amount of knowledge about the flaws of these systems, coupled with the reports of harms in an environment where our top medical organizations and officials admit that the true rate of harms cannot be known due to inadequate reporting infrastructure, policies, and procedures (see http://hcrenewal.blogspot.com/2014/04/fda-on-health-it-risk-reckless-or.html), my belief is that these systems in their present form do not improve patient safety.

My belief is that these systems as they are today decrease patient safety, perhaps markedly, over a reasonably-staffed clinician paper records system. 

To take the enthusiast view is to ignore all of the above.  

For instance, extrapolating the ECRI Deep Dive figures alone is alarming, and to date I have not seen any arguments whatsoever as to why those figures should not be extrapolated.

The situation is only to become worse as more and more hospitals without strong internal expertise increase the complexity of the in-house clinical information systems.

The line that "EHRs increase patient safety" in view of all the problems that are now apparent even to the most hyper-enthusiastic EHR pundit is, I believe, wishful thinking run amok.

Such statements defy common sense.

The need for a very robust reporting mandate on EHR-related close calls and actual harms sorely needed.

It is the only way to know for sure whether we've moved from the occasional paper record-related mishap to a more pervasive EHR-confusion related medical misadventure circus.

Unfortunately, I don't see such mandatory reporting taking place any time soon.  A "health IT safety center" without regulatory authority and receiving HIT mishap reports on a 'voluntary' basis is favored by the industry and its government sponsors (see http://hcrenewal.blogspot.com/2014/07/new-onc-director-karen-de-salvo-no.html).  A safety center will quite likely be "safely" ignored by the sellers and users of the systems, when it suits their financial interests (which is nearly always).  It is a band-aid solution to a very serious problem.

It seems apparent to me, considering all these problems, that health IT incentives should stop.  Further, new EHR rollouts need to be put on hold until this technology is more thoroughly vetted.  Until then, harms and deaths of patients are in part the fault of those who knew, should have known, or should have made it their business to know of the risks of bad health IT.

-- SS

Does organized medicine need to "man up" on healthcare information technology risk and harms?

After reading a number of articles on healthcare IT problems over the past few years authored by leaders of organized medicine, please excuse me if I wonder out loud if organized medicine's leadership does not suffer from healthcare IT ignorance, low "T", or both.

Case in point, a article by Robert B. Doherty, Senior Vice President of Governmental Affairs & Public Policy, American College of Physicians that appeared in the Philadelphia newspapers blog site "The Field Clinic" today, Monday, September 8, 2014.

The article is entitled "Why doctors hate electronic health records" (no kindness in that title!) and is at http://www.philly.com/philly/blogs/fieldclinic/Why-doctors-hate-electronic-health-records.html.

After an amusing and appropriate analogy to the autobile repair industry, the article makes some good points.

First, it attacks the canard about physicians being technophobes:

... It might be tempting to dismiss the doctors complaining about EHRs as technophobes who are unwilling to embrace new technologies, but the Rand investigators say that this isn’t the case: "... our study does not suggest that physicians are Luddites, technophobes, or dinosaurs.  Physicians recognized the important advances that EHRs have enabled, particularly in accessing information remotely (like checking a patient’s test results from home) and improving compliance with guideline-based care.”

The article, unfortunately, does not go far enough to point out that the real tension is between pragmatic clinicians and information technology hyper-enthusiasts and those who stand to profit from EHR diffusion, who ignore the downsides. (For more on that issue, see my March 11, 2012 essay "Doctors and EHRs: Reframing the 'Modernists v. Luddites' Canard to The Accurate 'Ardent Technophiles vs. Pragmatists' Reality" at http://hcrenewal.blogspot.com/2012/03/doctors-and-ehrs-reframing-modernists-v.html.)

The article's author offers relatively standard and obvious "prescriptions":

... The solution isn’t going back to paper records, but designing EHRs that work for doctors and patients. Here are some obvious steps:

• EHRs should provide physicians with abstracted, relevant clinical data in the most user-friendly way possible, rather than dumping reams of data on them that make it hard to extract the useful from the extraneous.
• EHRs should supplement but not substitute for physician decision-making, providing doctors with evidence on the effectiveness of different drugs and tests in the least intrusive and least repetitive manner possible.
• EHRs should facilitate face-to-face interactions between doctors and their patients not detract from them.  (In my most recent visit to my own primary care doctor. he spent almost the entire time looking at his EHR, rather than making eye contact with me). 
• EHRs should make it as easy and quick as possible for physicians to document in the record the care provided to the patient.
• EHRs must become fully interoperable, able to seamlessly exchange secure patient data with other EHRs.

The government has a lot of EHR standards, but the only one that really should matter is how useful EHRs are are in helping physicians take better care of patients.

That said, the failure to address the significant downsides, including compromised safety from bad health IT and actual harms, among others, is disappointing.  I have rarely if ever seen officials in organized medicine address that issue head-on.

Ironically, the author points out that RAND investigators wrote:

... The overarching problem, the authors contend, is that “no other industry, to our knowledge, has been under a universal mandate to adopt a new technology before its effects are fully understood...

Those "effects" happen to include not just clinician inconvenience, but direct patient harm, a phenomenon that in 2014 is poorly understood as admitted by FDA, the Institute of Medicine and numerous others.  That unacceptable state of affairs largely due to systematic impediments to understanding the magnitude of harms - that is, willful and deliberate blindness by those who know better (see the blog link below for more on these assertions if you are not a regular reader here).

My letter to Mr. Doherty at ACP speaks for itself:

From: Silverstein,Scot
Sent: Monday, September 08, 2014 2:43 PM
To: Robert Doherty, American College of Physicians
Subject: RE: "Why doctors hate electronic health records"

Dear Mr. Doherty,

Read with interest your piece "Why doctors hate electronic health records" at http://www.philly.com/philly/blogs/fieldclinic/Why-doctors-hate-electronic-health-records.html

Are you aware another reason for doctors, especially hospital-based ones, to "hate" EHRs (or, more correctly, the hyper-enthusiasts who push them and the industry that creates them) is due to the potential of these unregulated and poorly-engineered systems to contribute to or be causative of patient harms?

I have been expert witness on the Plaintiff's side in numerous cases where this has occurred...after my own mother was tragically and fatally injured in just such an accident.

These were cases where paper would have been more resilient.

FYI, in case you were unaware:

ECRI institute's voluntary 2012 "Deep Dive study of EHR" finding of 171 IT-related "incidents" in 36 member PSO hospitals in 9 weeks, resulting in 8 injuries and 3 possible deaths, is an example of why physicians ought "hate" the state of the health IT industry and its true lack of regulation, pre- and post-market surveillance, and other such factors prevalent in other mission-critical sectors.

More on these issues is at my blog post at the blog site of the Foundation for Integrity and Responsibility in Medicine, a 501(c)(3), at http://hcrenewal.blogspot.com/2014/04/fda-on-health-it-risk-reckless-or.html

I am educating the Plaintiff's Bar on these issues at AAJ national and state chapter meetings.

I have zero tolerance for bad health IT, and complacent clinical users of bad health IT.

Sincerely,

Scot Silverstein, MD

In fact, it should be ACP, AMA, the state societies etc. performing the education on the issue of health IT harms, not just me and a small group of patient's-rights-minded "health IT iconoclasts."

One day, I hope organized medicine will start taking "T" supplements and do what needs to be done to compel this industry - and the government that should be regulating it effectively - to man up. 

-- SS

President of the American College of Physicians on Electronic Medical Records

I've taken so much flak over the years for being an "anti-EHR zealot", "a critic of the use of computerized medical records in hospitals", or similar canards [see note below] that I am letting someone else be a spokesperson today.

I am simply posting a link to this essay by Virginia L. Hood, MBBS, MPH, FACP, President of the American College Of Physicians (ACP) with only one comment:

Electronic Medical Records have Yet to Fill Their Potential

http://www.acpinternist.org/archives/2011/10/presidents.htm

From the October ACP Internist, copyright © 2011 by the American College of Physicians

Read the whole essay at that link.

Nearly every issue mentioned is addressed extensively on this blog since 2004 and at my educational website "Contemporary Issues in Medical Informatics: Common Examples of Healthcare Information Technology Difficulties" at this link. The latter site was started not just last month or last year, but in 1999.

My only comment is that I was more than a decade ahead of my time in recognizing and writing about many of the issues she discusses. Sadly, few were listening; now physicians are not just being encouraged, but in fact prematurely coerced to adopt this technology - in the deficient state as it exists today - by HHS. Tens if not hundreds of billions of dollars have been earmarked for our 'National Program for IT in the HHS.'

Ready, shoot ... aim.

-- SS

[Note] In reality, I am a critic of the use of poorly designed, poorly implemented and poorly managed clinical IT in hospitals.

Out of the RUC - the American College of Physicians Initiates an Open Discussion

We and the other bloggers have been trying to provoke an open discussion of the secretive, unrepresentative, unaccountable process which the US Center for Medicare and Medicaid Services (CMS) uses to fix payments to physicians. That process may largely be responsible for the implosion of primary care in this country, and substantially responsible for how we manage to pay so much for health care, yet have worsening problems with access and quality.

See our previous discussions of the process, and the central role of the RBRVS Update Committee (RUC), most recently here, and in earlier posts (here, here, here, here, and here) and important articles by Bodenheimer et al,(1) and Goodson.(2)

The ACP Advocate blog, the apparently official voice of the American College of Physician on its advocacy efforts, took up the issue in this post authored by Robert B Doherty, ACP Senior Vice President for Governmental Affairs and Policy.

Doherty summarized some of the points made on Health Care Renewal and on DB's Medical Rants. He appeared not unsympathetic to some of the criticisms of the RUC and the process that Medicare uses to fix physician payments.

I will summarize some of the points he made in his responses below, and interpolate my replies. I have also submitted the same material as a comment to his post.

- The RUC just provides advice.

The RUC provides [just] recommendations to the Centers for Medicare and Medicaid Services (CMS) on the physician work relative value units (RVUs) under the resource-based relative value scale.

++ My comments: The RUC may say that all it provides is advice, but that advice is almost always uncritically accepted by CMS. Per the also excellent article by Goodson(2), the AMA itself claims that CMS follows more than 90% of the RUC's "recommendations." ++

- The RUC did propose some increases to payments to primary care physicians. (Regarding this point, he quoted from a letter written by the Chair of the RUC:

The RUC recommended significant increases to E&M (evaluation and management) services, which were implemented by the CMS on 1 January 2007. These permanent increases result in an additional $4.5 billion in E&M services payments each year! To imply that they are small and insignificant is preposterous. Family physicians may see their overall Medicare payment increase by 5% or more.

++ My comments: The RUC did very belatedly recommend some increases in evaluation and management codes, but these hardly made up for its years of neglect of primary care (to use polite terms), and this increase, as Dr Larson pointed out, benefited all physicians, not just primary care, or cognitive specialties, to the extent it was not nullified by across the board cuts necessitated by the SGR. ++

- The RUC is helping promote the concept of the medical home.

The RUC deserves credit for the evaluation and management increases, and more recently, for estimating the physician work involved in care coordination for the Medicare medical home demonstration project.

++ My comments: How well the RUC did in the case of the proposed medical home is unclear. See this post and its links to a serious critique of this work. ++

- The RUC ought to be reformed, but not abolished.

But the RUC does need to look at its own composition and processes. It needs to be more representative of primary care and more transparent in its deliberations. The new Obama administration and Congress would be well-advised to insist that the processes Medicare uses to determine the values of physician services be as transparent as possible, and include sufficient and appropriate representation and expertise from primary care. They should also require a better process for identifying overvalued services.

But making the RUC the main villain in a system created and run by the government misses the mark. We have to remember that it is Congress and CMS, not the RUC, who makes the rules. As long as the Medicare payment system pays based on volume instead of rewarding prevention and care coordination, primary care physicians' incomes will lag behind specialties that can generate more volume, because primary care doctors can only increase volume by cramming more patients into an already over-scheduled day. This would be true even if the RUC were reconstituted to include more primary care doctors.

And, we need to ask if the RUC were to disappear, who should recommend the work involved in physician services? Economists and physicians hired by the federal government?

++ My comments: I surely agree that the RUC ought to be more representative of primary care and more transparent. As noted in Dr Goodson's article, primary care has had a very small representation on the RUC. There is not a single designated seat for general internal medicine, but orthopedics effectively has two (one for orthopedics, one for spine surgery, which has a separate society).

Note further that many of the specialty societies that support RUC members are supported heavily by industry, that is, by pharmaceutical, biotechnology, and device companies. Such corporations benefit from irrational exuberance about procedures, since they sell the drugs, devices and supplies that are used in procedures. See posts here and here, for example, on some of the industry sponsorship of the AAOS, which sponsors an "orthopedic" seat on the RUC.
Such institutional conflicts of interest affecting the RUC have never been publicly
discussed.

The transparency issue is not trivial. The identities of the people who sit on the RUC have been SECRET. A few members have admitted publicly that they are, but the AMA - I'll say it again - keeps the membership roster of the the RUC secret. One wonders what they have to hide. Not only is the membership secret, of course, but the group's deliberations are also secret.

It is the privilege of the AMA, a private group, to keep the membership of the RUC secret. But I would note, that secret is also kept from the general AMA membership, who are presumably paying their dues to support this secret committee.

On the other hand, since the RUC functions as a de facto government agency (note again that CMS seemingly gets input from no other source for its revisions of RBRVS), having such important government decisions, which have nothing to do with national security, made in secret is offensive.

It is true that Congress and CMS made the rules that allowed all this to happen. There are very big questions about why CMS pursued this course. Maybe some investigative reporter, some congressional agency, or in a new administration, CMS itself will investigate how this happened.

But the AMA did not have to go along with it. They could have insisted on an open,
transparent, representative, accountable process, and refused to participate were that not allowed. Instead, they at least went along with a fee setting process that is opaque, unrepresentative, unaccountable, and not obviously subject to any ethical standards.

The RUC should disappear. Medicare should develop an open, transparent, representative, accountable process to negotiate what it pays physicians. The names of the people involved should be public. The people involved should be free of obvious personal conflicts of interest, and should not be sponsored by organizations with obvious institutional conflicts of interest.++

At any event, I salute Mr Doherty for getting this important policy issue more into the light. The RUC seems to be one of those things that it was not considered polite, or politically correct, to talk about, much less criticize. Maybe an open dialog will lead to some measurable reform of a physician payment system that badly needs it.

References
1. Bodenheimer T, Berenson RA, Rudolf P. The primary care-specialty income gap: why it matters. Ann Intern Med 2007; 146: 301-306. Link here.
2. Goodson JD. Unintended consequences of Resource-Based Relative Value Scale reimbursement. JAMA 2007; 298(19):2308-2310. Link here.

On ACP's Endorsement Of "Single Payer", And A Call For An End To Irrational Exuberance over EMR's

A letter to the Philadelphia Inquirer that likely will never make it into print due to its iconoclastic, "reality that nobody wants to hear" content. Also cc'd to the leaders of the American College of Physicians, on the ACP's endorsement of "single payer" and the oft-stated panacea of the EMR as the tool "to reduce medical administrative costs."

I believe it's time to put the brakes on the "irrational exuberance" that characterizes today's EMR efforts. Healthcare IT is a field that unless brought back to sanity will transfer countless dollars to the IT sector that healthcare and patients cannot afford, and will develop tools that make patient care even more unbearable for clinicians than it is today through inept design and inept or disingenuous "performance metrics." For much more on these issues, see my web site "Common Examples of Healthcare IT Failures" at this link.

In fact, EMR's are still an experimental technology and should be thought of as such. They were invented by researchers and experimenters in medical informatics and were slowly and deliberately being perfected, until massive reductions in costs of computing hardware and increases in speed and ubiquity gave many in the IT, government and payer sectors (via a leap of logic of supernova proportions) the technologically deterministic idea that every aspect of medicine could and should be easily automated. And that it would be hysterically profitable to do so: profitable for everyone except, of course, practitioners and patients.

To: sburling@phillynews.com
From: MedInformaticsMD
Date: 12/04/2007 01:29PM
Subject: Re: American College of Physicians endorse single-payer

Re: American College of Physicians endorse single-payer (Phila. Inquirer, Dec. 4, 2007, http://www.philly.com/philly/business/12109247.html)

Dear Ms. Burling,

While one can argue the merits and demerits of creeping socialism, and while I find it ironic that the ACP endorsed "single payer medicine" at the same time that the people of Venezuela rejected socialism, there is one item in your story reflecting another "irrational exuberance" that should not be taken at face value.

That item is the oft-repeated statement that electronic medical records work miracles, in this case that the "greater use of electronic medical records (EMR) reduces medical administrative costs."

In fact, I increasingly believe the opposite is true, even when the electronic medical record project is successful, which most are not.

The majority of information systems developments in most sectors are unsuccessful, and the larger and more complex, the harder they fall ("Pessimism, Computer Failure, and Information Systems Development in the Public Sector." Public Administration Review 67;5:917-929, Sept/Oct. 2007). Healthcare is no exception.

A number of organizations have spent billions on EMR systems, such as Kaiser Permanente, have had massive delays and cost overruns, and are still years away from anything resembling "reduction of administrative costs." See my post at http://hcrenewal.blogspot.com/2006/11/kaiser-healthcare-it-meltdown.html.

Electronic medical records require a huge investment and significant "upkeep.' This "cost of ownership" puts a big doubt upon EMR projects as a cost-reducing endeavor. Rather, EMR's should better be thought of as a cost center.

An EMR for small-group and solo-practice physicians costs $44,000 per physician, and generates an average ongoing $8,500 per year in annual costs, the past ACP president herself, Lynne Kirk, MD told the house Subcommittee on Regulations, Healthcare and Trade of the House Committee on Small Business in October 2007. "The business case does not exist to make this kind of capital investment," Kirk told the Subcommittee.

In fact the use of EMR's will not significantly reduce overall health care costs, the director of the Congressional Budget Office said at the release of the agency's 2007 report on long-term health care spending. Peter Orszag , CBO's director, said that according to data from the report, the return on investment for EMRs "is not going to be as substantial as people think."

My own university's faculty practice plan at Drexel attempted to implement electronic medical records. Due to failure of the billing component, the exact component that was supposed to help "reduce administrative costs" but instead raised it by a few million dollars to manually correct the errors, the result was a multimillion dollar lawsuit (link to online court records here) by Drexel against the EHR vendor AllScripts and Allscript's partner Medicomp System s , a "corporation specializing in the development of point-of-care tools for Electronic Medical Records ... to help overcome physician resistance to adoption. " Temple University Health System delayed electronic medical records rollout due in part to unaffordability and a likely, justified fear of costly problems, which came to my attention due to the decision's delaying the doctoral thesis work of a graduate student here.

I also believe the EMR is rapidly becoming a tool for payors to minimize their costs and maximize their profits, while inconveniencing physicians trying to take care of patients under increasingly pressured timelines due to poor design. EMR's are largely designed under processes led by technologists, not clinicians.

Finally, with regard to effectiveness of EMR's in actually improving healthcare quality, even that is doubtful. A research article in the Archives of Internal Medicine entitled “Electronic Health Record Use and the Quality of Ambulatory Care in the United States” (Arch Intern Med. 2007;167:1400-1405, link to abstract here ) reached what to many was a counterintuitive conclusion. The authors, EMR experts, examined EMR use throughout the U.S. and the association of EMR use with 17 basic quality indicators. They concluded that “ as implemented, EMR’s were not associated with better quality ambulatory care ,” and were bold enough to publish their findings, sure to be unpopular in the health IT industry.

It appears the clinical case may not exist, either, for EMR's as they are designed and implemented today.

These issues are international in scope. Richard Granger, former head of the UK's “Connecting for Health” national EMR program, had this to say about a program described by some UK members of Parliament as “the largest government IT debacle ever” (see here for more):

"Sometimes we put in stuff that I'm just ashamed of ... Some of the stuff that [our large American clinical IT vendor] has put in recently is appalling ... [vendor] and [prime contractor] had not listened to end users ... Failed marriages and co-dependency with subcontractors ... A string of problems ranging from missing appointment records, to inability to report on wait times ... Almost a dozen cancelled go-live dates ... Stupid or evil people ... Stockholm syndrome -identifying with suppliers' interests rather than your own ... A little coterie of people out there who are "alleged experts" who were dismissed for reasons of non-performance."

So, next time you hear that single payor systems enhanced by EMR's to "reduce administrative costs" are a panacea, think of Hugo Chavez' wondrous plans for a socialist utopia as President for Life of Venezuela.

You can read much more and see examples of EMR failure and mishaps at my web site "Common Examples of Healthcare IT Difficulties" at http://www.ischool.drexel.edu/faculty/ssilverstein/medinfo.htm

-- SS

Addendum: an editorial from a health IT publication whose editor understands reality, FierceHealthIT - Weekly News for Health IT Leaders:

The EMR rollout dilemma: The necessary evil
December 3, 2007

When it comes to EMRs, big healthcare organizations have a big, nasty problem on their hands. The problem? While they pretty much have to invest in an EMR system to stay competitive, by most IT industry standards this is a lousy time to jump in and do it. At the same time, however, they seem determined to move ahead.

Compared with other types of enterprise IT spending, EMR investments are a major crapshoot at this point, given the lack of support from some clinical staffers and the questions still floating around as to what features they should have. But in this case, providers are facing huge pressure from the federal government, some payers and hanks to ongoing PR efforts, even consumers to bring up an EMR system.

Sure, if they're going to spend the money, now's probably the time, rather than waiting five or ten years for the EMR product category to mature [I actually disagree with that - ed.] After all, organizations the size of Kaiser Permanente and Sutter Health--both rolling out the Epic EMR--will spend years integrating such systems into their already formidable infrastructure. So they have to begin getting their hands dirty with the technology now.

But there's still something odd [I would say "monstrously odd" - ed.] in how many formidable organizations are choosing to invest in a product whose feature set is still in question and whose popularity among key users is in doubt. In most industries, billion-dollar enterprises don't get pressured into buying a product this early in its lifecycle and cramming it into their operation. (The closest I can think of is the wave of ERP platform adoptions over the past decade or so--another very expensive boondoggle which only seems to be creating real value after years of heartache and expense.)

If nothing else, let's admit that the talk about avoidance of medical errors and efficiency improvements is a bit of a smokescreen--because if Kaiser was spending a few billion for that, it'd certainly be losing its shirt for quite some time into the future. While quality is a factor, I'd argue that most execs want to see EMRs in place so they can gather data needed for pay-for-performance incentives and shunt quality and outcomes stats to regulators.

As I see it, if health system leaders, health plans and government officials want EMRs in place so badly, they might want to start by being honest about their motives. Once they do that, they might get clinicians to see EMRs as more than just a necessary evil. - Anne

To which all I can add is "indeed."

-- SS

The AAFP Opens the Door for No Free Lunch

An email press release by the organization No Free Lunch today reveals that the American Academy of Family Physicians (AAFP) has reversed its previous decision (see post here), and will now allow No Free Lunch to have a booth in the exhibition hall during the AAFP annual meeting in San Francisco.
The email stated,

Following an outcry from among its members, the American Academy of Family Physicians has reversed its earlier decision to deny a booth to No Free Lunch and has invited the organization to exhibit at its meeting next week in San Francisco.
In August, The AAFP rejected No Free Lunch’s application to exhibit at its annual meeting—which will be attended by some 5,000 family physicians and slightly fewer exhibitors—stating that No Free Lunch’s position was “not within the character and purpose of the Scientific Assembly.” This despite the fact that the Coca-Cola Company, The McDonald’s Corporation, and The Distilled Spirits Council of the U.S. were all allotted space in the hall, as were countless pharmaceutical companies.
Many members were upset and even outraged that a society which they had supported for many years, and which gives industry almost unlimited access to physicians at its meetings, would not allow a small organization of health professionals to voice an opposing view. Allen Pelletier, for example, a family physician from Memphis, Tennessee, a long time AAFP member and newly elected fellow of the Academy, in an e-mail to AAFP CEO Dr. Douglas Henley, wrote “To my embarrassment, the organization that represents me as a practitioner and teacher of family medicine has shut down the possibility of open (and yes, critical) dialogue about how our practices are influenced by the pharmaceutical industry.” A family physician and AAFP member for 25 years from East Lansing, Michigan, wrote “. . . if an organization like No Free Lunch, well known for the role that it has played in encouraging awareness among physicians of the negative impact of pharmaceutical marketing, is denied the opportunity to set up a booth at the meeting, while commercial sponsors are encouraged to pay extra for more access to members and attendees, then the professional values of our specialty society have truly reached a new low.”

Good for AAFP for reversing course here. The issue, as the above AAFP members' emails made clear, was not whether AAFP should adopt No Free Luncrecommendationsomendations. The issue was a free speech issue, whether AAFP was willing to give No Free Lunch the opportunity to speak out about recommendationsomendations, even if their mode of expression is not as gentile as the AAFP might prefer, and everecommendationsomendations may upset some people. The AAFP already allows commercial interests to speak out about their wares. Their mode of expression may be polished, but is backed by plenty of money and marketing muscle.
Finally, the reasons the American College of Physicians (ACP) banned No Free Lunch from their last meeting remain murky. The public documentation about this decision only includes press releases by No Free Lunch and the ACP, and an article in the Wall Street Journal (available here). The ACP contended that No Free Lunch "caused trouble at its 2001 meeting, even sneaking in an undercover TV crew. Dr. Goodman [the leader of No Free Lunch] says that even if there were some problems, which he isn't sure is[sic] the case, that they weren't orchestrated by the organization" (per the Wall Street Journal). Again, in my humble opinion, an organization with an ethical and academic mission (like the ACP) ought to bend over backwards to ensure free expression and open communication , especially when one side of the argument is made by large, rich, and powerful organizations like big pharma corporations.

The Primary Care Squeeze: Who Will Be Part of the Solution?

In stark contrast to stories of ever more expensive drugs for ever more expansively defined ills, government research leaders getting six figure consulting fees, and multi-million dollar CEOs, ... primary care is in progressively worsening crisis.
Last week the American Medical News reported that family medicine has seen its eighth consecutive yearly decline in the number of US medical students matching to its residency positions. Since 1997, the number of US students going into family medicine training has dropped from 2340 to 1117, more than a 50% decrease. Fewer US students have matched in all primary care fields over the last 5 years.
This data still seems to puzzle the leadership of major US medical organizations. For example, the article quoted Steven F. Weinberger, Senior Vice President of the Medical Knowledge and Education Division of the American College of Physicians, "There's a concern that being the physician responsible for the ultimate care of the patient means life becomes a little more unpredictable in terms of hours. But there are wonderful ways to build models of practice to counter that." Furthermore, he said "another important issue is giving students the sense of the long-term gratification of the longitudinal care of patients." This is similar to previous comments made by him, and by leaders of the American Association of Medical Colleges (AAMC) and the American Academy of Family Practice (AAFP), (see this post) suggesting that the main reason that students were not going into primary care is that they hadn't learned about all its positive aspects.
I certainly agree that there are intellectual and emotional benefits to primary care practice. Maybe we aren't adequately teaching students about them. But it seems as if some of the folks leading large organizations like the ACP don't understand just how grueling primary care has become.
One way to understand its challenges is simply to page through some of the stories on Health Care Renewal.
On the other hand, see two articles from the Miami Herald last week. The first, "Primary Care MDs Under Pressure," described anecdotes of primary care doctors leaving practice "because they couldn't overcome the squeeze between low fees from insurers and soaring costs, or they refused to survive by cutting their time with patients." Ted Fisher, of the Florida Academy of Family Physicians, said as a result, "we see a big shortage coming in Florida...." The article included figures that primary care reimbursement has gone up 4.4% annually, while primary care overhead costs have gone up 7.7% annually. Discussions with physicians here in Rhode Island and southeastern Massachusetts suggest that we are being squeezed just as hard.
Why this story hasn't reached the leadership of the ACP, the AAMC, and the AAFP is not clear.
Robert Forster, Vice President, Health Care Services, and Medical Director of Blue Cross Blue Shield of Florida, was quoted as acknowledging that reimbursement to primary care physicians has not kept up with inflation, much less their rising costs. However, in the second article ("Primary Care is Often Undervalued"), he blamed it on society: "The importance of the primary care doctor doesn't have societal backing. The problem is that it's hard to measure the value of talking to a patient." Furthermore, "since the 1950s, American medicine has emphasized specialties and procedures over primary care. It's going to take some major changes in our society and our thinking to turn that around." Of course, "society" may be enchanted by the marvels of high-technology, sub-specialized care. However, in 2004, Blue Cross Blue Shield of Florida announced it has 28% of the Florida market, more than twice the share of any competitor. Why its Vice President, Health Care Services and Medical Director denies any personal or organizational responsibility for inadequate reimbursement for primary care is not clear either.
In summary, primary care is under seige by progressively rising costs and lower reimbursement. Since this seems to be public knowledge, it shouldn't be surprising that medical students are increasingly going into other fields. What is surprising, and troubling, is that leaders of major medical organizations either fail to recognize how hard it is to practice primary care, or recognize it, but fail to acknowledge any responsibility to do anything about the problem.
By avoiding any responsibility for the solution, such leaders become part of the problem.

Big Medical Organizations Still Don't Understand Why Medical Students Don't Choose Primary Care

In Internal Medicine News Online is this gem of an article about how our fearless leaders are trying to attract more students into primary care fields. According to Michael Whitcomb MD, Senior Vice President of Medical Education for the American Association of Medical Colleges (AAMC), and Steven Weinberger MD, Senior Vice President for Medical Knowledge and Education at the American College of Physicians (ACP), and someone anonymous from the American Academy of Family Practice (AAFP), the reasons students don't go into primary care include:

• "the way students see primary care"
• students don't see "the proper management of chronic care patients"
• "students often don't recognize the gratification of building relationships over many years"
• students don't have "access to competent role models in family medicine"

Some still-dedicated medical school faculty who toil with ever less support from medical schools (even as tuition rises much faster than inflation) might feel insulted by the leaders of the AAMC, ACP, and AAFP who think they aren't demonstrating "proper management of chronic care patients," and aren't "competent role models."
For a good response see KevinMD:
" Graduates today finish with more debt and higher practice costs than at any time in the history of U.S. medicine, while facing a resource-constraining reimbursement system that has been racheting down physicians' incomes for many years now. Let the researchers puzzle over this: why would anyone want to go into a field where every indication is that the annoying stressors become ever more burdensome while the costs of operating a practice rise relentlessly and reimbursement is nearly flat. "
As Medical Rants put it:
"Understanding student decision making is not rocket science. Kevin does primary care - and he understands what our leaders apparently do not understand. "

Well, actually, Dr Weinberger of the ACP also said that "repairing the payment system, reducing administrative hassles, articulating the value of internal medicine, and redesigning training to better meet the scope of practice" are also important.

But it still seems like the leaders of the organizations that are supposed to support primary care don't understand the pressures on primary care physicians. The rising tide of paperwork and bureaucracy are far more than "hassles." The AAMC, ACP, and the AAFP should fight to support physicians' core values, not merely "articulate" the value of primary care and market it as "attractive"

The relatively small Society of General Internal Medicine recognized that primary care physicians face "chaos," not just "hassles." (Its annual meeting this year has the explicit theme of "Out of Chaos.") But the bigger, powerful, better funded AAMC, ACP, and AAFP still don't get it.