On the destruction of medicine as a profession: "Try bending a lawyer over a barrel"

From a physician colleague, a dedicated professional, reposted with redaction of locale with permission.

This speaks for itself.  I believe there are a great number of medical professionals who would speak out this way, if they did not fear retaliation (as does my colleague, hence anonymity) or if they were not suffering from the syndrome of clinician learned helplessness (http://hcrenewal.blogspot.com/2007/10/physicians-learned-helplessness.html):

Scot,

Yesterday I spent some time in a family docs office in [redacted] who has been experiencing an EHR failure in his office. Naturally its messed up his work flow not to mention occupying hours on end of his ostensibly personal time. His reaction was mostly one of frustration.

In another situation, the ABMS is acquiring near dictatorial powers over physicians' livelihoods by essentially mandating an expensive, time consuming jumping through of hoops in the form of MOC requirements which may well evolve into MOL. Its a shakedown. Except for a few thousand members of AAPS that is seeking legal redress in Federal court, organized medicine is silent. Physicians who are undoubtedly frustrated just play the game in a grim resignation.

Where is the moral outrage? Where is the righteous anger? Another physician, a close friend of mine, feels exactly the same way. This healthcare system is poisoning our souls and is engaged in a full frontal assault against our ability to ply our trade (which we have invested so dearly in) as critical, free thinking human beings.

Extortion at its best. More ominously, we are being extinguished, not transformed,  as a profession. Remolded into subservient "providers". With little blow back. Can you even imagine any other profession allowing this to happen? Try bending a lawyer over a barrel. We are exploited blue collar workers without union representation. We are essentially working in a  meatpacking plant that Sinclair Lewis wrote of.

I am so tired and ashamed of being associated with a gutless group of people who call themselves physicians. I just had to get it off my chest.

If people remain indifferent to having their physicians bureaucratically overburdened and demoralized, the outcome will not be pretty in times of medical extremis.

-- SS

Guest Post: Incompetent Management Breeds Demoralized Physicians

Health Care Renewal presents a guest post by Dr Howard Brody, John P McGovern Centennial Chair of Family Medicine, Director of the Institute for Medical Humanities at University of Texas - Medical Branch at Galveston, and blogger at Hooked: Ethics, Medicine and Pharma. 

Danielle Ofri, a prominent internist/author at Bellevue in New York, started a recent op-ed piece, “Last week I was ready to quit medicine."

She described an encounter most physicians can relate to—a 15-minute appointment slot, a new patient who spoke only Bengali, a long and complicated problem list, a bag containing 18 different medicines, two forms that had to be filled out by the doctor on this day’s visit, and a computer that froze while she was trying to keep up with the electronic charting. She described how, 45 minutes into the supposedly 15-minute visit, she had a phone in one ear with the Bengali translator and tech support on hold in the other ear.

Ofri’s plaint caught my attention because I had recently put up a guest post on Health Care Renewal about another highly skilled, caring physician who was seriously considering quitting practice. This led me to write a column for some of our local newspapers about demoralized doctors

In the space allowed in an op-ed column, you can’t go into great depth in analyzing a complicated situation. So here’s what I would have wanted to say.

We can list all the management failures that this encounter represents. I won’t even start with the electronic record as that’s such a frequent theme in this blog. Who scheduled such a patient for a 15-minute visit? Where is the pharmacist who could have done a better job of going through all the lady’s medicines? Where is the staffer who could have filled out the forms for Dr. Ofri to sign? This is just to scratch the surface.

There are two things worrisome about this long list of management failures. If the goal of the health care system is actually to take good care of patients, then it seems obvious that Dr. Ofri, who wanted to try to provide high-quality care, had roadblock after roadblock thrown in her way.

Cynics will protest that this system obviously has no interest in quality patient care and seeks only to maximize revenue. If that’s so, is it really true that a board-certified MD is the most efficient labor source for keyboarding data into a computer, filling out paper forms, and doing all the other busy-work tasks that Dr. Ofri had to juggle? Can anyone really believe that this management structure supports either quality care or efficient resource use?

If the management of U.S. hospitals was severely understaffed or underpaid, then we could perhaps forgive such lapses. But we know that while the growth of physicians in the U.S. has been slow, the number of administrators has grown by leaps and bounds [The number of health care managers increased by 726% from 1983-2000 while physician numbers increased by 39%, look here - Ed]  . And we know that at least at the high end, these managers are paid munificent sums, and are lauded for their supposed genius (look here for example). 

So we appear to have a system that is slowly (in some cases rapidly) driving the best doctors out of practice, and yet somehow imagines that everything is going all right and there’s no problem—or if there’s a problem, it’s those whining doctors.

All us medical educators know that when we ask the first-year class how may of them have been told by practicing physicians that they’re making a big mistake coming to medical school, the majority will raise their hands. Yet the managers of America’s health systems apparently believe that they can go on demoralizing good practitioners and nothing bad will happen.

This may sound as if I am saying that health care managers are all evil people, but that’s an unfair characterization. These folks are simply trying to do what our society tells them. As I explained some time ago, most of our popular and political discourse has been captured by a belief system that can be variously called neoliberalism, market fundamentalism, or economism. The ideology can be summarized as a quasi-religious faith in the so-called “free market,” steadfast opposition to government regulation of the market, and opposition to just about any form of taxes (for more on the nature of economism, look here.)

Among other things, this ideology teaches us that everything important in our society can be accurately captured in objective measures of “productivity” and “efficiency.”  [This is akin to the "shareholder value" theory of management (look here), or "financialization." - Ed]  Once one has mastered the basic concepts taught in MBA school, there’s no need to learn anything about health care and what makes it a unique activity; there’s no basic difference between providing health care and flipping burgers at McDonalds or making widgets. [We have called this generic management. - Ed.]. And so we get the crazy style of management well documented on this blog, not because of personal nastiness or ill will, but due to the ideological Kool-Aid everyone has been drinking for several decades now.

Today’s physicians seem to be like the proverbial frog being boiled in the pot of water because the heat was turned up so gradually the frog never figured out it needed to jump. [That is, they are suffering from "learned helplessness." - Ed] Dr. Ofri herself seems to represent a typical frog. Why? Perhaps it’s the style of the blog or op-ed writer to start off with a downer and then try to end on an upbeat note. Or perhaps it’s the natural physician’s tendency to stay away from policy questions. I’m not sure.

After starting us off with this hard-hitting description of a dysfunctional system, Dr. Ofri ends by opining that things are going to be better in the future because more women are entering medicine and because today’s medical students are more tech savvy. She gives herself credit for managing to forge a bond with the patient because they sat together and faced this adversity. She cites an upbeat study, “when asked what was the most satisfying aspect of medical practice, the number one answer was relationships with patients. This is what keeps us going on even the most trying of days.”

Dr. Ofri gets full credit for remembering the importance of relationships, and feels that she bonded more firmly with her patient because they went through all this together. How about a word, though, about the people behind the curtain, who are responsible for all that she and her patient had to go through, and who don’t seem to have a clue how bad it is and what it all means? 

Dr Howard Brody

GUEST BLOG - What Can Doctors Do to Combat Business Malfeasance in Health Care?

Dr Gene Dorio is a an internist and geriatrician in California, described in the Los Angeles Times as an "old school physician."  He would welcome discussion with anyone interested in his proposal.  Please email him directly at grd51 at aol dot com, or email me for forwarding.    

As a Health Care Renewal reader, learning of medical business malfeasance irritates my moral conscience, yet lack of legal intervention frustrates my inner core.

I am chairman of the Department of Medicine at a small community hospital in Southern California, and as I battle the Administration during Medical Executive Committee meetings, I am a lone voice. Some of my colleagues nod their heads, while others later tell me of their support, but few vocally nor in writing openly give their opinion. Why?

Most fear hospital financial retaliation, but I also know they don’t have time to formulate an opinion. You would think well-educated doctors who daily advocate on behalf of patients would be better attuned to being involved in our great medical debate. Because they have remained silent, “big business” jumped in and took over financial medical decision-making.

Using our medical license is the business scheme they use to make their money. With sophisticated business techniques, they have shut out doctors and dangled dollars as we all jump for their “carrots.” That successful business model and attitude is outside the realm of doctor’s poor business and public relations sense, with the noose continually tightening.

Realizing business would be nowhere without our medical license is our trump card...which we haven’t played yet!

What can we do? Logically, bring their business malfeasance forward on blogs (like Health Care Renewal) with the hope physicians and the public will be upset. It does stir the pot for some of our colleagues, but for the most part, doctor attention is now focused on just trying to survive. The public is rendered helpless by the continually confusing medical legalese by the well-financed business propaganda machine. This is where our frustration arises, as the backlash-opinion tsunami of their business outrage never materializes, especially from doctors.

Therefore, my first thought for a possible solution is focus on the public, clarifying the legalese, and use abhorrent stories of business abuse and patient care sacrifice for business profit. We must make them the villain.

Secondly, organize physician writers into a small group launching a “counter offensive” against their propaganda. The public still highly respect physicians and gravitates to their opinions and stories. With the right motivated people, they would think-tank refined opinions for the national spotlight.

Thirdly, network with national blogs and magazines, and city-printed newspapers for article publication as op-eds, letters to the editors, journal articles, and personal stories.

Fourthly, and probably the hardest, not get discouraged.

Health Care Renewal defines the problem, but not always the solution. Even when there might be solutions, they must be broadcast and directed at a higher level to ignite public opinion.

If you think this might be worthy for 2013 (as if we aren’t all busy enough!), I will be happy to spearhead this project with those advocate colleagues and idealists who might be interested.

Our profession is under assault from big business, and finding clarity is the shield we need to defend society and our patients.

Dr Gene Dorio

The Perils of Physicians Practicing as Corporate Employees: the Contract Trap

A seriously chilling cautionary tale corroborated some of my previously expressed fears about the perils of physicians practicing as corporate employees.  It unlikely venue was the April 25, 2011 issue of Medical Economics.  The article, not yet on the web, was "Selling to a Corporation Poses Challenges," by Todd R C Neely.

Here is how the case started:

A start-up company with a new medical treatment became a publicly traded corporation. The company's top managers were not physicians; they were finance and business experts familiar with the ways of Wall Street.

To meet the corporation's goals and Wall Street expectations, the company used stock sale proceeds to aggressively market itself to doctors and buy established physician practices around the country. It quickly captured market share, exponentially raised the number of patients by the practices it owned, and developed substantial revenue streams.

The physicians who sold their practices thought that selling would be a win-win situation for them and for the corporation. As marketed to them, the company would handle the business aspects of owning a medical practice - the ubiquitous paperwork, employee issues, and all the rest of the nonclinical task so distasteful to doctors. The physicians would spend all their work time practicing medicine using the latest technology. Benefiting from the company's promotion to the public, they would see an increase in their patient base. They would receive a base salary and, most significantly, a percentage of the profits of their practice.

But here is how things turned out:

Everything was great until the end of the first year. The physicians expected large payments from their practices' increased profits, but the large bonuses never came.

What went wrong? The physicians were so blinded by the marketing pitch that they apparently never read the fine print:

In negotiating the sale of the practices and the employee contracts, the doctors had not required the company to specify in writing what expenses the corporation would charge an individual practice and what accounting rules would be followed. So the corporation charged the practices for marketing, accounting, human resources, financing, and other services, wiping out the profits of each practice.

The contracts were apparently designed by the corporation to favor all its interests (which should not have been surprising), but was accepted as is by the physicians:

The contracts specified in precise terms the physicians' responsibilities, noncompete provisions, confidentiality, dispute resolution and the like. But although the contracts stated the corporation's initial responsibilities - mainly making payment on the negotiated purchase price - it phrased the company's other obligations in remarkably vague terms, or, astonishingly, did not specify them at all. The company was to make its 'best efforts' to accomplish certain goals, but the contract left the phrase 'best efforts' undefined. The phrase turned out to be quite malleable. The company's other responsibilities were to be determined at a later, unspecified time.

The company's best efforts always turned out to be whatever efforts it chose to make.

It was a trap,baited by marketing, into which the physicians neatly fell:

Many sought legal advice and were told they had no legal resource. The noncompete clauses - fair provisions under the contract terms to which the physicians thought they were agreeing but that were disastrous under the terms (or lack thereof) of the actual contract - were broad, tight, specific, and ironclad. Many of the physicians even were barred from practicing medicine within the geographic area in which they lived. And under the equally ironclad confidentiality clause, the doctors could not publicly discuss their situations or, for that matter, anything else of significance about the corporation; if they did, they would be subject to high fines and penalties.

What had appeared to the doctors as a mutually beneficial situation turned into a nightmare for them. They lost their practices and money and took years to recover. They had no legal recourse. They could not even warn others. The corporation could, and did, continue with impunity.

Note that it is now obvious why the article was so vague about the identity of the corporation and the physicians it ensnared, and why it took so long for even such a vague version of this story to surface. The confidentiality (and probably anti-disparagement) clauses made it hazardous for anyone who signed these contracts to be forthright witnesses. 

Obviously, the willingness of corporations to employ such clauses means that there may be many more cases like this out there, hidden behind the veil of contractual restrictions on free speech.

We previously discussed how physicians often seem willing to blithely sign contracts without fully understanding them, thereby sacrificing their economic well-being and core values.  Here is another striking case of this phenomenon.  We previously attributed this tendency to learned helplessness. 

The author of this article, however, suggested  that physicians were victims of carefully targeted marketing based on psychological manipulation.  It was meant to capitalize on three major factors: physicians' naive belief that everyone involved with medicine is interested in helping people by behaving rationally and logically; physicians' over-confidence in their ability to avoid failure (presumably including failure due to ignorance or misinterpretation of legal contracts); and physicians' feelings of entitlement. 

In addition, the physicians seemed (probably foolishly) unaware that corporate executives are not interested in physicians' core values:

Unlike physicians, the corporation and its top executives, non-doctors all, were involved in the practice of medicine solely to make money; the medical practices, and the very practice of medicine, were just commodities [to them].

This observation corresponds with numerous observations about how leaders of health care organizations may ignore, or be expressly hostile towards physicians' core values. Thus, while the article went on to give some straight-forward advice about negotiating combined practice buy-out and corporate employment agreements, it becomes obvious that the main lesson is: physicians should not practice medicine as corporate employees. They should not sell their practices to and become employees of for-profit corporations as a way to practice medicine.  Otherwise, rather than being practitioners, they will end up as medical assembly line workers for bosses who only care about the revenue they generate.

Physicians who have already inadvertently, foolishly, or under duress signed contracts that could threaten their professionalism and their patients' welfare need to do the right thing and challenge these contracts.  , or else there will soon be nothing left of the medical profession, and no one left to ethically care for patients. 

With each new anecdote, it becomes clearer that the corporate practice of medicine will end up exploiting physicians and patients alike. So there is also a main lesson for patients: you should not go to doctors who are corporate employees, or practices or clinics that are run by corporations. If you do, you will end up being used only as a means for the bosses to make money.

At a policy level, if we do not stop the corporate practice of medicine, we will all end up as increasingly unhealthy cogs in the corporate health care machine. 

Are Health IT Designers, Testers and Purchasers Trying to Harm Patients? Part 2 of a Series

(Note: Part 1 of this series is here, part 2 is here, part 3 is here, part 4 is here, part 5 is here, part 6 is here, part 7 is here, and part 8 is here. 2011 addendums: a post that can be considered part 9 is here, part 10 is here.)

At the (deliberately) provocatively-titled piece "Are Health IT Designers, Testers and Purchasers Trying to Harm Patients? Part 1", I wrote that I would be presenting mockups showing the EHR deficiencies I am hearing about. These deficiencies in basic human computer interaction, biomedical information science, and presentation of information create a terrible user experience for clinicians.

The title of these posts are deliberately provocative because the stakes of the issues addressed are so high.

These hellish user experiences are causing clinician cognitive overload, distracting and tiring them, and due to violations of fundamental good practices in information display, actually promoting error.

These violations are primarily due to lack of clinician input at design, sluggish vendor correction of reported critical deficits, programmer convenience, contractual gagging of a healthcare organization's ability to share these defects with other users and the public at large, and vendor immunity from liability on the basis of "learned intermediaries" (clinicians) between the defective IT and the patient.

Imagine if aviation worked this way. Imagine if the crash of the Continental Connection Flight 3407 had been due to defective instrumentation as suggested by the pilot's union.

I cannot present actual screen shots of vendor EHR defects, since the vendor contracts forbid that on the basis of intellectual property protection. However, I am drawing mockups to substantially illustrate the problems I am hearing about.

I am starting off with a relatively simple example. Many more will follow in future parts of this series.

This one can be called "Warning, no warnings" and reflects two problems I've heard about rolled into one:

(WARNING! No warnings! Click to enlarge)

This is a fictional representation of a screen from an actual major vendor EHR in use at many large hospitals in this country today.

Note the following:

• A warning that there are no warnings about abnormal results. "Please review all results carefully, there are no indicator flags" - in 2009?
• A results section that says "negative" and "results final." Most busy clinicians' eyes would stop there, especially in the wee hours as this report is from.
• An addendum to the report that the result is actually positive for MRSA, one of the most feared drug resistant pathogens today. In labs and diagnostic departments, a change from an initial impression or result happens. Unfortunately most EMR's do not support the old style method of erasure, or crossing out erroneous data with a pencil!
• No flag on that addendum of any kind, although at the lab at the point of data entry, a flag was requested and seen by the reporting technician!

The lack of a flag to signal an abnormal result saves a vendor the inclusion and interface of 1 binary bit of information (well, to be fair, 8 bits or one byte, practically speaking) in computers and networks that even at consumer grade can now pass millions of bits/second, and the contents of an entire encyclopedia in milliseconds.

This is sheer stupidity. (It reminds me of the Y2K issue.)
It's bad enough that the clinician is forced to hunt around every result for an indication of normalcy or abnormalcy.

Even worse, there is a disparity between what is seen at the lab - a flag calling attention to an abnormal addendum - and what is seen in the clinician view.

While a fictitious screen, this is not a fictitious example. This type of incident (I say 'type', as the specifics of the patient's condition were different) occurred to a patient whose treatment was in fact delayed until someone more than 24 hours later noticed the addendum. The patient's ultimate fate was not reported to me.

Even still, the leaders at the organization using this EHR are considering adding a report about this flaw to the regular queue of vendor fixes, rather than taking immediate, definitive "FIX THIS, NOW!" action.

This is despite the common sense view that if this happens again before a fix and a patient is harmed or dies, the hospital system will be held seriously accountable for the delays, and IT personnel will likely be on the stand. (The vendor, of course, gets held harmless.)

Imagine a jury's reaction: CIO - "uh, we didn't think the problem all that serious, and didn't have the resources to fix it right away, but we did call the vendor who said they'd attend to it one day real soon."

I can also put blame on the physicians for their physicians' learned helplessness - trying to muddle through their work with such a system, rather than refusing to use them in this condition. Or simply (in the manner of an old time surgeon I once rounded with in a summer NSF program for high school students) picking up the terminals and smashing them as the potentially dangerous junk they are.

One could blame the doctors for not reading below the "negative, results final" mark, but why should that be needed? Why is it the responsibility of the extremely busy physicians and other clinicians to provide their extra labor for the convenience of IT and IT vendors? Would a jury hold the clinicians accountable, seeing this display?

Would an aircraft manufacturer get away with blaming a pilot for an accident caused by horrible user interaction design of a plane's instrument displays, say, a hard to find stall warning that lacked flags or audible alerts?

It is unbelievable to me that a system like this could be put into production in a hospital. Simply unfathomable.

If I am involved as an expert witness in such cases, I will be sure to have the plaintiff attorneys ask the IT personnel about their clinical credentials.

This system was CCHIT "certified", I am told. Of what value is "certification" if it allows this type of design issue, and others to follow in future installments, on to the market?

More screens in part 3 of this series. It gets worse.

Far worse.

(Part 1 of this series is here and Part 3 is here).
-- SS

addendum:

Some have complained I am being "politically incorrect." At a time when our banks, major industries, investments, lifestyle and retirements have been seriously eroded by a combination of secrecy, incompetence, and criminal behavior on an unprecedented scale, I think such people need to get their priorities in order.

Physicians' Unexpected Un-Helplessness: Executives Invited To Leave Nashville-Based Healthcare System

At "Physicians' Expected Helplessness" I wrote that:

I am going to coin a new term to describe what I have observed as a corollary to physicians' learned helplessness: "Physicians' Expected Helplessness."

I observed that "Physician's learned helplessness", an adverse effect of dysfunctional medical training and culture described here, had perhaps led to societal expectations of physicians being weak in defense of their profession and its patient-protective values, and "having a target pasted to their backs."

In a case of human bites dog - or perhaps, more to the point, doctors bite dogs - a physician revolt has led to the ouster of unpopular and apparently ineffectual executives including the CEO, COO and Chief of HR at a large healthcare system based in Nashville.

Two more executives leave Saint Thomas Health Services

By Getahn Ward
THE TENNESSEAN

http://www.tennessean.com/article/20090212/BUSINESS01/902120346

Two more executives have left Saint Thomas Health Services, continuing changes after physician leaders recently cast votes of no confidence in the management team.

The position of Bev Weber, chief operating officer for the Nashville-based four-hospital health system, was eliminated, spokeswoman Rebecca Climer confirmed late Wednesday. Angelle Rosata, chief human resources officer, also has left, Climer said.

Their departures follow last week's resignation of Chief Executive Jim Houser, less than two weeks after the no-confidence votes by medical staff leaders at three of the system's hospitals — Saint Thomas and Baptist in Nashville and Middle Tennessee Medical Center in Murfreesboro.

Doctors were concerned about a review of operations that they expected to include budget cuts and more centralized management of the hospitals. [Translation: even more mission hostile, autocratic leadership by non clinical bureaucrats -ed.]

Patrick Madden, who ran a Pensacola, Fla., hospital system for Saint Thomas Health's Catholic-run owner Ascension Health, began his role as interim CEO of the Nashville-based health system Tuesday.

"The elimination of the system-level COO position will allow for greater communication and interaction between the hospital chief executive officers and our new interim CEO and his leadership team," Climer said in a statement.

Weber, who joined Saint Thomas Health in May 2006, was an intermediary [and probable obstructionist - ed.] between Houser and CEOs of the system's hospitals. Doctors feared the hospitals would lose much of their authority under a proposed structure they believed was being considered as part of the review.

Weber was a target along with Houser of the no-confidence votes.

The COO position was actually eliminated due to the position serving as an apparent bottleneck between CEO and the medical staff.

It should be remembered - and made clear to "management" by physicians and other clinicians - that clinicians are the enablers of healthcare, whereas executives and near everyone else are facilitators of healthcare.

As such, when push comes to shove the physicians "own" the hospital (and could in an emergency provide a lot of services even if the hospital burned to the ground). However, they only can protect their own interests if they stand up for themselves and for medicine's core values. That also means abandoning quaint notions of "political correctness" and "inclusiveness" as the sole means of interacting with those who do not share those values.

This is a phenomenon that hopefully may set an example for other medical staffs beleaguered with mission-hostile management.

-- SS

"Physicians' Expected Helplessness"

At "Physicians' Learned Helplessness", HC Renewal Blog described a term coined by a lawyer and presented in an article in Medscape General Medicine.

The lawyer suggested that physicians have developed a "learned helplessness" [Bond C. The training of the "helpless" physician. Medscape General Medicine 2007; 9(3):47].

This learned helplessness obstructs physicians from standing up for their profession, its faithful execution (faithful to science and to the Hippocratic oath, the ability to be faithful being interfered with by an increasing number of opportunistic non medical interlopers), and to their own livelihoods.

Two major points the lawyer described accounting for physicians' learned helplessness are:

Beyond the basics of medical economics, young physicians are generally not introduced to the regulatory and political environment in which they will have to practice.

and

Young physicians become so well trained in deferring gratification that many give up on ever getting any meaningful rewards for their sacrifices. With their resilience worn away, many just give up the fight.

These are keen observations by a lawyer. I am going to coin a new term to describe what I have observed as a corollary to physicians' learned helplessness:

"Physicians' expected helplessness"

In a comment to my post "Will the U.S. spend the Economic Recovery Act's $20 billion for Healthcare IT more wisely than the UK?", where I presented a government report on a true quagmire, the UK's national program for health IT, I received a comment that:

"... I believe that you have been a little too divisive in setting the business IT crowd up as an antagonist ... the rhetoric that you use has been at times abrasive and exclusionary... implying, whatever your intention, that there shouldn't be any role in health care implementations whatsoever for IT generalists."

Ignoring the hysterical conclusion that my "intention is that there should be no role whatsoever in HIT for IT generalists" [** see note below], this comment was not at all unique.

The comment reminded me of many other comments and pieces of feedback that I and like minded medical colleagues describing healthcare and health IT incompetence and malfeasance have received over the years: "be nice."

Here's the problem.

Why do people -- including some physicians - expect physicians and other clinicians to defend their professions and ultimately the patients to whom they are responsible in an "inclusionary" and genteel manner?

People want doctors to be their staunch defenders when they are sick. They want doctors to spare no language, make no compromise in getting them the very best treatment. They don't advice doctors to be "genteel" when helping them with an overbearing and unfair denial of life saving treatment by an insurer, for example - unless the patient is Darwinian extinction-level daft, that is.

But in defending their own occupation from invasion, for example by non medical IT leaders who believe their wisdom supercedes that of clinicians in development and deployment of medical tools (electronic health records, CPOE, decision support etc.) that happen to involve computers, people expect physicians to be - passive and polite?

The union leaders defending bus drivers I observed in my time as Medical Programs Manager in the Philadelphia regional transit authority would have laughed a person issuing such a comment right out of the room. In fact, I dare say nobody would be so bold as to even issue such a weak-kneed, emasculate comment as the aforementioned indented one in the presence of such personnel.

Why, then, do people make such suggestions about 'physician political correctness', and why do some physicians buy into it?

Due to an expectation of physician helplessness, that is, "physicians' expected helplessness."

I call on my clinical colleagues to fight both physician's learned helplessness, and end others' expectations of physicians' helplessness, especially by those who count on it towards their own ends.

As one Transport Worker's Union leader said in discussing medical issues about busdrivers and other line personnel, while banging his fist on the table, "What the f*** are you idiots doing to my membership?" (I knew the union leader to be generally polite from my off hours encounters with him on the local commuter train.)

Such attitudes at crucial moments did help preserve his members' rights against edicts of senior management (who we reported to). Such directness would probably help protect physicians' rights as well, allowing them to better care for patients, and avoiding phenomena as recently described in the NY Times here: "When Doctors and Nurses Can’t Do the Right Thing."

Appeasement of non medical interlopers in medicine, who overstep their bounds and core competiencies, helps neither physicians nor patients.

It does help the career aspirations and incomes of those appeased, however.

-- SS

Note:

[**] I, in fact, teach such IT personnel at the graduate level to prepare them for facilitative roles in HIT. I am concerned, however, when such personnel are put in medical leadership roles, through either custom and tradition or managerial imperialism, that takes them outside their core competencies.

Pharma Union cowed into submission?

In various posts including this one, I've commented on the environment of cutbacks, quality issues, and fear that seems to permeate pharma.

Now a labor union leader at Merck has responded to the Philadelphia Inquirer article "FDA report shows problems at Merck vaccine plant." He writes in a letter to the editor:

Concerns at Merck

The article "FDA: Problems at Merck's vaccine plant" (Inquirer, April 24) indicated the concerns raised after an inspection at our facility, Merck's West Point site. We, the United Steelworkers Union members, are dedicated to the creation of quality products through all phases of the manufacturing process. We are committed to following FDA guidelines, industry standards, and the FDA's Good Manufacturing Practices, all of which are the foundation for a successful pharmaceutical and vaccine production plant.

The company has implemented new ideas on how to function at our site. The expectation placed on our members is that they are required to do more with less. This business philosophy is not unique to large corporations but it is new to the pharmaceutical industry. Our members have worked diligently to ensure that the demands that have been placed on them have been met. They also want to ensure that their jobs are secure, but the article has raised concerns for them and their families about the future.

Phil Hughes
Vice president
United Steelworkers Local 10-0086
North Wales (PA)

This somewhat cryptic letter can be interpreted in a number of ways. A clear message is that the union members are being asked to "do more with less", implying overwork. This seems an explanatory theme in the FDA 483 Inspection Report referenced in the Inquirer article, a copy of which I have obtained. There are, in fact, phrases in paragraphs of that FDA inspection report that do not belong in the same paragraph, such as:

5. SOP 1330, Headquarters Review of Lot Numbers for Product Quality Complaints (PQCs), dated 14 May 2007, states that all deaths and life threatening adverse experiences [with vaccines] require lot checks with batch record review. This is not always performed.

and

Rejects from the first pass through the inspection equipment are sent through the inspection equipment a second time and only those that are rejected a second time are discarded. [Four examples involving vials of Varivax, Zostavax and ProQuad follow.]

What is most concerning about the union leader's letter to the editor, however, is this:

They [our union member Merck employees] also want to ensure that their jobs are secure, but the article has raised concerns for them and their families about the future.

I ask why an article such as the one published in the Inquirer would raise concerns for Merck unionized workers about their "future" (i.e., jobs).

Is the union concerned about retaliation in the form of layoffs for the substandard report? Since it's unlikely Merck vaccine sales will be affected by easily correctable FDA inspection problems, and since it's also unlikely Merck Vaccine Division will go out of business, being touted as it is by Merck management as a significant source of company income (e.g., via the new Herpes vaccine), the fear of layoff retaliation appears possible.

I can only say that if the unions are so concerned and so milquetoast in their approach to employee overwork via mild-mannered letters to the editor, imagine what the non-unionized employees must be feeling.

Finally, I once worked as Medical Programs Manager for the regional transit authority in Philadelphia. The leader of its biggest union, Transport Workers Union local 234, would likely have had quite a different response in the Inquirer to the problems caused by his employees being made to "do more with less" in a life-critical operation.

When I first met Mr. Lombardo it was at a medical department meeting where he was banging his fists on the table, shouting at the doctors for f***ing around with his employees via workers comp denials, drug tests, etc. At the time I thought this behavior frightening and unprofessional, but now I see its value.

I wish I'd had a union leader will testicles representing me in my past few positions.

-- SS

Physicians and Contracts: A Cautionary Tale

A conversation yesterday with one of my colleagues reminded me of this issue. So forgive me if I reference some articles that are a few weeks old.

The relevant news article by Lisa Girion was in the Los Angeles Times the beginning of November. The issue was that a major California insurer, Blue Cross of California, a subsidiary of Wellpoint Inc, was accused of putting a confidentiality provision into its contracts with physicians and hospitals that prevented them from consulting lawyers for their help in contract negotiation:

The state stepped into a bitter battle Thursday between Blue Cross of California and the doctors, hospitals and medical labs that serve about 700,000 people covered by the state's largest health plan.

At issue is the contentious financial relationship between medical providers and Blue Cross, which the state's top HMO regulator warned might worsen the plight of California's struggling hospitals.

The dispute began this year when Blue Cross sought to require hospitals, physicians and labs to sign a confidentiality agreement that would prevent them from publicly discussing fee negotiations.

But the providers balked, saying it prevented them from using lawyers and other outside consultants to represent them in fee negotiations, a routine practice.

If they refuse to go along with the rules Blue Cross lays down for the negotiations, the providers say, the health plan threatens to stop sending them patients.

On Thursday, the Department of Managed Health Care issued a cease-and-desist order forbidding Blue Cross to continue its efforts.

This tactic seems, at a minimum, grossly unfair to the physicians and hospitals. It is not the first time a Wellpoint insurer has been accused of unfair practices that seem to contradict its high toned statement of "commitments"

Note that a recent American Medical News article discussed some of the technical aspects of confidentiality provisions that may appear in contracts.

But the larger issue here to me is the problems physicians have when confronted with the prospect of signing contracts. As Lisa Girion wrote in the LA Times article,

Francisco Silva, a legislative advocate for the California Medical Assn., said the physicians' organization was disappointed that the order failed to address contracts that already had been signed by providers.

'We were hoping for something broader,' he said of the order. 'While it clearly indicates that the confidentiality agreement in the contracts was illegal, it did not go back and declare the existing contracts void.'

Silva said he believed hundreds of physicians had signed contracts that they negotiated on their own because they felt they had no choice. 'For some of these physicians, particularly if they are small offices, they don't have the ability to negotiate with the most powerful insurance company in the state,' he said.

This alludes to two linked phenomena:

• Physicians are often confronted with contracts that others, including large and powerful organizations, wish them to sign.
• Physicians often feel they MUST sign these contracts, even if they do not understand them, or fear they contain provisions that will disadvantage the physicians or their patients.

This was discussed in a Medscape article on physicians' learned helplessness [Bond C. The training of the "helpless" physician. Medscape General Medicine 2007; 9(3):47] that we posted about here:

In place of old-fashioned fee-for-service medicine in virtually every medical market in America, the economic lifeblood of today's medical practice depends almost entirely on contracts. Almost all of a physician's private patient flow depends on his or her contractual relationships: Private patients are provided either under an employment contract with an employer or they come into the practice through a contract between the physician and a health maintenance organization (HMO) or preferred provider organization (PPO). However, few young physicians are trained in how to analyze contracts, or when, where, and how to get the appropriate help with their contracting relationships. Instead, unfortunately, they are blithely following the model of older physicians who literally signed away fee-for-service medicine and continue, for the most part, to accept what health plans offer without significant legal or economic scrutiny.

In fact, yesterday my colleague told me yesterday about a case in which some physicians were handed a contract, and they "just folded," in her words, signing the contract without completely understanding it, even though it probably contained objectionable provisions.

I have personally witnessed several other anecdotes in which seemingly smart, dedicated physicians were willing to sign complex contracts which they clearly did not understand, usually with the excuse that "we would not be given this contract to sign if it were not in our best interest." The contracts were long, written in complex legalese, and contained numerous questionable provisions, including provisions about confidentiality.

In the words of my son, "what were they smoking?"

Maybe it was because I grew up in a family full of lawyers, but I always thought one should never sign a contract when in doubt about any aspect of its meaning, and one should never feel compelled to sign a contract.

What is going on here? Were the physicians so conditioned by their prior hierarchical, ascetic training (as described in the Bond article above) that they really believed no one would ever give them a contract to sign that was not in their and their patients' best interests? Were they too busy and tired to put in the effort to read the contract? Were they embarrassed to admit they did not understand it? Were they too conflict averse to contemplate refusing to sign the contract until they understood it and found it satisfactory?

As Bond wrote, I believe we physicians let many aspects of the health care system go bad because we were too busy, too embarrassed, or too intimidated to refuse to sign contracts that were bad for us or our patients.

So here is my (non-legal) advice to all physicians.

• Read fully any contract which you are asked to sign
• If you do not fully understand it, or have trouble reading it, do not sign it. (Hint, it is likely that any contracts longer than 1-2 pages single spaced in 12 point font may be difficult to understand.)
• If you still think there may be value to you in signing it, consult a lawyer and again, do not sign the contract unless the lawyer can explain it to you, and his or her explanation leaves you with confidence that signing it would be good for you and your patients.
  

ADDENDUM (19 November, 2007): see comments here on the Covert Rationing Blog.

"While Rome Burns"

The latest issue of the British Medical Journal featured a number of remarkable articles on the perilous state of the UK health care system. The main points were well summarized in a lead editorial by Editor Fiona Godlee, ominously titled, "While Rome Burns."

Something strange is happening in the NHS [National Health Service].

Something important is quietly dying. I don't think it is too fanciful to call it the spirit of medical professionalism. And we, the medical profession, are watching it die.

Far from being privatised, medicine in England has become ever more a creature of the state.

All that has really changed ... is who does the kicking and who is kicked. Increasingly centralised decision making, driven by a political imperative for constant reform, has left us victim to 'a patchwork of mutually contradictory ideas struggling for dominance.'

And although medicine has embraced the need for evidence based medicine, policy making remains largely an evidence-free zone. [Richard Lehman wrote,] "the personal responsibility of our professional leadership to mark out where the evidence lies, what it says, and what it is lacking.'

But where is our leadership? And where, asks Ian Greener, are the voices raised in protest against the breakdown of Aneuran Bevan's founding concordat: that the government would fund the health service but leave its operational running to the doctors. 'The government has found ways to interfere in medical practice on a remarkable scale,' he writes. In the absence of coherent protest we might conclude that doctors have once more had their mouths stuffed with gold or that the medical profession wholeheartedly approves of the government's reforms. However, the most likely reason is more worrying still, as Greener agrees: that most doctors no longer have the will or power to stop the reforms.

I remember sitting in one committee meeting (I will not say where or when or about what) in which we were contemplating some new abuse of power by some administrator. The committee seemed unable to come up with a response. Finally, one member, a clinical psychologist, decried the learned helplessness that seemed to have infected us.

Fiona Godlee has taken on the role of Cassandra to warn us that a similar learned helplessness may have also infected British doctors.

Unless we heed her warning and conquer our learned helplessness, whether in the US, in the UK, or in other countries, we all will surely watch professionalism die at the hands of the managers, bureaucrats, and executives.

The Consequences of Breaking the Physicians' "Guild"

In 1988, Alain Enthoven, an original member and driving force of the Jackson Hole group, published a short manifesto about "managed competition." (Entoven AC. Theory and Practice of Managed Competition in Health Care Finance. Amsterdam: North Holland, 1988.) This is now not easy to find (but see Amazon here).

In this volume, Enthoven expounded on his scheme to wrest power over health care from physicians and give it to managers and bureaucrats. Enthoven thought of physicians as part of a tightly organized "guild," that is, an economic alliance. His model for this was a pre-World War II document from a French medical society. Basically, he thought such guilds, which he believed to be in place in all Western democracies except in the UK and Scandinavia, were based on principles that were "not the natural expression of a free market in health care," (p.33) and furthermore, that the guild model associated with health insurance "makes it very difficult for government or private payors to control cost growth," (p.41) while they paradoxically "can also produce poor service (p. 42). To combat physicians' overwhelming economic power, Enthoven called for managers to use "tools they have found to counteract market failure." (p. 98) Finally, he suggested using a coordinated strategy to "break up the guild," noting that "overcoming the guild has not been easy in the United States.... However, the guild has broken down." (P. 122)

Some recent opinion pieces document the consequences of breaking up the guild, and turning health care over to managers and bureaucrats.

Debunking Business Dogmas

US News and World Report reminds us that the conventional wisdom among business managers has often proved to be wrong. Yet many health care managers were big supporters of the dogmas debunked by two two management professors, Jeffrey Pfeffer and Robert Sutton. (See the amazingly titled Hard Facts, Dangerous Half-Truths, and Total Nonsense: Profiting From Evidence-Based Management) :

• Financial Incentives Drive Good Performance (but instead, they have driven a huge number of health care dollars into the pockets of management, for example, see this recent post).
• First Movers Have the Advantage
• Layoffs Are Good Ways to Cut Costs (still the philosophy of too many health care executives who see everyone, except themselves, as interchangable, and are quick to dispatch those with whom they disagree)
• Mergers Are a Good Idea (but remember the mergers of NYU-Mt Sinai, UCSF -Stanford, and especially the mergers that created the Allegheny Health Education and Research Foundation, all now defunct)
• Life and Work Should Be Kept Separate (which really meant don't treat your employees very well, because they can always return to their lives outside of work).

Let's see how long it takes for the news to get out to health care managers.
A Melancholic Look at the Marketing of Pharmaceuticals
In the Atlantic Monthly, Carl Elliott's take on the commercialization of American health care, and how drug marketing has compromised physicians is a must-read. (Web access requires a subscription. The article was briefly posted in its entirety here, but the Atlantic Monthly forced the web-site to take it down. Therefore, I have provided some key quotes, and hope that the Atlantic Monthly will not find them excessive:

For better or worse, America has turned its healthcare system over to the same market forces that transformed the village hardware store into Home Depot and the corner pharmacy into a strip-mall CVS.

For decades the medical community has debated whether gifts and perks from reps have any real effect. Doctors insist that they do not. Studies in the medical literature indicate just the opposite. Doctors who take gifts from a company, studies show, are more likely to prescribe that company’s drugs or ask that they be added to their hospital’s formulary. The pharmaceutical industry has managed this debate skillfully, pouring vast resources into gifts for doctors while simultaneously reassuring them that their integrity prevents them from being influenced.

Doctors’ belief in their own incorruptibility appears to be honestly held. It is rare to hear a doctor—even in private, off-the-record conversation—admit that industry gifts have made a difference in his or her prescribing. In fact, according to one small study of medical residents in the Canadian Medical Association Journal, one way to convince doctors that they cannot be influenced by gifts may be to give them one; the more gifts a doctor takes, the more likely that doctor is to believe that the gifts have had no effect. This helps explain why it makes sense for reps to give away even small gifts. A particular gift may have no influence, but it might make a doctor more apt to think that he or she would not be influenced by larger gifts in the future.

The late 1980s and the 1990s [were] a period when the drug industry was undergoing
key transformations. Its ethos was changing from that of the country-club establishment to the aggressive, newmoney entrepreneur. Impressed by the success of AIDS activists in pushing for faster drug approvals, the drug industry increased pressure on the FDA to let companies bring drugs to the market more quickly. As a result, in 1992 Congress passed the Prescription Drug User Fee Act, under which drug companies pay a variety of fees to the FDA, with the aim of speeding up drug approval (thereby making the drug industry a major funder of the agency set up to regulate it). In 1997 the FDA dropped most restrictions on direct-to-consumer advertising of prescription drugs, opening the gate for the eventual Levitra ads on Super Bowl Sunday and Zoloft cartoons during daytime television shows. The drug industry also became a big political player in Washington: by 2005, according to The Center for Public Integrity, its lobbying organization had become the largest in the country.

Many companies started hitting for the fences, concentrating on potential blockbuster drugs for chronic illnesses in huge populations: Claritin for allergies, Viagra for impotence, Vioxx for arthritis, Prozac for depression. Successful drugs were followed by a flurry of competing me-too drugs. For most of the 1990s and the early part of this decade, the pharmaceutical industry was easily the most profitable business sector in America. In 2002, according to Public Citizen,
a nonprofit watchdog group, the combined profits of the top ten pharmaceutical companies in the Fortune 500 exceeded the combined profits of the other 490 companies.

During this period reps began to feel the influence of a new generation of executives intent on bringing market values to an industry that had been slow to embrace them. Anthony Wild, who was hired to lead Parke-Davis in the mid-1990s, told the journalist Greg Critser, the author of Generation Rx, that one of his first moves upon his appointment was to increase the incentive pay given to successful reps. Wild saw no reason to cap reps’ incentives. As he said to the company’s older executives, “Why not let them get rich?”

The industry began hiring more and more reps, many with backgrounds in sales (rather than, say, pharmacy, nursing, or biology). Some older reps say that during this period the industry replaced the serious detail man with “Pharma Barbie” and “Pharma Ken,” whose medical knowledge was exceeded by their looks and catering skills. A newer, regimented style of selling began to replace the improvisational, more personal style of the old-school reps. Whatever was left of an ethic of service gave way to an ethic of salesmanship.

Many doctors began to feel as though they deserved whatever gifts and perks they could get because reps were such an irritation.

The trick is to give doctors gifts without making them feel that they are being bought. “Bribes that aren’t considered bribes,” Oldani says. “This, my friend, is the essence of pharmaceutical gifting.” According to Oldani, the way to make a gift feel different from a bribe is to make it personal.

Such gifts do not come with an explicit quid pro quo, of course. Whatever obligation doctors feel to write scripts for a rep’s products usually comes from the general sense of reciprocity implied by the ritual of gift-giving. But it is impossible to avoid the hard reality informing these ritualized exchanges: reps would not give doctors free stuff if they did not expect more scripts.

Drug company–sponsored consultancies, advisory-board memberships, and speaking engagements have become so common,especially among medical-school faculty.... The industry as a whole is hiring more and more doctors as speakers. In 2004, it sponsored nearly twice as many educational events led by doctors as by reps. Not long before, the numbers had been roughly equal. This raises the question, Are doctors becoming the new drug reps?

According to an internal study by Merck, reported in The Wall Street Journal, doctors who attended a lecture by another doctor subsequently wrote nearly four times more prescriptions for Vioxx than doctors who attended an event led by a rep. The return on investment for doctor-led events was nearly twice that of rep-led events, even after subtracting the generous fees Merck paid to the doctors who spoke. These speaking invitations work much like gifts. While reps hope, of course, that a doctor who is speaking on behalf of their company will give their drugs good PR, they also know that such a doctor is more likely to write prescriptions for their drugs.

The semi-official industry term for these speakers and consultants is “thought leaders,” or “key opinion leaders.” Some thought leaders do not stay loyal to one company but rather generate a tidy supplemental income by speaking and consulting for a number of different companies. Reps refer to these doctors as “drug whores.”
Thought leaders serve an indispensable function when it comes to a potentially very lucrative marketing niche: offlabel promotion, or promoting a drug for uses other than those for which it was approved by the FDA—something reps are strictly forbidden to do.

Now for the most melancholy conclusions,

In 1997, John Lantos, a pediatrician and ethicist at the University of Chicago, wrote a book called Do We Still Need Doctors? We will always need health care, of course. But, as Lantos observes, it is not clear that we will always need to get our health care from doctors. Many of us already get it from other providers—nurses, physical therapists, clinical psychologists, nutritionists, respiratory therapists, and so on. The figure of “the doctor” is not cast in stone.

We simply live in a country that has decided that the traditional figure of the doctor is not worth preserving in the face of modern economics. Instead, we put our trust in the market.

Not if Health Care Renewal can help it!

The Seven Minute Visit

Peter Salgo is a physician who is also upset about the demise of the traditional figure of the doctor, but seemingly despairs about doctors' prospects for challenging the managers and bureaucrats. He just wrote an op-ed in the New York Times. He sees the problem beginning when managers broke the physicians' "guild,"

Patients aren't unhappy just because health care costs too much (though they would certainly like it to be more affordable). Rather, people sense a malaise within the system that has eroded the respect they feel patients deserve.

As health-care dollars became scarce in the 1980's and 90's, hospitals asked their business people to attend clinical meetings. The object was to see what doctors were doing that cost a lot of money, then to try and do things more efficiently. Almost immediately, I noticed that business jargon was becoming commonplace. "Patients" began to disappear. They were replaced by "consumers." They eventually became "customers."

Doctors in hospitals all over the country began hearing the same business language and facing the same pressures to "keep things moving." I used to be asked how well my patients were doing. Suddenly administrators were asking how long I was planning on keeping sick people in the intensive care unit.

Yet, he seems to feel a degree of learned helplessness,

Doctors know you cannot provide compassion in seven-minute aliquots. But we have felt powerless to change things. The medical establishment has, many of us feel, simply rolled over and gone along to get along. It has sacrificed patients' best interests on the altar of financial return.
This leaves the solution to the problem in the hands of our patients. You, the patient, are the system's best hope. Evaluate what it is you expect from your doctor, then ask for it. If you are unhappy with your doctor, fire him. If you cannot get more than a seven-minute face-to-face encounter with your doctor, he needs fewer patients.

The problem with this scheme, of course, is that primary care doctors are getting scarcer and scarcer. The American College of Physicians just reported, for example, that the number of medical school graduates training in general internal medicine has reached a new low. So in my humble opinion, we doctors cannot just wearily leave the field, hoping that patients alone will be able to take on the bureaucrats and managers. The doctors, along with other health professionals, and patients are all in this mess together, and we will all need to work to clean it up.

I do agree with Salgo's hopes for the results of doing something.

In one respect the business people are right. Restoring the doctor-patient relationship will not save anyone any money. But I submit that it doesn't have to. There are other ways to curtail health care costs. Some involve high technology; others do not. None of them requires patients to sacrifice their self-respect.

We can and must reduce health care expenses. But we cannot do it at the expense of patients' well-being. The doctor-patient relationship is critical to the integrity of the health care system. It is not disposable. Turning doctors into shopkeepers who regard patients as customers is unacceptable.