Memorial Day

Last year I pointed out that Memorial Day was slipping in our collective consciousness from a day of solemn remembrance of those who died in the service of our country to just another “vacation Monday” or the marker of the start of the Summer season.

A recent experience reinforced for me just how important it is for us to make sure we never lose the deeper meaning of the day.

My wife and I traveled to Washington, DC a couple of weeks ago to witness the “arsenal of democracy” flyover. The event included over 50 WWII warplanes, and coincided with the 70th anniversary of “V-E (Victory in Europe) Day” – the defeat of Germany by Allied Forces. As an airplane buff, I found the flyover stirring. It was an historic opportunity to see the “warbirds” aloft, flying in formation, instead of on the pages of history books or on static display in a museum.

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Professionalism

Every so often the Journal of the American Medical Association (JAMA) is devoted to a single topic. The May 12 edition was devoted to “professionalism and governance” and the articles addressed a range of related subjects from medical education to board certification. I was particularly drawn, for obvious reasons, to the section on “professionalism and employment.”

I think it is fair to say that physicians have often cited their commitment to professionalism as a justification for the high value placed on independent private practice. That is, independence – of insurance companies, corporate overlords or pretty much anybody telling them how to practice – is the only way to assure that they can consistently act in the best interests of their patients.

This way of thinking is now severely challenged.

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Congress and Dr. Bayes

I was driving to work the other day, and there was a story on the radio about the Congressional reaction to the latest recommendations for breast cancer screening from the United States Preventive Services Task Force (USPSTF).

Here’s the background. USPSTF published recommendations in late 2009 for the use of screening mammography in different age groups. For women between 40 and 50 years old, the panel concluded “that the current evidence is insufficient to assess the additional benefits and harms of clinical breast examination (CBE) beyond screening mammography in women 40 years or older.” In other words, they did not recommend biennial mammograms – which they did for women between 50 and 74 years old – for the younger cohort. That led to a firestorm of criticism that younger women would be “denied” mammography, and Congress wrote into the Affordable Care Act that “exchange” (Obamacare) insurance plans cover regular mammography for women over 40.

Fast forward to now.

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I Guess They Were Listening

Some time ago, I wrote that the maintenance of certification requirements of the American Board of Internal Medicine (ABIM) were more like a shakedown than a civic-minded attempt to improve the quality of medical care. I was not alone. Many professional societies, including, I am happy to say, the American College of Cardiology were highly critical of the program.

The good news is that the ABIM heard the critics loud and clear. Despite earlier public defense of the policies, it has since done a complete “about face” and is now in a “listening” mode in anticipation of revising the program.

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Mistakes about “Patient Satisfaction”

I had two experiences recently that reminded me that many doctors and nurses remain resistant to measuring and improving how patients experience the care we provide. One was a face-to-face discussion with a senior physician. The other was reading an article by a nurse. Both the doctor and the nurse denounced the growing focus on the patient experience by citing the threat to quality of care, and I believe both of them were totally wrong.

The encounter with the physician came as I addressed a group of newly hired physicians. As I typically do in these circumstances, I outlined our Medical Group’s commitment to increasing the visibility of the results of our patient experience surveys. We have been providing our physicians with reports on their patients’ feedback for the better part of a year, and we anticipate posting physician-specific results on our public website within a few months. During the Q&A, one of the physicians objected to the plan, saying that “patients can’t judge the quality of care that we provide.”

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Patient Advocates? Really?

I was disturbed by a recent article in the New York Times about the Texas Medical Board. The piece described the decision by the Board to sharply curtail the use of telemedicine in the state. Specifically, the Board mandated that telemedicine services could only be provided in the context of a pre-existing patient/physician relationship, and that such a relationship must be established face-to-face, and not via electronic means. According to the Times, the restrictions were strongly supported by the Texas Medical Association.

Sigh.

This seems to me to be a wrongheaded, backward looking and overall pretty lame attempt to stem the inexorable tide of patients and physicians connecting in new ways. I really wish I could believe the Board member who said he voted for the new restriction because he was “terribly, terribly worried about the absence of responsibility and accountability” in electronic encounters. It sounded to me, instead, that he was “terribly, terribly worried” about a new business model for medical care that provides greater convenience and lower cost to patients than traditional office visits.

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Great Doctors of Today and Tomorrow

I recently wrote about the wonderfully inspirational documentary Rx: The Quiet Revolution, which tells the story of how four different groups are transforming health care for the better.  Each group has some pretty amazing physicians who are committed to putting the patient at the center of the system, and they all have a lot to teach the rest of us about truly caring for patients as we “deliver care.” That got me thinking about physicians in our own Health System who are role-models for great care, and also about assuring that future physicians are just as caring and empathetic.

Well, as far as role-models go, it is hard to imagine a better group than the winners of this year’s Patients’ Choice Awards, given to those members of our Medical Group who achieved the highest scores on their patient experience surveys. They are:

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Whose Record Is It?

A recent piece in the New York Times profiled a young man with a remarkable medical history, and an equally remarkable approach to sharing it. I think it raises some profound issues regarding the self-monitoring movement and the “ownership” of patients’ health information, both of which have the potential to change our traditional practices in a big way.

The guy – Steven Keating – is not your average Joe. He is a graduate student at MIT who trained as a mechanical engineer and is working in the cutting-edge MIT Media Lab. He also had a brain tumor the size of a tennis ball. His website hosts all of his medical records, including his pre- and post-op brain scans and, believe it or not, a video of his tumor resection surgery.

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There is Good News Out There

I had the good fortune last week to see a screening of excerpts from an extraordinary documentary film that will be shown on PBS television stations in April. The film is called Rx: the quiet revolution and highlights four case studies. Each is an inspiring example of new models of health care delivery that are advancing the “triple aim” of better care for individuals, better health outcomes for communities, and lower costs. Our own remarkable Dr. Jennifer Mieres is the film’s executive producer.

The screening left me inspired and in awe of the great work being done by front line professionals all across the country. It also introduced me to a fabulous metaphor for the importance of engaging patients in their own care.

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Health and Healthcare

It has been known for a long time that “healthcare” – all the stuff that we do, prescribe and provide – is a minor determinant of how “healthy” any of us is. Overall health, or more technically, the variability in health outcomes, is much more dependent on the combination of genetics, personal behavior (think smoking and seat belts), environmental factors and socioeconomic status than it is on healthcare.

I was thinking about that when I read in the New York Times about how some healthcare provider systems, driven by the need to cut costs, are starting to address some of the non-medical social needs of their patients. These kinds of innovative community-based interventions started to get traction after they were highlighted by an influential profile by Atul Gawande in the The New Yorker. Their diffusion has been driven by the expansion of novel payment models that have started to reward providers for reducing utilization of services like ER visits and hospitalizations, the very services that they have traditionally been paid for.
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