Category Archives: Physician Strategies

The Future of Medical Practice

I had the opportunity last week to talk and learn about the future of office-based medical practice. The occasion was my participation in a panel discussion sponsored by a manufacturer of equipment for medical offices. A professional facilitator conducted a day-long interactive interview of 6 panelists, strategically selected from non-competing health care markets across the country. We talked about what was going on nationally, regionally and in our own organizations in order to provide a context for the sponsor’s strategic planning.

Much of what we talked about centered on the transition from “volume to value,” the catch-phrase for the movement away from fee-for-service to some form of quality-based payment system. The content of the discussion reminded me of the saying that “the future is already here, it’s just not distributed evenly yet.” Physician leaders from west-coast organizations described a landscape of capitated payments and “accountable care” that we talk a lot about but have not yet lived in a significant way. A representative of an institution in Boston spoke of a more highly consolidated provider community. Those stories were interesting, but not entirely novel. Here are a few things that were:

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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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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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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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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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A Global Force for Good

A few years ago, the United States Navy launched a new recruiting and marketing campaign using the slogan: “America’s Navy – a global force for good.” The line was apparently a flop, and the Navy threw it overboard for “protecting America the world over,” but I liked it. I thought it captured a deep truth about the Navy, which is that it is undoubtedly a “global force” and that the force exists for a good purpose, but I guess most people thought that it made the Navy sound too much like a bunch of social workers.

I was reminded of the phrase, and of an experience I had while serving in the Navy Medical Corps, when I read a recent article in the Annals of Internal Medicine.  A Navy physician retold the story of a mission he was on to a remote village in Honduras. He and his team were flown into small villages, where they would “see dozens of patients each day and dispense an assortment of symptomatic medications” and where “the most practical health benefit that we provided villagers consisted of hundreds of tooth extractions.” He further noted that “although advertised as humanitarian missions, these exercises provided US military personnel with experience working with military and civil authorities from host nations.”

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Shared Accountability

There are plenty of good reasons why thoughtful physicians are often unhappy with the current approach to measuring the quality of care they provide. Some, of course, object to the whole notion of quality measurement, but I believe they are in a shrinking minority clinging to an anachronistic mental model in which each physician defines for himself what constitutes high quality care. I have addressed this previously. But even those, who like me, believe it is essential (and possible) to measure quality, can point to legitimate shortcomings in the way it is done.

Among these shortcomings is the imperfect process by which individual physicians’ “results” are “adjusted” to account for differences in the patients they care for. In the simplest case, when the quality of care is judged by looking at patient outcomes, this risk-adjustment is meant to reflect the fact that clinical outcomes reflect both the baseline characteristics of the patients being treated and the treatment they get. For example, if one were to use in-hospital mortality rates to assess the quality of care for acute myocardial infarction, it would be essential to know “how sick” the patients, on average, were on presentation. A 50 year-old man with a small inferior wall MI is likely to live even in the absence of good care (or any care for that matter), whereas a 90 year-old woman with cardiogenic shock from an anterior wall MI is likely to die even with state-of-the art care. Any attempt to assess the quality of care for a population of MI patients must take this into consideration.

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Residency Ratings

I have been a big proponent of seeking the feedback of our patients regarding their experiences with our care, and of pushing our organization to be more transparent about the results. I believe that sharing performance motivates everyone to raise his game, and that we should embrace valid ratings on specific measures. On the other hand, I have always thought that global “rankings” divorced from specific performance measures make little sense.

As Malcolm Gladwell pointed out in the New Yorker a few years ago rankings of complex, multidimensional things like cars or colleges are inevitably flawed, because they don’t account for the fact that different people will value various attributes in different ways. There is no “best car” since I may value handling and acceleration, and you may value styling and safety. Likewise, there is no “best college” because one student may value class size or athletic facilities while another values research opportunities and proximity to a large city.

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Patient Safety, Swiss Cheese and the Secret Service

I was listening to the news on my way to work last week, and heard a story about the review conducted after the well-publicized security breach at the White House. Like many people, I was shocked when the story of the fence-jumper first broke. How was it possible that some guy with a knife managed to get over the fence, cross the lawn, enter the White House and get deep into the building before he was stopped? The answer, according to NPR’s reporting of the Department of Homeland Security investigation is that a whole sequence of events made it possible:

It turns out that the top part of the fence that he climbed over was broken, and it didn’t have that kind of ornamental spike that might have slowed him down. Gonzalez then set off alarms when he got over the fence, and an officer assigned to the alarm board announced over the Secret Service radio there was a jumper. But they didn’t know the radio couldn’t override other normal radio traffic. Other officers said they didn’t see Gonzalez because of a construction project along the fence line itself. And in one of the most perhaps striking breaches, a K-9 officer was in his Secret Service van on the White House driveway. But he was talking on his personal cell phone when this happened. He didn’t have his radio earpiece in his ear. His backup radio was in his locker. Officers did pursue Gonzalez, but they didn’t fire because they didn’t think he was armed. He did have a knife. He went through some bushes that officers thought were impenetrable, but he was able to get through them and to the front door. And then an alarm that would’ve alerted an officer inside the front door was muted, and she was overpowered by Gonzales when he burst through the door. So just a string of miscues.

The explanation rang true. Of course it was no “one thing” that went wrong; it was a series of events, no one of which in isolation was sufficient to cause a problem but, when strung together, led to a catastrophic system failure. The explanation also sounded familiar. It is a perfect example of the “swiss cheese” conceptual model of patient safety.
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Sometimes “Sorry” is all it Takes

In my administrative role, I have the great pleasure of signing thank you letters to patients and family members who have acknowledged the great care they have received by one of our physicians or other caregivers. It is a nice way to tell the patient “we got your note” and to simultaneously recognize the provider by copying her or him. The best part is that I get to read the patients’ letters, which are filled with gratitude, and remind me of the great privilege we have to make a positive difference in the lives of our patients.

Sadly, I also have to deal with the occasional patient complaint. Although these are clearly a lot less fun to address, they also point out the impact that we have on the lives of the patients and families that we serve.

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