Starting With Curious

I introduced this analogy at a Pediatric Grand Rounds on Population Health Management and Payment Innovation, as a way to conceptualize the changing role for providers in the evolving health care environment.  My grandfather was a cab driver in New York City in the 1940s and 50s.  He and most other drivers at the time were owner-operators.  Although there were some regulations around fares, etc., he was more or less on his own – he paid for his gas, insurance, upkeep, etc., and whatever he had left after paying expenses he kept.  What regulation there was, was enforced by the requirement for a medallion (of which there were a limited supply) in order to operate legally.  Within the constraints of government regulations, though, they set their own practice.  They could pick the neighborhoods they operated in, the hours they worked, the routes they drove.

How is this relevant to healthcare?  The medallion was the equivalent of a medical license (of which there are also, in practice, a limited supply), and he was in essence a solo practitioner.  Sometimes cabs would come together into a cooperative of several owner-operators, sort of like a group practice, but still controlled by the drivers themselves.

As the costs of obtaining a medallion and operating the cab (e.g., fuel prices) go up, it gets harder for an individual driver to make a living as an owner-operator.  Moreover, the system itself is inefficient and wasteful.  Lots of drivers want to be in the nicer neighborhoods where the tips are better; fewer want to drive long routes out of town with no way to recoup the time for the return trip.  Cabs circle around waiting for people who need a ride, wasting gas.  There is no way to efficiently match the size of the vehicle with the number of people in a party: a group of 6 might have to wait some time for a large enough car to come by.  So a system of leased cabs, managed by a cab company, evolved.  The company had a phone line, so people in need of a ride can call.  A dispatcher sends the closest, most appropriate size vehicle.  When the rider pays her fare, it actually goes to the cab company, not to the driver.  The driver gets a fee (he’s essentially an employee), the company pays the expenses (including not only the vehicle operating costs but also the salaries for the dispatchers), and keeps whatever is left as profit.  The company, not the individual driver, sets the guidelines about where and when the cab goes.  And a company that does a good job of minimizing costs benefits financially.  They will do that by paying as little as possible for a unit of service (cheaper insurance, less expensive gas, decreasing payments to the drivers), and by eliminating waste (e.g., not having drivers circling around, sending the right cab to the right place at the right time).

This is where the health care system is heading.  We are moving away from managing the medical care of an individual to managing the health of a population.  As specialists, we have been like the owner-operator cab drivers of my grandfather’s era.  We are used to focusing on providing a service to an individual patient and getting paid for that service, according to our own preferences and individual guidelines.  In the future, providers (and I use that term to include not only physicians but also hospitals) will be like the drivers in a cab company.  Payment will not go directly to the provider, it will go to the health manager (e.g., an ACO).  Like the cab company, this manager will use “dispatchers” to direct the right care to the right place at the right time.  Payment to providers will not be the usual fee-for-service: it may be a salary, or some modified payment for services but with shared risk or shared savings.  And of course, the health manager will attempt to minimize costs by pressuring payments to providers and eliminating unnecessary utilization.

Sounds bleak?  What provider in her right mind wants to be a cab driver working for a large company, being told what to do by a dispatcher?!  The hope lies in shifting our thinking from being an individual provider to being part of a system.  I, myself, might just drive the cab, but I have to be a fully-participating member of the company, with a voice and a stake in figuring out the dispatching protocols, minimizing variation and waste, and sharing in the profit (and risk) of doing a good (or bad) job.  In an era when health spending needs to come down from unsustainable levels, those who are only providers can only lose, in the form of lower reimbursement for fewer services.  But those who also participate in the function of managing the fleet can reap the benefits and thrive.  That doesn’t mean that someone who is now an allergist or a surgeon will stop doing what he or she does.  A cab company doesn’t survive without the cabs and great drivers.  It does mean that we need to figure out how to operate in the larger system, how to work with the managers and payers and primary care providers (and most of all, the riders) to reduce costs, provide a better service, and improve health.

One more note.  As first noted in a 1960 article by Theodore Levitt in the Harvard Business Review, railroads largely went bankrupt because they saw themselves as being in the railroad business, rather than in the transportation business.  As cars and buses flourished, demand for rail services went down.  We not only have to make the shift from being cab drivers to being a cab company, we need to be a transportation company.  Or, in our terms, we need to shift from being providers to being managers, and not just medical managers but healthcare (or better, health) managers.  When alternatives to hospitals spread, we’ll be better poised to bring our expertise to whatever those alternatives are.

“Don’t it always seem to go

You don’t know what you’ve got ‘til it’s gone…”

“Defensive medicine” has long been a favorite rationale for our health care costs.  Indeed, in a recent survey of physicians in JAMA, trial lawyers were assigned the greatest responsibility for reducing health care costs:  60% of respondents thought they had a major role, followed by insurers (59%), pharma and device manufacturers (56%), hospitals (56%), and patients (52%).  In contrast, only 36% of physicians thought physicians had a major role in cost control.

I’ve never been a huge fan of the defensive medicine hypothesis.  First, several studies have suggested that only a very small percentage (around 3%) of total health care spending can be attributed to malpractice.  Second, poor outcomes and allegations of malpractice can arise from errors of commission as well as of omission.  A fatal allergic reaction to an antibiotic prescribed unnecessarily for a viral illness could as easily open a provider up to a liability claim as not doing an unnecessary CT scan for a child with trivial head injury, so I would imagine someone fearful of a lawsuit would hesitate to do both.  Most important, in my own experience (admittedly skewed by working in academic centers), overuse appears to be driven far more strongly by factors such as the desire for more complete information before making decisions (more on that in a subsequent blog), and by financial incentives.

A recent study, though, provides what appears to be compelling evidence of the effect of fear of malpractice on use of diagnostic tests.  An article in the August issue of Health Affairs linked physicians’ responses regarding their levels of malpractice concern as reported in the 2008 Health Tracking Physician Survey to Medicare Parts A and B claims for the patients they treated during the study period, 2007–09, focusing on use of various diagnostic tests for complaints of chest pain, headache, or lower back pain.  The investigators found higher rates of imaging by physicians who had reported high vs. low concern about malpractice on the survey, although the magnitudes were modest.  This would suggest that defensive medicine may be a significant contributor to overall healthcare costs.  However, the study undercuts the assertion that moves to limit malpractice claims would help – there was no association between diagnostic testing and various measures of actual state malpractice risk, only with the physician’s reported subjective level of concern.

Which raises several questions.  Where does the fear arise from, if not from the actual climate of the state within which the physicians practice?  Is it truly a fear of liability, or is that just an expression of an underlying tendency to place a premium on diagnostic certainty?  Providers tend to fall into one of two camps – “test minimizers” and “risk minimizers” – based on their tolerance for uncertainty.  In either case, if individual provider attitudes override public policy, how can we address this factor in the effort to control costs?  At the very least, it suggests that the doctors have at least as much responsibility as the trial lawyers.

This song about burnout on the job was quite popular in 1977 (original version by Johnny Paycheck; subsequently also recorded by Dead Kennedys).  While many of you are not old enough to have been assaulted by the recording on AM radio, the sentiment probably isn’t at all foreign.  The phenomenon of burnout among medical professionals has been the subject of both serious research and discussion in the lay press.  A 2012 study in JAMA Internal Medicine revealed high levels of self-reported burnout among physicians, especially in “front-line” specialties such as family practice and emergency medicine, where over half of physicians reported some form of burnout.  (Fortunately, both primary care pediatrics and pediatric sub-specialties had below average rates.)  Also, physicians had higher rates of burnout than the general population.  (There are studies showing similar statistics for nurses, but I haven’t been able to find any studies specifically dealing with burnout among advanced practice providers.  I think we can assume it’s fairly similar.)

Burnout is defined as “a syndrome characterized by a loss of enthusiasm for work (emotional exhaustion), feelings of cynicism (depersonalization), and a low sense of personal accomplishment.”  Effects of burnout include symptoms of depression and/or anxiety, loss of empathy and objectivization of patients and co-workers, unprofessional behavior, and high rates of error.  It can also lead people to leave the profession.  Thus, burnout is a problem for the physicians, for their patients, and ultimately for the system.

While a good bit has been written about the prevalence of burnout, there seems to be little data on what can be done to prevent it.  It doesn’t appear to correlate with hours worked, income, or satisfaction with work-life balance, but data are limited.

In the meantime, try this two-item screening tool for identifying burnout:

How often do you agree with the statement “I feel burned out from my work”?

Never

Less than once a month

A few times a month

Once a week

A few times a week

Every day

How often do you agree with the statement, “I have become more callous toward people since I took this job”?

Never

Less than once a month

A few times a month

Once a week

A few times a week

Every day

If, after that, you need a little pick-me-up, watch this – a good reminder of our value of health.

The teen had been referred to the ED for evaluation of a mediastinal mass found on a chest X-ray; he and his mother both knew his primary physician was worried about cancer.  We performed a CT and a slew of lab tests.  The lab tests were pretty non-specific and not overly concerning.  As we reviewed the test results with them, the patient said, “Yeah, but I’m gonna die, aren’t I?”  At that particular moment, when we didn’t even have a diagnosis, much less a prognosis, I was more focused on whether he had laboratory signs of blood stream or organ involvement.  He couldn’t have cared less about a white count or liver enzymes – he wanted to know if he was going to live.

Providers often find themselves focusing on things that are at best of indirect interest to our patients.  Nobody cares what their hemoglobin A1c or HDL level is (except for a few hypercompetitive types who brag about their biometrics after their screening), except to the extent that they are indicators of what truly matters – mortality or morbidity.  People don’t want a healthy blood pressure, they want a healthy life.

Why have we not paid more attention to these patient-centered outcomes?  One thing is, we like to measure what we can affect.  I may be able to improve someone’s pulmonary function with an inhaled steroid; the link between the prescription and their overall quality of life is more tenuous.   It’s also more difficult to measure something as abstract and multifactorial as “quality of life.”  At the very least, tools for determining patient-centered outcomes can be more time consuming to use, and if not properly developed may be less valid and reliable than “hard” measures such as lab results.  There is a developing science around measurement of patient-oriented outcomes.  The Patient Centered Outcomes Research Institute (PCORI), created under the Affordable Care Act, serves as a promoter and funder of efforts to advance such measurements.  But, while there are a growing number of tools for measuring both disease-specific and generic quality of life across the age spectrum, such tools are not incorporated into routine clinical care.

There has been much discussion of “meaningful use” of the EHR.  But if you look at many of the measures, one can ask, meaningful to whom?  Documenting BMI, keeping INR in a certain range for patients on warfarin, prescribing steroids for patients with asthma – I doubt very much that our patients care about these in and of themselves.  If we want the EHR to be truly meaningful, we should think about incorporating patient-centered outcomes into the record.  This would promote discussion of these outcomes with patients and families, and allow us to determine how effective our care is in improving them.

It’s pretty clear that by looking only at conventional measures of effectiveness, we are missing a big part of the picture, the part that matters most to the people we are trying to help.  A conventional measure of success of ED treatment of acute asthma is discharge to home (with a prescription for systemic steroids), and no unscheduled return visits within a set period (usually a week).  By that measure, the ED where I used to work did a good job.  But when we looked at patients “successfully” discharged to home, we found that nearly half had either prolonged symptoms, substantial missed school or day care, or significant activity limitation.  While we were congratulating ourselves for keeping these children out of the hospital, they were sitting at home coughing and wheezing and being miserable.

If we are going to act in the service of children and families, we need to understand and measure what is important to them – to have a mutual understanding of what constitutes “success.”

I recently recounted for someone the story of how, during the oral exam for my surgery rotation in medical school, one of the senior attending physicians made me cry.  Literally.  He belittled and humiliated me, and what was worse, he seemed to be enjoying himself.  Now, I don’t think there are very many true sadists in the healthcare profession, but we have to admit that, in the grip of the intensity of what we do, we sometimes lack a certain amount of sensitivity and civility.  We are not always respectful.

Sometimes it’s directed toward patients.  Not necessarily as overt rudeness, but more subtly, such as keeping people waiting without apology, not introducing ourselves or addressing people by name, etc.  Other times it’s a lack of respect for our colleagues.  A recent study from the Journal of General Internal Medicine revealed the extent to which physicians criticize other physicians to patients, often with inappropriate language (e.g., “This guy’s an idiot!”).   The situation is no better when it comes to relationships among other members of the healthcare team.  While perhaps 5% of physicians can be described as chronically disruptive, disruptive behaviors are well documented among both physicians and nurses.

I confess to being guilty myself.  As time goes on, I find it harder to get back on task when I am interrupted.  It shouldn’t be a surprise that interruptions are very common in the emergency department.  But I find that when a nurse “interrupts” something I am doing because there is something that she interprets as more urgent, I sometimes – especially if my perception of the urgency is different – react in a manner that is curt or dismissive.  It makes me come across as difficult to approach, which has a negative impact on our ability to work as a team, and ultimately perhaps on the effectiveness and safety of our care.  (And needless to say, I am not always correct in that relative perception of urgency.)

Even little things, things we may not ourselves perceive as disrespectful, can damage the team relationship.  For example, in a recent survey, only 4% of physicians agreed with the statement that nurse practitioners should be paid the same as physicians when providing the same services.  Now, this is certainly a complex issue, but consider what it sounds like to a nurse practitioner to hear that she or he should be paid less for doing the same thing.

Fortunately, a little respect goes a long way.  When wait times in the ED are long, trying everyone’s patience, I’ve seen the simple act of apologizing and recognizing the inconvenience to the family melt the icy stare that greeted me when I walked in the room.  Thanking a nurse for alerting us to a monitor alarm, telling a physician assistant “nice job” when she picks up an exam finding we missed, talking candidly but with respect to a consultant with whom we may disagree on a management plan – these are all ways of living our value of integrity.