Tuesday, February 22, 2011

Doctors in Wisconsin Sign Fake Sick Notes for Protesters; Civilization to Collapse Shortly

Whenever I begin to think that I have Sold Out in life and have embraced respectable living and taken an establishment career track, something will happen to remind me that, whatever desires I might nurture in the bosom of my soul to be acceptable and thus accepted, I am in fact a person with a fringe philosophy that most in my profession would consider dangerously radical.

A long sentence, that, but a good summary of my reactions to recent blog posts by my medical blog siblings. Their scorn was directed at physicians (several, apparently, from the Department of Family Medicine at the University of Wisconsin School of Medicine) writing fake sick notes for the protesters hunkered down for the political fight in Madison, Wisconsin, in which Governor Scott Walker is attempting to rewrite, and effectively strip, the collective bargaining power of public-sector workers. Health Care Renewal led the charge, calling it "the face of postmodern medicine: lying," while Happy Hospitalist danced a little jig after having 10,000 hits after Instapundit's shout-out on his post calling these docs "an embarrassment to their profession." db's Medical Rants piled on, saying much of the same.

I'd be so much more impressed by these sermons if they weren't so over-the-top in both their collective tone and in their historical comparisons. Based on their posts, you'd think that because of this little stunt, which is equal parts civil disobedience and wink-wink chicanery, the world was coming to an end or thereabouts. Happy uses the event to scream with a certain incoherence at Democratic pols involved in the fight, and HCR compares the sick-note signing to doctors who enabled the legal claims of minor car accident victims by medically legitimizing their fake symptoms. (Is this really the same thing? If so, do tell me what is in it for the docs this time around; accident-injury fakery yields a financial benefit for the doc, which is, to my moral compass, considerably more troubling.) db uses lots of words heard at White Coat Ceremonies and the like, intoning about the "sacred trust [between physician and] society."

Curiously, back in 2003, db (of whom I am normally a fan) not only chose not to utter so much as a peep about the potential dissolution of that sacred trust when doctors in New Jersey refused to see patients as a protest about malpractice insurance rates, he wrote several entries that were sympathetic toward them (such as here and here--the latter entry explicitly entreating us to understand the motivations of the physicians, while never wondering if it's maybe unbecoming for a physician--as well as a violation of that supposedly precious "sacred trust"--to tell a patient to go Shove It). Last year, when urologist Jack Cassell thought it a good idea to notify patients that, had any of them voted for Obama, they should seek care elsewhere, db did not see fit to call this man to account for what I would define as deeply unethical behavior (from what I could find on db's archives, at any rate), though perhaps he was unaware.

To be clear: I'm not so sure I'm supportive of these docs, and I do think they've gotten themselves into swift waters without, it appears, thinking carefully about the consequences of their actions (at the very least, they didn't take into account the political consequences, if not the moral ones). But this isn't the beginning of some fake sick-note movement, and none of these people are doing it for personal gain. I don't have qualms with raising doubts about the ethical wisdom of their actions, but the smell of sulfur coming from these heavy-handed judgements is a bit much for me.

UPDATE: So far I appear to stand alone among doc blogs in not jumping up and down in blistering condemnation of the sick note scandal: GruntDoc's quick take is here and Retired Doc shakes his head here. RW Donnell, who against all expectations manages to once again defend the status quo, airs his thoughts here among various entries.

Monday, February 21, 2011

Michele Bachmann, the First Lady, Breast Milk, and Much Ado About Nothing

It makes for a very intriguing headline: could some political spat somehow realign self-identified liberals with Michele Bachmann, and conservatives with Michelle Obama?

At first, while glancing at the NYT headline, "A Breast Feeding Plan Mixes Partisan Reactions," I thought that perhaps the moon was indeed in the Seventh House, and Jupiter had aligned with Mars.

But as much as NYT and some other outlets would like to have you believe that we've reached the Age Of Aquarius, I'm thinking more that we've reached the Age of Same-Old, Same-Old, with a page from the Mountains Out Of Molehills playbook.

To recount the mini-saga, last week Representative Bachmann fired a broadside at the First Lady during an interview with radio host Laura Ingraham for "the government's role in breastfeeding," as Ingraham's website proudly chirps. Ms. Obama has been promoting breastfeeding for almost a year now, from what I can find on the WhiteHouse.gov website, but Bachmann was reacting to the latest news that the IRS had announced that breast pumps, which can cost up to several hundred dollars, would be available for a tax break. Bachmann first complained about the tax break--something very un-Republican like--by complaining that "government is the answer to everything." She then added, "to think that government has to go out and buy my breast pump—you want to talk about nanny state, I think we just got a new definition,” in classically Bachmannian rhetoric which is either exasperatingly stupid or chillingly cynical, since a tax break in no way implies that the government is going to purchase breast pumps for the mothers of America.

[That's my emphasis, by the way. Also, I have been unable to find the link to the actual IRS announcement, though many outlets report on it, as TIME does here, or ABC News does here--the ABC News link is dead.Typing in "breast pumps" into the IRS search engine turns up nothing, and searching IRS.gov on "breasts" does turn up a lengthy document released in August, though I could find no breast pump references while perusing it. Nor could I find a press release on tax breaks for devices designed for the liberation of boob juice. Needless to say, I am having an enormous amount of fun tonight.]

Anyway, the story received attention from media outlets in search of culture-war fodder or some such, and lots of outlets, even including ones across the Pond, ran with it. Which, no doubt, is precisely what Representative Bachmann had hoped for, even if the attack made no real sense: she's in the headlines. Maybe this is part of a coordinated effort to put her name in the mix for the 2012 Republican Presidential primaries, and chip into the Republican/conservative gal-appeal of Sarah Palin, who, perhaps sensing a missed opportunity, got in a shot in at the First Lady in a speech in Long Island.

Who knows? Who cares? But the Times article tried a new slant: the reactions from party loyalists were flipped. "On blogs and in interviews, some liberal Democrats found themselves agreeing with Representative Bachmann...some conservatives, meanwhile, stood up for Mrs. Obama for promoting what they said was a healthier choice," the Times reporter, Kate Zernike, observed.

Which is technically correct, as the article goes on to quote some self-described liberals siding with the utter nonsense of Ms. Bachmann, and conservatives siding with Ms. Obama. But as numbers go--and after a not-exhaustive and not-scientific but well-intentioned reading of comments at the soft-left Times, the soft-right WaPo, the harder-left Salon and a few other places to boot--I found no evidence of massive political realignment.  I found a small number of comments from self-described conservatives supporting the First Lady, a good many more criticizing her, and more than half of those totally missing the point...but no comments from liberals defending Bachmann.

(As a side note, I read the Salon comments with a certain horror--the comments section has become a den of lefty sleaze. On many topics I am of one mind with Salon's editorial staff, and I share in their righteous fury at the various injustices of the world, but reading the comments section of pretty much any Salon political article these days is chilling. Civility is considered quaint as commenters attempt to outvulgarize each other, and the menacing allusions to violence would make you think you had just walked into a Tea Party rally. It's disturbing.)

I was feeling quite proud of this analysis until I discovered this article from HuffPo that explains how Zernike used one anonymous commenter, and a second equally anonymous "progressive mother in Brooklynite" as a source to gin up what amounts to a fake article. NYT should be a bit embarrassed; if it isn't Billy is on their behalf.

PS--The Billy Rubin Blog is up to four--yes, count 'em, four!--followers! Please feel free to get on board, or get an RSS feed so that new entries will be sent directly to your e-mail and you won't have to check back every so often for updates. We appreciate it!

Friday, February 18, 2011

Will Doctors Be Relevant in the World of Watson?

Like so many other people, I watched Jeopardy this week with rapt attention as I saw IBM's uber-computer Watson clean the clocks of Jeopardy's two greatest champions, Ken Jennings and Brad Rutter. My reaction--that of fascination bordering on the point of awe simultaneously mixed with a not insignificant amount of apprehension--was probably also shared by a good number of viewers. Did we witness the creation of something worthy of comparison to the Brandenburg Concertos, or Frankenstein? No way to know at the moment. Check back with the Billy Rubin Blog in about four or five decades. I promise to do a follow-up entry at that time.

While watching the informational clips during the Jeopardy show in the first round, where various Big Bluers explained the mission and the challenges of developing Watson, I was struck by how Watson could be used in medicine. Give it a patient who explains their symptoms, then feed Watson with basic lab or other clinical data, and you could easily produce a computer doc that would rival the best in the biz. IBM seems to have had the same thought, as Carey Goldberg of the CommonHealth blog notes, as they have partnered with Nuance Communications of Burlington, MA to set up computer systems built on the advances gained from the making of Watson.

Leave aside the rather terrifying fact that this could deprive me of a job in the decades to come, it's not hard to see the ways in which a Doc Watson could outperform a flesh-and-blood physician. Take, for instance, the news story this week about the neurologic event of TV anchor Serene Branson, which earned speculation from ER physicians as well as a Happy Hospitalist as to the diagnosis (for a prescient discussion of the media portrayal, see Gary Schweitzer's HealthNewsReview entry here). Leave aside the dramatic videotape of Ms. Branson for a moment. What's the diagnosis?

The immediate speculation was that Branson suffered a Transient Ischemic Attack or "mini-stroke." To me, this never quite made sense for the simple fact that Branson is young, and TIAs are typically a disease of people in their 6th decade and beyond. Of course, there are outliers, as demonstrated by the sad story of professional baseball pitcher Darryl Kile, who died in his sleep in midseason at age 33 and was found at autopsy to have obstruction of two major coronary arteries, which is extremely unusual for one so young. So although a TIA seemed possible, I thought that the list of possible diagnoses included things like Multiple Sclerosis, and since I'm an ID doc I immediately thought of neurologic diseases associated with HIV. Other docs weighed in on the blogs and several proposed the possibility that this was a complex migraine headache This is now the official diagnosis of the authorities who have cared for her at the UCLA medical center (though, as Happy notes, this pronouncement came from a neurosurgeon, which from a medical standpoint is very odd and not entirely appropriate).

The diagnosis might be spot-on but it's a tough one to make. What could a Doc Watson do that we couldn't? Watson would be able to take the patient's age, take the information from all the data generated by her care (vital signs, physical exam findings, the history of garbled speech, any pertinent information from her family and social history, labs and radiologic tests) and arrive at a mathematically precise risk assessment for each of these various diagnoses, just as it did in trying to answer Alex Trebek's questions. (Yes, I know, it's the other way around in Jeopardy. Let's just move on.)

That is, I can note in a vague way based on my learning in medicine that TIAs are less likely to occur in younger people, but I have no idea the precise numbers; for Watson, I would assume that it would be a small matter to incorporate hundreds of epidemiologic studies allowing it to calculate multiple probabilities for all sorts of diseases. It's not that Watson would be doing anything different than what we do every day when we form differential diagnoses on patients, it's just that Watson would have three huge advantages: it could access considerably more information than we can (we are limited by how much we can read, and then remember, while for Watson that's just a download), it can then take that information and process it orders of magnitude more quickly, and it can describe the likelihood of an uncertain diagnosis with a precision that is virtually impossible for a lone human physician to do in live time while seeing a patient.

I'm not a computer specialist and don't know the inner workings of Watson, but I don't think this is wild speculation on my part. I suspect that we're not far away from being able to feed information into Watson-like programs that will help our diagnostic accuracy increase tremendously in the years to come. I also suspect that there will come a point where Watson-like programs will obviate the need for physicians. Hope I'm retired by that point!

Hat tips to Grunt Doc, Gary Schweitzer, Happy Hospitalist, CommonHealth.

Monday, February 14, 2011

Another Milestone

Among various items for which it is tedious to be Jewish, the adherence to the lunar calendar must rank relatively high. We're talking about a people who have won Nobel prizes in every field, far out of proportion to their actual numbers on this earth, leading the world in physicists, mathematicians, and astronomers. And they can't use a modern calendar? Leap months every few years? Please.

Its tediousness bothers me at this hour because tonight marks the end of my first year on earth without my father. That is, by the Christian, or Solar, calendar, call it what you will. And herein lies the problem: the official mourning period ended for me some several weeks back. But even then that wasn't the completion of a Jewish, lunar year, because for reasons which I am not especially curious, the mourning period ends at 11 months in Jewish tradition. Then there was the Jewish year marking...yet another date. And I am ignoring the two or three other periods of Jewish mourning, which include shiva (the seven days following the burial) or shloshim (the thirty days), each of which has its own particular rites & obligations. Fortunately, as I am just a hair shy of atheist, the specifics didn't trouble me a great deal, with the sole exception of the prohibition against shaving during the shloshim, to which I adhered, in what is perhaps a term not used in jest, religiously.

But in my spiritual clock, as it were, I always measured Dad's death by the date of February 15th. To hell with this lunar nonsense, I thought--I don't pay attention to the Jewish calendar in any other part of my life except to show up for High Holidays or Passover when I'm told. The truth is that I have not taken Jewish chronology into my bones, and the 11 months came and went without any reflection, without making a point to go to the synagogue to say kaddish (Pops could have cared less, which helps assuage my guilt in this respect), without any reckoning of any sort. But in my quiet moments over the past few weeks, I see his face in my mind's eye, I think about how much of my father's son I have become--against even my own expectations and understanding--and how this past year would have been had he been part of it.

Paradoxically (or, for those who know me, likely not paradoxically at all) I have found myself in these moments taking comfort in about the least respectful of ways, saying to myself things like it's almost been a year since Dad bit it or yep, he sure bought the farm when he went to get the mail. I have giggled with a certain childish giddiness of the magnificent tribute paid to Graham Chapman by his Monty Python alum and longtime collaborator, John Cleese: "he's kicked the bucket, hopped the twig, bit the dust, snuffed it, breathed his last, and gone to meet the great Head of Light Entertainment in the sky." On New Year's Eve, a friend asked a truly loving and caring question about how my mother has fared since father's death, and perhaps a bit too mischievously I immediately flipped back, "actually she's been doing really well. She's really risen to the occasion. Dad should have died more often."

I'm glad I said it as I not only think the line is funny, but I think Dad would have laughed at it. And I'm glad to have a laugh when I think about him even in death, as I loved to tease him in life, especially after I overcame my fears of this man whose quiet thoughtfulness intimidated the oft-loquacious-and-not-nearly-as-thoughtful-me for many years. But the mirth is short-lived, and the truth undeniable: my heart is broken. I do miss him, and doubly so as I tried to make up for lost time once I figured out exactly how to be his son, as well as the fact that I am as much my father's son as I am my mother's--something much easier to spot, for me as well as everyone else. For nearly four decades our similarities had escaped my notice; now I ruminate upon them often.

I write this tonight not to excessively hash over these details (though readers will kindly forgive for the little bit of hashing I have done above), but rather to write about the toughest reckoning of all surrounding his death. To wit: I experienced his death both as a son and as a doctor, and I remain undecided as to whether I've screwed the pooch. But let me explain a little.

My father had reasonably clear instructions in his "living will" that he did not want what we in the biz would call "heroic measures." That is, if, say, his heart stopped beating, he would not want anyone to start CPR or shock him or do much anything else. For an in-hospital strategy, that works fine, but Dad's heart chose to stop beating out by the mailbox for the condo association. A neighbor, who of course knew nothing of that living will, called 911. The EMTs arrived and were able to resuscitate him. I can't and don't blame anybody for "saving" Dad's life at that point. But after that things get murky.

The blow-by-blow of the next ten days is unnecessary to recount, but the gist is that he underwent a series of maneuvers designed to give him the best chance of not only surviving "the event," as we call it (it was almost certainly something known as Sudden Cardiac Death, though even that's a loose term), but surviving it "neurologically intact." My sense from the start was that we needed to get the tube out of my father and let him die. It wasn't that I didn't want him to pull through. It wasn't--or at least I think it wasn't--that I had seen enough cases of patients like this to know the steep odds he faced in having anything approaching a "meaningful" recovery. Rather, it was the knowledge that a ventilator isn't what he wanted! Yet despite this we had doctor after doctor, from the ICU attending to the PCP, continue to tell us to stay the course.

Several days of back-and-forth passed until I finally said that he would be extubated or I would leave, and my mother agreed. We approached the hospital and explained our position, said that we understood the recommendations of the doctors, but were no longer in agreement with them. The following morning my father's primary care internist relented and acquiesced to our demands--though not without a subtle parting shot where he said, after acknowledging our position, that "it's not something I would do for one of my family members." Dad was extubated that morning, and died a few days later.

And there's the rub for me. I spent a week trying to be such a good doctor and seeing the reasonableness of their point of view, as well as their medical management, that I may have forgotten how to be a good son in the process and fight for what my father wanted, which was to be left alone. (For what it is worth, I have no qualms with their medical management; as far as I am aware all of the doctors involved in his case made fine medical judgements.) In particular, I have spent much of the past year unclear if I have been furious with the loose ethics of Dad's PCP, who imposed his own ethics onto the situation without regard for Dad's wishes (which might be shorthanded as live at all costs), or if I am just disappointed with him and understand that he made a tough call with which I might disagree but hardly one that deserves scorn. And, since my identity is split between son and doc, I have vacillated on even whether I am angry, flinging myself into meta-analysis upon meta-analysis, or am just trying to manufacture anger on my father's behalf, since I see the quandary of the PCP, who pushed, pushed, pushed for us to keep him, and hope, alive. Not how I'd play it but totally justifiable from a medical standpoint. So am I a furious son, or a distant doc? Search me.

What fills me with dread is that I may be bringing that shit into a room when I admit patients on Friday nights. I am not Sir William Osler--while I think I am a very competent doc I have never quite been able to make medicine sing like a few of my fellow residents--but I do pride myself on my ability to communicate with patients and their families. If I have a strength, it is in helping families through the kinds of moments that my family went through one (solar) year ago. But I can't tell at the moment whether I bring that damned baggage into those rooms, and I don't know when I'll be able to sleep soundly knowing that I haven't let my own experiences get in the way of what I do very well, at least in my own opinion. Thus I am being tested but have no way of knowing the grade.

Until I can find some internal method of ascertaining my own emotional and intellectual response, a one-year anniversary can't serve as a marker for some kind of closure for me. Pops may rest in peace, but his son the doc continues to cope in the aftermath, wondering how he did as a son, wondering what it has done to him as a doctor.

Sunday, February 13, 2011

Industrialization Comes to a Small Hospital

If the relationship I have with the University Medical Center where I work is like a spousal relationship (substantial, committed, long-term, serious), then the hospital where I moonlight is more like a friends-with-privileges arrangement. I 've been moonlighting at this small hospital (about 200 beds) for the past five years now, and my feelings for the place are unquestionably fond, but my emotional and spiritual investment in it is minor. I use her for a little extra sustenance, not merely financial, as I like the people there and they--shockingly and inscrutably--appear to like me back in turn. In short, I like her but I do not love her. I want her to thrive but my heart will not be broken if she doesn't.

That said, my heart did a little breaking this weekend when I strolled in for an evening shift, ready to enjoy the give and take with patients and staff alike, and emerged 10 hours later having bade farewell to five employees (four docs and one secretary) that I had come to respect. They are all headed out the door, and while each has some particular reasons for departing, they all share one common motivation: the hospital is "industrializing" its hospitalist work force (using it for lack of a better word, I am definitely open to suggestions), and about 40 percent of the current hospitalist group has decided nearly en banc to look for greener pastures. Amazingly, after these departures are complete and the new crop of docs comes in, I am going to end up being one of the graybeards of the group, either the second or third most senior of the hospitalists...perhaps apropos since my actual beard has been sprouting grays & whites more insistently these past few months. What I find somewhat sad and slightly disconcerting about this is that I am, among the medicine physicians at least, becoming the one with the longest institutional memory.

But let's backup a moment and explain how we got here.

This hospital used to operate on the old model: if a patient was admitted to the hospital under the medicine service (i.e. not for a surgical procedure), the patient was usually under the care of that patient's primary care physician. I'm oversimplifying things here, but since internal medicine had begun to get significantly more complicated in the '80s and '90s, that old model, where the outpatient doc doing rounds and writing orders at 7 a.m. on the way into office hours, became increasingly impractical. The "hospitalist" movement sprang up as a consequence, and a new specialty was created: full-time inpatient internal medicine doctors whose sole job was to take care of internal medicine patients during a hospitalization.

At my hospital, about 10 or so years ago a few physicians began hospitalist work, and they would contract with particular medical groups to take care of that group's patients when they were admitted. When I first came to moonlight there that first hospitalist group was small, covering perhaps a third of all the patients admitted to the hospital. If a patient was admitted, the ER doc would call us, and we were supposed to check to see whether the patient belonged to our contracting medical group, and if they didn't we were supposed to inform the ER that such a patient was the "responsibility" of some other group. Since I found spending 15-20 minutes figuring out who "owned" such-and-such a patient rather tedious, and since I was moonlighting at least in part to maintain my hard-earned internal medicine skills, I just admitted everyone they told me to without concern for the primary physician, and accepted the frequent lectures from some of the full-time hospitalists the following morning when I found out that 5 of the 8 patients I admitted didn't "belong" to the group. (Their group still made money off those admissions since they could bill for them, while then as now I was paid to work by the hour, so I don't feel so bad about the whole thing.)

Anyway, once the primary care physicians saw how much contracting with hospitalists relieved their work burdens, a clamor arose to expand the hospitalist group, and the hospital started placing direct pressure to achieve this, because if the PCPs could find hospitalists at the other nearby small community hospital, then my hospital's revenue stream would start to dry up. The problem was (and I say this from the perspective of an outsider who watched from afar, so take my observations both with a grain of salt and at your own risk) the group couldn't expand fast enough to keep up with the demand. This led directly to a major problem, which was that the hospitalists who had been recruited had to shoulder larger and larger amounts of work, and see more and more patients, in order to keep up with the demand. The hospital, feeling perilously close to losing its patient base, mandated that within 6-9 months the hospitalist group be prepared take on all of the patients previously seen by the PCPs. But there weren't enough boots on the ground: each individual hospitalist was seeing more than 20 patients a day, which is far too many to do good medicine on a daily basis, and so morale sank. A few people departed, making matters worse, since larger amounts of work had to be shouldered by even fewer hospitalists.

Long story short, the hospital became concerned enough to take the program over and administer it directly. They promised to recruit more physicians and resolve the morale problem by lowering the patient census for each doc. I was skeptical and on the verge of hanging up my spurs, wondering in particular how the hospital thought it was better situated to recruit nearly a dozen physicians where the private group had failed, but over the next several months I was pleasantly surprised to see the administration deliver on pretty much all of its promises. I stayed on and met several new colleagues with whom I was proud to work. I thought that this little community hospital had solved the riddle of creating a stable hospitalist group, with at least some of the docs serving for years to come, becoming part of the fabric of not only the hospital, but of the community as well. And what better way for a community hospital to achieve its mission than by effecting this change?

Alas--that happy arrangement lasted about 18 months. While the hospital managed to succeed in a stellar manner in creating and sustaining a decent group of physicians devoted solely to the hospital and its patients, it came at a high cost. Literally. I have no idea of the numbers involved but by the summer of last year the administration began discussions with various companies who would take over the hospitalist group and administer them. The one they chose to take to the prom is a for-profit company, listed on the NYSE I am told, who must have promised huge savings for the hospital. Whence my term "industrialization": I remain uncertain as to whether this is the optimal word. Either way, the affairs of a major chunk of how this hospital runs was going to be dictated by a company run from far away, with its primary concern for the economic welfare of its shareholders rather than the health of the community who live and sometimes die within the hospital walls.

The administration found the pitch so irresistible that within the span of a few months, they went from trying to "explore options" with the hospitalist group, to submitting a take-it-or-leave-it offer to each individual physician that they become employees of this "hospitalist corporation" or submit their resignations. (To digress briefly, from my own narrow standpoint their offer seemed quite handsome, as the corporation would cover my malpractice insurance, which costs me nearly $10 thousand per year--that covers several nice bottles of zinfandel, I can assure you--and I was not required to work a minimum number of shifts for coverage.)

So over the past 3-4 months I watched with dismay the hospital re-create the exact situation it was trying to solve when it first took over the group, and this weekend I saw off some colleagues that not only will I miss, but much more importantly my "girlfriend" the hospital will as well. And this was just a quirky night where my schedules intersected with theirs: there are several other physicians who also chose to call it quits whom I haven't seen.

What kind of financial alchemy does this company perform to both make a profit for itself and save money at this not-for-profit hospital? After all, they can't increase the revenue stream unless they have a plan to make everyone in Small New England Town sicker, or unless they plan to blow up Other Local Community Hospital. Cutting costs may be part of it but I haven't read anything in the documents I signed that rewarded physicians by limiting test utilization, an approach that's totally reasonable in concept and very difficult to execute in reality.

Again, because of my very part-time status, my answer is far from definitive, but my suspicion is that they're not giving us a new wheel so much as repackaging the old one. Which is to say that the way they will generate more revenue by increasing the individual doc's workload. Overhead for hospitalists is relatively small (depending on how a hospital would charge a practice for things like office space and computer access), but salary is huge. Cut the size of the group by a third and you've found a lot of previously missing money--I'm thinking something approaching $2 million based on my back-of-the-napkin calculation for this particular hospital. I have no experience with hospital budgets, but for a hospital of that size, I'm guessing that's a serious amount of cash. Some of that, of course, will go directly to the pockets of the shareholders of Hospitalist Corporation, but the hospital stands to benefit from this arrangement.

As to whether the whole venture will succeed, I have no idea. My nature is to be suspicious of anything tied to the term "for-profit," and doubly so when it applies to entities involved in healthcare. But that is--to appropriate a term from RW Donnell--a bias, and it may well prove to be a faulty one in this instance. At this particular moment in the life of this particular hospital, its influence cannot be described as anything other than destructive, but I remain open to the idea that this new, industrialized relationship might benefit everyone by the time we next sing Auld Lang Syne. To say that I am optimistic, however, may be saying too much. We will see, and barring an unforeseen event, I'll be around at least long enough to see the immediate effects of the transition, which takes place in less than a month.

Tuesday, February 8, 2011

Readmission Rates as a Means to Measure Hospital Quality

My alarm is set to let loose the soothing tones of NPR at 6:15 each weekday morning, and I spend the first seven of those minutes in the pleasant haze before actually rising (which is less pleasant). This usually coincides with the final story before the news headlines, and this morning's piece brought news that the Massachusetts state government is planning to "stop paying hospitals where the re-admission rate is higher than the statewide average." This is expected to save the Commonwealth roughly $8 million annually in a budget that, like most of the states in the Union, is strapped for cash.

Let's leave aside the most egregious part of this policy: namely, that half of all hospitals should be made to take a financial hit, even if every hospital in Massachusetts improves its readmission rates, since by definition half of any defined group is always above the average. There's a cruel logic at work there, or rather more likely, none at all. But for the sake of argument let's assume that some clever legislator thought of this and worked out some model to adjust for this problem, measuring hospitals against some baseline of expected performance rather than against each other. Is it still a good idea?

Maybe, but to expect politicians and/or bureaucrats to get this right just now is...well, color me skeptical.

Measuring a given hospital's performance isn't very difficult: you just collect data on the number of admissions, the kind of admissions, the length of those admissions, how many people die in the hospital, how many have surgical complications, and the like. With computerized databases this takes only the amount of time that one wants to spend querying the data, and it's equally easy to cross-check the admissions to see how many patients are re-admitted to the hospital within one month (the typical measuring stick) with the same problem. What is difficult is knowing the standard to which that hospital's performance should be compared.

Wait, you say--why not compare all the hospitals against each other? You can actually do this via this news piece from USA Today; the slightly more tedious, and less user-friendly, version put out by the federal government is here. What if the re-admission rate for, say, pneumonia at Hospital A is 15.9 percent, while at Hospital B it is a stunning 22.5? (The national average, as illustrated here, is 18.3 percent.) Should we punish Hospital B, deprive its operating budget of potentially hundreds of thousands of dollars, and maybe send some of that cash over to Hospital A, a gleaming example of the finest medicine practiced in the US?

It's not such a hypothetical: I took the data from two actual hospitals here in Massachusetts. Hospital A is a small, regional center about an hour or so outside of Boston, while Hospital B is an academic medical center in the heart of the city. I'm sure "A" is a fine hospital with good doctors, but for my money, send me to "B" any day of the week! But why would I think such a thing given those stats (which, I'm confident, would be similar for virtually any medical condition such as heart attacks and asthma)?

The answer is that "B" is a large urban, tertiary-care center. Why is this relevant? Because of their size, they have many different ethnic groups passing through their doors, including at least two major immigrant populations: more opportunities for misunderstandings--both cultural and linguistic--that can lead to readmission. Because "B" is urban, it has the kinds of patients that "A" rarely sees, who happen to be the kinds of patients at highest risk for readmission: single mothers working two jobs who can't find time for follow-up appointments, working poor who can't afford meds, semi-literate patients who only partially understand the bizarre language of doctors and nurses, drug addicts. Because they are a tertiary-care center, they take referrals of the sickest patients in town--precisely the kind of patients that make many nurses and doctors from Hospital A pee in their pants when so confronted. For all of these reasons, Hospital B is very far from being on a level playing field, and while I'd probably be fine being taken care of at either place for routine stuff, I would very much rather be at Hospital B for even the slightest setback.

With the fancy computerization has come significantly increased access to data, and the arguments and counterarguments about how to use hospital outcomes data have been circulating for a few years. Take, for instance, the discussion about hospital mortality statistics, as evidenced by this editorial in the British Medical Journal last April, or very recent news stub by Harvard University here. Contrast this with a warm account in 2009 of Baylor University's lower readmission rates for heart failure, and its emphasis of defining the admission rates relative to the national average. Baylor may well be a model for how all hospitals should construct their programs; I'm not a heart failure specialist so I can't comment. The story, however, plants the idea that everything better than the mean signifies a better hospital, and everything worse, worse--an idea that can be misinterpreted with potentially disastrous consequences for certain patients.

My fears about how this is going to play out in the years to come is that hospitals will continue to feel budgetary pressures from government agencies and insurance companies alike, and those that care for the sickest and most vulnerable patients (read: often not white, frequently the poorest, sometimes immigrants who do not speak English well or at all, just to name a few attributes) are going to suffer the brunt of this well-meaning but so far not-ready-for-prime-time approach to measuring a given hospital's quality.

Saturday, February 5, 2011

A Journal Declines Drug-Industry Advertising

It's not The New England Journal of Medicine, but it's a start. Word today from Gary Schweitzer's Health News Review Blog, passed along from the Croakley Blog, that the journal Emergency Medicine Australasia has decided to eliminate advertisements from drug companies. A brief excerpt from their editorial (full editorial available here):

Doctors need to stop being used as agents of the drug industry in the complex financial arrangement between drug companies and consumers. It is time to show leadership and make a stand, and medical journals have a critical role to play in this. At EMA we have therefore drawn a line in the sand, and have stopped all drug advertising forthwith. We invite other journals to show their support and follow suit, by declaring their hand and doing the same.

Now that's some writing that would make George Orwell proud!

Wednesday, February 2, 2011

The Mathematics of Residency Interviews

This year I have just completed my first season of interviewing applicants to the internal medicine residency program at my University hospital-based program. It's something I always wanted to do, and after living through the interview process on the other side of the coin I'm inclined to help out in the years to come. My guess is that it's more fun than medical school interviews, where the stakes are higher and the candidates more nervous by virtue of the fact that everyone applying for residency is going to get in somewhere, it's just a question of where. In internal medicine especially (and doubly so since I don't work at a Hospital whose first name is "Massachusetts General"), we're trying to vie for their love as much as the other way around. So I put on a little salesman schtick at the same time I'm trying to appraise the person before me. And most of the time it's quite fun.

That said, my impressions count for about two percent of where soon-to-be-Doctor so-and-so is going to end up on the rank list. Bob Seger may have complained that he felt like a number, but we'll assume that he wasn't singing about the process of becoming a doctor, however accurate his assessment would have been. In order to become a doctor in this country, one must become a number. The only question is: how high is it? The answer to that determines whether you will become a dermatologist or family practice resident, or whether you will cruise the halls in your snappy white coat at Johns Hopkins, or at Southern Podunk Community Health Center.

The Number for our residency program is, I suspect, calculated in a manner similar to other programs of its ilk around the country. For example, you get a certain number of points for having certain kinds of grades. In most medical schools there are three grades for the "clinical rotations," that is, when you actually see patients: "honors," which is like an "A"; "high pass," which is like a "B"; and "Pass," which is like a "C." (It is rare to fail once you've gotten that far in med school; for more on this feel free to read Blind Eye by James Stewart, but have a bottle of booze at the ready.) So, if you had, say, honors for your internal medicine grade, you'd get a 3, but if you got a high pass, you'd get a 2, and so on. Since our program is internal medicine, we have a category for the general internal medicine rotation, a category for the more intensive internal medicine rotation known as a sub-internship, and a category for all the other clinical rotations put together. Thus, if you had honors in both internal medicine and in the sub-I, but only a spotty showing in all your other classes, you'd end up with an 8...not too shabby, in fact.

Anyway, we have other scoring categories for things like research and leadership positions, how well you did on the nationalized standardized medical examinations, and so on, and the total number of points one can have, if they were a perfect candidate in our system, is somewhere in the high thirties. The interview accounts for four of these points, and each candidate interviews with two different faculty members. Thus, you might make a killer impression, but it won't save you if you didn't do so well in those other categories; your number is more or less fixed before you've even shaken my hand. (On the other hand, if you interview badly it will count against you in a most unpleasant way: say or do something offensive and there's a special category marked "Red Flags," reserved for people who do something socially inappropriate during the interview day. Red Flags will pretty much put you at the bottom of the rank list, or remove you from it entirely. Don't make ethnic jokes, students!)

Much could be said about this process but in the interests of time I will say that, in general, it appears that it works for the majority of candidates in determining who's going to be a decent match for a program. It won't really help you learn who is going to be very good, nor will it help you identify who is going to drive the medicine faculty bananas, but it will do just fine for the average, solid resident. (The truly stellar, as well as the truly awful, are pretty easy to spot; I'm talking about the residents who come in with the same grades as their classmates and turn out to be future Chief Residents. These guys & gals are hard to find in this kind of application process, and I'm not sure how you'd spot them in a time-efficient manner regardless.)

But grades can translate to interesting numbers, and the interpretation of the former can very much influence the assignation of the latter, which in turn can make the difference between whether a given candidate will end up at Man's Greatest Hospital or McGrungy State City Hospital. Let's take, for example, the grades of this (anonymous) student: high passes in most clinical rotations (internal medicine, surgery, psychiatry, and family medicine) and passes in two (OB/GYN and pediatrics). The student's "overall" recommendation by the medical school is "strongly recommend," which means that they regard this student as being in the second highest of four categories ("enthusiastically recommend," "strongly recommend," "recommend with confidence," and finally, with what approximates a straight face in medical school bureaucratise, "recommend").

Let's take a closer look at this student, though. When you consider this student's grade in relation to those of the student's classmates (I would like to show the chart, but have privacy concerns for the student, and have altered the classes to maintain that privacy), you discover that in some cases the numbers are damning, and in others they provide no useful information at all. For instance, this student got a "high pass" in psychiatry, but roughly two-thirds of the students got a high pass, and virtually nobody got a mere "pass." Thus an "honors" is useful information (top third of class), as is a "pass" (this student stinks), but not so much for the middle category. All of this students high pass grades have a similar flavor; they tell you that the student was competent, but don't really indicate if he or she was a cut above--the original intent of the high pass designation. The distribution of the OB/GYN grades is about what it should be: top 10-ish percent got honors, a bit less than 30 percent got high pass (a bit too large, but closer to the mark), and the rest got pass...so this student is average, what you'd expect of a "pass" grade. The pediatric grade, by contrast, indicates something more concerning: due to the grade inflation only twenty percent got a pass--that is, the bottom twenty percent, more like a "D" than a "C". Not so hot! Now that overall "strongly recommend" status looks a touch fishy to me and seems inflated. And sure enough, almost half of this class is given this label. If I were a better than average but not outstanding med student, I'd feel ripped off by this school.

Balancing these variables is part of the art of ranking, but no matter how you slice the bread, someone's going to end up higher on a given program's rank list due to some medical school's grade inflation, while others will inadvertently get dinged. I see no easy way around this except to give greater weight to national standardized tests. Unfortunately, they only speak to how well a person knows how to take tests, and perhaps how much "book medicine" they know. It won't tell you a lick about how good a doc they'll be.

The rank list meeting, where faculty try to jockey position for certain pet candidates (though my understanding is that the bumps are very minimal and most people's rank order is pretty well fixed), is taking place in a few weeks. Maybe sometime in July or August, after I've had a chance to make a survey of the new bunch, I'll drop a line about how things turned out.