How Should Doctors Get Paid? – Part 2

Hourly Wage, Piecework or Quality?

A long time ago, when I worked in Sweden’s Socialized health care system, there were no incentives to see more patients. In the hospital and in the outpatient offices there were scheduled coffee breaks at 10 and at 3 o’clock, lunch was an hour, and everyone left on the dot at five. On-call work was reimbursed as time off. Any extra income would have been taxed at the prevailing marginal income tax rate of somewhere around 80%.

There was, in my view, a culture of giving less than you were able to, a lack of urgency, and a patient-unfriendly set of barriers. One example: most clinics took phone calls only for an hour or two in the morning. After that, there was no patient access; no additions were made to providers’ schedules, even if some patients didn’t keep their appointments, not that there was a way to call and make a same-day cancellation.

As my father always said: “There must be a reward for working”. But, high productivity can sometimes mean churning out patient visits without accomplishing much, or it can mean providing unnecessary care just to increase revenue. For example, some of my patients who spend winters in warmer climates come back with tall tales of excessive testing while away.

A recent Wall Street Journal article offers an interactive display of doctors who collect the highest Medicare payments. The difference between providers in the same specialties across the country makes interesting reading. It is hard to imagine that many individual doctors are billing Medicare more than $10,000,000 per year.

So it might make sense to insure against paying for excessive care by also demanding a certain level of quality.

But defining quality is fraught with scientific and ethical problems, since quality targets really aren’t, or shouldn’t be, the same for all of our patients.

The scientific community, for example, knows that elderly diabetics with “ideal” blood sugars are more likely to suffer harm or die than those with sugars that are a little higher. Even though the American Diabetes Association has embraced higher blood sugar targets for older diabetics, many healthcare organizations’ quality assurance programs treat all diabetics the same and penalize doctors who individualize treatment goals in accordance with the scientific evidence or common sense.

In almost every area of medicine there are individual nuances that must be considered if we are to best serve each of our patients. It is ironic and very sad that, right now, those who pay us are looking for simple (or simplistic), universally applicable quality targets just as the explosion in our understanding of genetics is promising to usher in the era of “personalized medicine”.

Up until now, the gold standard of scientific research has been to prove which standardized interventions work best for large groups of patients, even if there are subgroups that aren’t helped at all by them.

Who should define the “quality” measures of our work?

The central question for how doctors might be paid for quality in the future hinges on the priorities of whoever holds the purse strings. Insurance companies, if we overlook profit motives that also exist, prioritize population management. They pay for what works for most people, knowing full well that some patients will not get the best care for their individual situations, for example when certain medications are not covered. Politicians also favor the population view of health care.

If patients pay us directly, they expect us to deliver the care that works for them. If the Government or an insurance company pays us, they expect us to deliver care that meets their standards, because they don’t trust the patients – their constituents and customers – to know what is best for them. And their focus is to have us do what helps most of our patients, even if some are not helped and some, or many, aren’t happy with what they are getting.

With all the political talk about “Patient Centeredness” during the current health care reform, may I suggest that patients need to be given more choice about how their health care dollars are spent. With limited choice and no responsibility, patients tend to feel entitled and deprived at the same time. This creates a toxic environment for delivering health care. I have never met a patient who felt in partnership with his or her insurance company – ever. And I don’t expect to.

In order to maintain what partnership is left today between doctors and patients, we need a cost-quality paradigm that is shared by patients and providers. We also need to foster and maintain a sense of stewardship that is elusive if all that is at stake is someone else’s money.

I think there are ways to achieve this.

(More to come…)

Neve Assume – Indeed!

A couple of weeks ago I wrote a post titled “Never Assume” about a handful of patients, whose case histories took an unexpected turn.

Well, as it happened, a few more twists and turns unfolded since then:

Peter Bartley, the man with upper abdominal pain and black stool, not just from the Pepto-Bismol he had taken, had his upper endoscopy. It only showed some mild gastritis without bleeding. Fortunately, the surgeon also did a colonoscopy, which showed an actively bleeding polyp almost the size of a clementine in his transverse colon.

Black stool is generally thought to be from the stomach or duodenum, located above the ligament of Treitz. It has been said that it takes the digestive juices 14 hours to change the color of our hemoglobin into black melena. Peter’s intestinal transit time must have been slower than most people’s for this to happen with a bleeding polyp in his colon.

Norma Daigle, who had received another patient’s trazodone and Lexapro, called the other day and told Autumn she wanted some trazodone of her own, because it had made her sleep so well.

Beatrice Nash, whose hip pain seemed to come from a mass in her left pelvis, had her CT scan. It showed a very large probable lipoma, a harmless fatty tumor. She has seen the surgeon, who wrote in his not that she described the pain as sharp and coming directly from the hip, and not at all from somewhere higher up than that. He didn’t think the lipoma had anything to do with the hip pain, and recommended she see an orthopedic surgeon.

As it happened, a few days later she had a follow up visit with her orthopedist for a cortisone shot to her arthritic knee. I eagerly read through his note to see if he thought her pain was from the hip joint or not, but there was no mention at all of her hip pain!

Diane Fehrer, who never seemed to remember to take her thyroid medication, accepted the pharmacy’s offer to put her pills in monthly calendar bubble packs. I am keeping my fingers crossed that she will remember to look at the bubble pack every day, and I keep wondering: If she does take her levothyroxine every day, will my prescribed dose be too high and cause her tremors, palpitations or even atrial fibrillation?

Finally, Matt Wikert, the physical therapist with high blood pressure and chest pains, showed up at the hospital for his stress test as planned. Earlier that morning he had a 45 minute episode of chest pain. His EKG showed some subtle changes from the one I had done, so the stress test was cancelled and he was admitted for observation. He ruled out for myocardial infarction and was discharged with plans for a rescheduled stress test. We still don’t have a date for it.

Every day, just like that day a few weeks ago, I see patients whose stories don’t quite fit the expected pattern. In the words of Sir William Osler:

“Variability is the law of life, and as no two faces are the same, so no two bodies are alike, and no two individuals react alike and behave alike under the abnormal conditions which we know as disease.”

How Should Doctors Get Paid? – Part 1

It’s a strange business we are in.

I can freeze a couple of warts in less than a minute and send a bill to a patient’s commercial insurance for much more money than for a fifteen minute visit to change their blood pressure medication.

I can see a Medicaid or Medicare patient for five minutes or forty-five, and up until now, because I work for a Federally Qualified Health Center, the payment we actually receive is the same.

I can chat briefly with a patient who comes in for a dressing change done by my nurse, quickly make sure the wound and the dressing look okay and charge for an office visit. But I cannot bill anything for spending a half hour on the phone with a distraught patient who just developed terrible side effects from his new medication and whose X-ray results suggest he needs more testing.

As a primary care physician I get dozens of reports every day, from specialists, emergency rooms, the local Veterans’ clinic and so on, and everybody expects me to go over all these reports with a fine-toothed comb.

A specialist will write “I recommend an angiogram”, and we have to call his office to make sure if that means he ordered it, or that he wants us to order it.

An emergency room doctor orders a CT scan to rule out a blood clot in someone’s lung and gets a verbal reading by the radiologist that there is no clot. But the final CT report, dictated after the emergency room doctor’s shift has ended, suggests a possible small lung cancer. Did anyone at the ER deal with this, or is it up to me to contact the patient and arrange for followup testing? All of this takes time, but we cannot bill for it.

Most people are aware these days that procedures are reimbursed at a higher rate than “cognitive work”, but many patients are shocked to hear that doctors essentially cannot bill for any work that isn’t done face to face with a patient. This fact, not technophobia, is probably the biggest reason why doctors and patients aren’t emailing, for example.

Just lately, there is a new trickle of money flowing into medical offices for the type of between-visit oversight that goes with the new Patient-Centered Medical Home model of care, but it is not enough money to substantially change how doctors’ time is scheduled.

Taking a primary care physician away from direct patient care for just an hour can cost the employer somewhere around $400 in lost revenue. In today’s economic climate, few health care organizations can afford to fully embrace the notion of all the different indirect care activities others think physicians should engage in besides seeing patients one by one for a fee.

Of the three professions, physicians probably have the most confusing payment arrangement: Members of the clergy tend to make a straight salary regardless of how busy they are, lawyers bill for their time whether spent with the client or without, but we only get paid if someone is watching us.

If a tree falls in the forest, does it still make a noise?

If a doctor isn’t face to face with a patient, is he still a doctor? Is he still doctoring?

I say yes, but, then, how should we get paid?

(To be continued…)

Never Assume

Peter Bartley came into the office today with a two day history of black, tarry stools. The day before this started, he had had a terrible case of indigestion and took several slugs of Pepto-Bismol to quiet it down. This had helped, and he was feeling quite well today, but the color of his stools bothered him.

“His stools are probably black because of the Pepto”, Autumn said as she filled me in. I had another patient to see before Peter, so I asked Autumn to get orthostatic vitals on him while I went in to see Norma Daigle for her regular 3 month visit.

Norma’s thyroid test was normal, and her blood pressure was stable, but she looked very concerned, and she was clutching a pill bottle between her hands.

“Bigtown Pharmacy delivered this yesterday along with my other medicines, but I don’t know what it was for, so I didn’t take it”, she said, adding “there was also a bottle of trazodone, and I took one of those because I used to take them and I knew it worked good helping me sleep”.

I looked at the bottle. It contained escitalopram, the generic form of Lexapro. Norma is on lithium and Prozac. Lexapro in addition would be redundant and could bring on a manic episode if she were to take it for any length of time. At the upper right hand corner of the label was the prescriber’s name, a psychiatrist at Cityside Hospital.

“It’s from Dr. Hirsh, did you ever see him?” I handed the bottle back to her. She frowned and said “never heard of him”.

I called Bigtown Pharmacy on my cell phone. I posed my question and was put on hold for less than a minute. The pharmacist came on and admitted they had made a mistake. The medication was for Nancy Daigle, another patient of mine.

The pharmacist asked “Can we pick the medications up at your office this afternoon?”

“Well, one bottle is here and the other one is at the patient’s house”, I explained.

“Tell her we’ll pick both up at her house”, said the embarrassed pharmacist.

“Good thing you read labels”, I said to Norma, who just sat there, shaking her head.

Peter Bartley’s standing blood pressure was the same as when he sat down. His pulse was normal. As I placed my hand in the upper center of his abdomen and pushed slowly downward, he winced a little. His black stool tested strongly positive for blood. I told him it looked like he might have a bleeding ulcer and not just black stool from Pepto-Bismol.

My next patient, Beatrice Nash, was in for pain in her left hip. She had already been to the emergency room for this, and her hip x-ray had been normal. As I listened to her symptoms, I knew this was no ordinary groin pull, as the emergency room doctor had thought.

“I hurt more after I stand for a while”, Beatrice said.

“Show me where”, I asked her, and she put her left hand over the bony pelvis, well above the hip joint. Both hips and both knees had full movement without pain, her straight leg raising test was normal, there was no pain when I resisted her hip movements, and there was no groin hernia when she stood up. After she laid down on the exam table, I palpated her abdomen and there, deep in the left lower quadrant, was a tender mass.

“Is this where you hurt when you stand up”, I asked.

“Yes, that’s where I hurt”, she answered.

“We need to get some bloodwork and a CT scan of your abdomen and pelvis”, I said, “because it doesn’t look like your hip is the problem. You might have some sort of cyst in your pelvis.” I was worried this could be a tumor, but felt pleased that I had come up with a plausible explanation for her pain.

Diane Fehrer’s TSH was even more out of range than last time, when I bumped up the dose of her thyroid medicine, and she was feeling very tired.

“Are you sure you haven’t missed any pills”, I asked her, but she said she was sure she always remembered to take them. “Let me just double check with the pharmacy that you got the right strength”, I said and pulled out my cell phone. The pharmacy technician’s answers to my questions explained her slipping thyroid status: Diane had not picked up her old dose of levothyroxine for several weeks before her previous blood test, and last months’s new prescription was still waiting for her at the drugstore.

Next up was Matt Wikert, who had run some high blood pressures at home. The other day at at the nursing home where he is working as a physical therapist, the nurse had recorded 178/98 and had wondered if I wanted to see him right away. I said to have him check it a few more times and see me today. His pressure at check-in was 148/80.

“So your blood pressure looks better today. How are you feeling”, I asked.

“Well, I still have some pressure in my chest…”, he began.

My heart sank. The nurse had not said anything about chest pain, and I had not specifically asked. I know better. Fortunately his EKG was normal, and the character of the pain was quite atypical, so it probably isn’t angina, but, still, it was a sobering reminder that you really can’t assume anything in the practice of medicine:

A chief complaint is often only the patient’s self-diagnosis, or interpretation of a symptom. A high blood pressure can seem more significant than a vague pressure in the chest, and a pain above the hip can seem easier to explain as a hip pain than something there is no word for.

A pharmacist or a physician can get their patients mixed up, and patients forget their pills more often than we’d like to believe.

Not all patients with black stool while on Pepto-Bismol have black stool because of the Pepto-Bismol. Some have a bleeding ulcer, which is why they took the Pepto-Bismol in the first place.

And, if we hurry in our work, we are more likely to assume, instead of evaluate and examine thoroughly.

Bedside Manner and the Pendulum Effect

David Mendel’s book “Proper Doctoring”, published in 1984, the year I finished my residency training, just came out in a new edition, seven years after his death. Born in London in 1922, his words very much sound like those of the generation before me, but they are somehow also timeless and as relevant today as they were thirty years ago.

On the topic of bedside manner, he writes:

“One absolutely essential ingredient of proper doctoring us the much-maligned bedside manner. The best doctors acquire one over the years, but many never do. I think that this is due to the usual overswing of the pendulum. Around the turn of the century, medical remedies were not very effective; in the circumstances the bedside manner was all there was. Now that we can cure many diseases, both doctors and the public have replaced the wise avuncular physician of the past with the ’intensive care whizz-kid’ image. We don’t need all that mumbo-jumbo when we have proper scientific methods, they say.”

Indeed, a physician from the generation before Mendel, Swedish-born Axel Munthe, writes about his days as a popular young doctor in Paris in his 1929 memoir, “The Story of San Michele”. At the time there were some very successful doctors in Paris, who had the reputation of being quacks, with fake diplomas but with charming bedside manners. They were all called to the police precinct to have their credentials examined. The most successful one showed up at the last minute and requested a private meeting with the Commisaire. He implored the official to keep his diploma from a prestigious German university secret, as he felt he owed his financial success to his reputation of being a quack.

Today, eighty-five years after Munthe’s best seller and thirty years after Mendel’s book, the pendulum has yet to turn back. The caring 1970’s family doctor, Marcus Welby, has given up his spot to “House”, whose brilliance excuses his personality deficiencies.

Mendel describes science as one of four legs on “the medical couch”. The other three are wisdom, experience and caring.

William Osler, by many viewed as the father of modern medicine in North America, in an anecdote retold by author and physician Larry Dossey, exemplified good bedside manner:

“After revolutionizing how medicine was taught and practiced in the United States and Canada, in 1905, at the peak of his fame, he was lured to England where he became the Regius Professor of Medicine at Oxford. One day he went to a graduation ceremony at Oxford, wearing the impressive academic robes that are a feature of the occasion. On the way he stopped by the home of his friend and colleague, Ernest Mallam.

One of Mallam’s young sons was desperately sick with whooping cough. The child would not respond to the ministrations of his parents or nurses and appeared to be dying. Osler loved children greatly and had a special way with them. He would often play with them, and children would invariably admit him into their world. So when Osler appeared in his dramatic ceremonial robes, the little boy was captivated. Never had he seen a human like this! After a brief examination Osler sat by the bed, peeled a peach, cut and sugared it, and fed it bit by bit to the enthralled, speechless boy. It was his first nourishment in days. Although recovery was unlikely, Osler returned for the next 40 days, each time dressed in his magnificent robes, and personally fed the child. Within a few days the tide had turned and the little boy’s recovery was assured.”

Larry Dossey goes on to say:

“Compassion is not antiquated. It remains a crucial factor in healing and will never go out of style. It is always available for any healthcare professional who is wise enough to claim it.”

Bedside manner is sometimes now included in medical school curricula, but ultimately it is probably better inspired than taught. If we as physicians give more thought to the roots of our profession, or “proper doctoring”, we will be less distracted by the technical aspects of our work, and more likely to see our patients and their suffering as the real and only reason we entered our profession.

And may the pendulum soon return.

Aequanimitas – Doctors Stirred, not Shaken

Doctors today are often accused of being uncaring: Their eyes are glued to their computer screens and their attention is focused on test results and technology instead of patients.

But some doctors care too much: A seasoned cardiologist blogs about letting his emotions lead him astray in keeping an elderly patient on life support too long. Was it his emotional attachment to the charming, elderly woman, or was it professional hubris, Dr. Sandeep Jauhar asks himself.

Sir William Osler wrote a hundred years ago about the mindset behind the conduct of skilled, seasoned physicians. He used the ancient word Aequanimitas, derived from the Latin words “aequus” (even) and “animus” (mind/soul). Every religion values the concept, and many of them use the actual word, equanimity, as do teachers of Buddhism and yoga.

Osler wrote about the levelheadedness required of doctors:

“Imperturbability means coolness and presence of mind under all circumstances, calmness amid storm, clearness of judgment in moments of grave peril, immobility, impassiveness, or, to use an old and expressive word, phlegm. It is the quality which is most appreciated by the laity though often misunderstood by them; and the physician who has the misfortune to be without it, who betrays indecision and worry, and who shows that he is flustered and flurried in ordinary emergencies, loses rapidly the confidence of his patients.”

Some people have taken this to mean that Osler somehow didn’t care deeply for his patients, but he emphasized that this was not a call to be uncaring:

“Cultivate, then, gentlemen, such a judicious measure of obtuseness as will enable you to meet the exigencies of practice with firmness and courage, without, at the same time, hardening “the human heart by which we live.”

In Osler’s time, many more diseases were incurable than now, and he spoke to medical students about the limitations and uncertainties of medical practice:

“A distressing feature in the life which you are about to enter, a feature which will press hardly upon the finer spirits among you and ruffle their equanimity, is the uncertainty which pertains not alone to our science and arts but to the very hopes and fears which make us men. In seeking absolute truth we aim at the unattainable, and must be content with finding broken portions.”

This acceptance of not knowing and not being able to control the ultimate outcome of our efforts has become unpalatable for some in healthcare today. We are now workers in a medical “industry”, based on a manufacturing paradigm. And the goals of this industry are not necessarily those of its “customers” – our patients. Corporate quality metrics can clash with patients’ desires.

Just like Osler spoke about equanimity in the face of suffering and the ravages of disease in the early 1900’s, we may want to apply it to the modern frustrations of doctors today; if we cannot control the system of healthcare where our patients’ and our own lives intersect, we risk descending into a spiral of frustration. Borrowing from Buddhist writings, there is an alternative to despair today, too, in equanimity:

“Without this….it’s easy to fall into compassion fatigue, helper-burnout, and even despair. Equanimity allows you to open your heart and offer love, kindness, compassion, and rejoicing, while letting go of your expectations and attachment to results. Equanimity endows the other three brahmaviharas (sublime attitudes, Buddhist virtues), with kshanti: patience, persistence, and forbearance.”

Frank Jude Boccio, teacher of yoga and Zen Buddhism

True equanimity is being stirred in our hearts by the needs of each one of our patients. But we must not be shaken into despair or resignation by their suffering, by the limitations of medical science, or by the shortcomings of a healthcare system we cannot control.

Monocular Vision in Horses and Physicians

The horse that came into my life has made me think about many things from a different perspective. I have learned about the horse’s subtle ways of communicating, her extrasensory (compared to our own) perception, and her instincts of flight. I have also become more aware of the energy I bring to my relationship with her. With no learned tricks or horse management skills, I have established a way of communicating with her built solely on mutual respect and affection.

She always tries to see what I am looking at, my books and the picture of me and her on my iPhone. I know that horses have an almost 360 degree field of vision, but a very small area of binocular vision. They also have a blind spot right in front of their nose.

Monocular vision gives horses the ability to detect danger from almost every angle, but with fewer details than our human vision. A wind blown piece of paper can seem as threatening as an approaching predator.

Even when grazing lazily on warm summer afternoons, my horse has one ear turned in each direction and she maintains her 360 degree visual vigil. She is always multitasking.

This is where I have started to see parallels with my own workday. I seldom have the luxury of doing one thing at a time, namely take care of the patient in front of me. Today’s physicians, like horses on the savanna, seem to be having to keep a 360 degree field of awareness, even when we are alone with our patients in the exam room.

It is not enough to be doing the work of diagnosis, of weighing all the components of crafting a treatment plan: If I choose to prescribe a quinolone antibiotic, what is my patient’s kidney function, is he on blood thinners, did I double check the allergy list? I must also remember to print the patient information, even though I verbally warned my patient about the risk for tendon rupture. I must be aware if his insurance covers my choice of drug and, because he is on replacement steroids for his Addison’s disease, I need to submit a prior authorization request to Medicaid, which wants me to go on record that I am aware of the theoretically increased risk of tendon injury, even though my patient is only on replacement steroid therapy.

I must also be cognizant of the time, my schedule, the health maintenance reminders and the chronic disease monitoring my patient is due for.

All these considerations, which happen almost subconsciously, need to be documented in the medical record, both for medicolegal and for billing purposes. Watching out for all the pitfalls in patient care is probably a lot like grazing on the savanna for my Arabian and her ancestors.

Any wonder, then, that sometimes, at the end of a busy day, I feel as if I have done a lot more than the doctoring I bargained for.

Stepping into the ten foot stall of my 800 lb friend, I cannot afford to be edgy or distracted. This is when we spend time together inside, focusing on our shared field of binocular vision, where we share the depths of each other’s gaze, and where we share our territory with mutual respect.

This is the focus I must strive at maintaining every day, at work as well as in my dealings with those I love. I need my 360 awareness, but as a human being, and not an animal of prey, I need to keep my main focus straight ahead, or I will lose my depth and my courage.


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