Demand Apathy

Monday afternoons are always the same.  I pick up the kids from their grandparents.  We drive home with their backpacks and a carton of home made food.  We park in the garage, and carry all the contents of the car into the house.  As the kids unload, I push the recycle container to the front for street pickup the next day. 

Occasionally, I stop and socialize.  Yesterday, I waited at the edge of the sidewalk as a neighbor approached.  A young healthy fellow, I was surprised to see his posture stooped and his head bent forward.  Apparently he was under the weather.  He had a slew of symptoms: fevers, chills, and a sore back. 

I enquired about his recent doctors visit.  His physician was top rate, I had suggested him myself.  But that's when my neighbor's face became particularly animated.  His visit  the week before had ended in blood tests and an Xray.  But seven days later, no results.  In fact, several calls over the last forty eight hours had been left unanswered. 

I shook my head, and watched him stumble into his house.  I knew his doctor to be of high quality, but ever since he had been bought by the local hospital, the number of complaints had risen.  It was a common issue.  A few patients each week were showing up at my doorstep because they felt like the practice they had been going to for years no longer cared for them. 

I would like to believe that this was only happening in the big medical groups, but I have heard the same among private practices also.  And sadly, I feel fairly certain that I know why.

In the old world, physicians answered only to one master: the patient.  In the new world order, patients are becoming a lowly voice in the crowd of entities shouting at physicians.  There is a kind of demand apathy.  After tending to the insurance companies, the government, the hospital, the medical group administrators, and the electronic medical record, your physician may or may not have time to address your needs.

We talk of the devastation of physician suicide.  We lament as more and more doctors bow out of clinical practice.  But on a larger scale, what may be most harmful to the American populace is the great apathy that is sprouting in this once proud profession.

My neighbor will eventually get better.  The virus attacking his system will abate.  The inflammation will resolve.

His trust in the system, however, has suffered a mortal blow.

Invisible Consequences, The Fall Of The Clinician/Teacher

It was just like every other email I had gotten in the past.  A young student at a local university was interested in primary care, and wanted to shadow me for a month between his second and third years.  I responded swiftly.  I was delighted to bolster the interest in my speciality.  Over the years I had helped train students, residents, nurses, and nurse practitioners.  By exposing them to the office, hospital, nursing home, and hospice and palliative care, I felt I gave them a window into a nontraditional view of Internal Medicine.

He showed up on a Friday for clinic.  His excitement was palpable.  He jumped out of his seat, and trailed behind me from room to room.  But something was off that afternoon.  The patients were elderly and difficult.  Their problems were amorphous and complex.  I could see the fatigue and consternation after each visit, though he said little.

This is not how a student glamorizes the specialty when daydreaming about their future.  Eventually those that learn from me, however, realize this is a small part of the job.  They also experience the thrill of the diagnostic process, the humility of human interaction, and the privilege of becoming a part of your patients lives.

The student's gaze seemed especially trained on me when I was being distracted: the cell phone call from a nursing home in the middle of a visit, or the unending overhead pages pulling me away from what I was doing.  Time and again, though, his eyes glazed over most when I was typing on the computer.  The strain of meaningful use had altered my most intimate interactions.  As my patients were bemoaning their newest symptoms, I was busy clicking, making sure to print the after visit summary and patient education.

Meaningful use has been the tipping point, the beginning of the avalanche.  I was able to keep it together before.  Now, I have become a befuddled, frazzled, ball of stress instead of cool and in control. And this student saw right through me.

It's not that I don't enjoy teaching.  I encourage any who want to spend some time in my office.  But the number of emails has decreased dramatically. 

And like this student, those who do show up once, often decline to return again.

Content Is The First Principal

I think we suffer from medium confusion. 

Twitter, Facebook, and blogs are just a medium.  They are not an end unto themselves but more a mere tool or amplifier.  Our digital footprint may be littered with pictures and pithy tweets, but what separates a key opinion leader from a follower is content.

Content is the first principal.  It is where intelligence, meets communication, and dances with relevance.  Content is the work product of our brilliance.  Without it, creation dies and curation flops about like a fish out of water.

In the new world order, communication relies on content amplified by medium to be curated, aggregated, and most importantly commented on.  Content begets content, tweet begets retweet, blog post begets civil discourse through dissenting blog post.

When we create and amplify garbage, we dilute the medium.  And here's the rub, the content by key opinion leaders becomes lost in a sea of excrement. The true content producer has but two options in this great arms race towards relevance, amplify louder or increase output.  Both of which ultimately lead to burnout.

And then the true drivers of change like Mike Sevilla bow out.  We've been all yelling so loud that our faces have turned blue.  We have one up'd ourselves into TED talks and book deals.  The stakes get greater, the amplifiers are turned up higher.

Instead of killing innovation, we need to embrace it.  We have created a social media behemoth.

The future of this important endeavor lies in better filters.

We need to learn to use them more liberally!

Is Social Media A Kingmaker? @drmikesevilla Take A Bow!

It's hard to believe that just seven hours earlier I had been watching Sting belt out Roxanne at Ravinia.  Relegated to lawn seats, I craned my neck around the entrance of the pavilion to catch a glimpse.  The large screens on either side of the stage reflected a solitary figure with guitar in hand.  He was in complete control.  The words came out almost effortlessly, but the sound and quality was unmistakable.  The crowd swayed back and forth, jumping up and down.  Thousands of hands raised, and voices sang along.  After all these years, he was still at the very top. 

This morning I crawled into the car at five AM to make the lonely trip to the hospital.  As I turned off my block and onto a larger street, I was again struck by a solitary figure.  He had a backpack, shorts, and a large brimmed hat.  He walked in the middle of the empty street, and as I passed I caught a glimpse of his face.  He was staring toward the sunrise with his hat in his hand, and a satisfied smile on his lips.

*

The healthcare social media community was stunned to find this week that one of our most respected and stalwart leaders has decided to sign off.  @drmikesevilla has made the personal decision to withdraw from social media.  In a series of raw posts on his blog this week, he enumerates the uncertainty and frustration many of us have felt over the years.  It does not serve to reiterate.  You can read his posts here. 

I feel a real connection to Mike Sevilla.  We started blogging at the exact same time in 2006.  I read some of his very first blog posts and he mine.  For years now, I have watched in envy and joy to see his meteoric rise.  In many ways, I often felt that my social media destiny was more akin to the lone journeyman on the empty road smiling quietly in the sun.  And yes, Mike was more like Sting, belting it out for crowds of adoring fans.

Only with time, have I realized that actually, we share in the fact that both of our paths have been littered with both very public and private moments.

We ask ourselves if we are relevant, we shout in the echo chamber, and then we wait for the ether to confirm or deny our deep held suspicions.

The mistake is expecting social media to be a kingmaker.

Mike, you were a king before you wrote your first blog post, and you will be one after you publish your last tweet.

Who knows the wondrous unheard melody that Sting cooed to his daughter as he rocked her to sleep.  Our lonely journeyman may enjoy the hustle and bustle of Time Square just as much as the little street I found him wandering on.

You touched us Mike, so take a bow.

We will be here when you return.  And if you don't,

That's OK too!

A Unified Voice

Many ask of our profession.

Are you knight or knave?

The supposition, that there exists a dichotomy of options for the current physician, is a false one.  Likely we are a little bit of both, and many shades in between.  The maddening belief that the future of our healthcare system depends on this delineation is preposterous.  I would more aptly characterize us as pawns. 

The time for change has come.

After patiently listening to my rants and raves, my readers are starting to wonder if I have any solutions for the problems I so frequently call to attention.  I have many thoughts, and a few suggestions for a path forward. 

Change, I fear, will only lead to debacle if left in the hands of politicians, economists, and administrators.  Our current state of misery stems from such loss of control.  We didn't enter this profession to care for the economy of a nation, we would much rather focus on the well being of each and every one of it's members.  Yet along with our brother and sister care providers, we are the primary driver and product of the system.  Without us, the health of this nation falls to it's knees. 

Whether knight, knave, or pawn, no soldier would enter battle without a strong suite of armour.  Yes, my fellow physicians, it's time we banded together to protect ourselves from the fall out of this massive system makeover.  This in no way changes our commitment to our patients. 

As conscientious physicians actively engaged in the care of our community, I see no way forward other then the en masse rejection of the following economically wastefull and time consuming entities:

ICD-10
CPT
Coding and Compliance
Meaningful Use
Face to face evaluations
HIPAA

By abolishing the above policies, billions of dollars of waste could be cleansed from the system.  Make billing easy and straight forward.  Each visit could be either low, moderate, or high complexity.  Submission should be in a centralized, simplified, form that should not require lavish amounts of time or billing professionals.  How much would medicare save if it didn't have to process so many million complex claims?

A universal electronic medical record that houses clinical notes, labs, and radiology is all that's necessary.  The bells and whistles add very little.  Don't make physicians slaves to big data by ensnaring them in an overly complex reporting system.

HIPAA is too complicated and costly, and needs to be converted to common sense privacy laws that aren't so dangerous and prohibitive.

I could go on, but these are a few common sense suggestions that would help the system greatly without detracting from clinical care.

Unfortunately, unless physicians learn how to use a unified voice, the likelihood for substantial change is minimal.

Picked To The Bone

My first instinct was to yell into the phone as loudly as possible.

Run away, run away while you still have time. 

But I suspected that the medical student on the the other side of the mobile would have been traumatized.  She was just trying to find an attending to shadow.  How was she supposed to know that at that exact moment the nursing home administrator had pulled out thousands of computer generated order sheets.  Each bearing my hand written signature but apparently now needed to be dated.  For ten years I had signed these documents without dating them.  But all the sudden some distant regulation had changed,  and I was on the hook.

Certainly annoying, but no big deal.  At least, no big deal unless taken in context of the rest of my day.  It started at 6AM with a phone call from the nursing home announcing a skin tear.

Sorry to wake you doc, we are following the wound care protocol, but its regulations, you know!

Then there was the discharge from the hospital.  After seeing the patient and documenting appropriately, a new litany of computer/paperwork: med-reconciliation, continuity of care form, discharge instructions, and a face to face eval.

The office was no better.  The papers on my desk had stacked up over the last twenty four hours.  I plowed through the hand written narcotic scripts, assisted living history and physical forms, duplicate death certificates, FMLA, and disability questionaires.  Of course, the power wheel chair application for my paraplegic patient was denied because I forgot to strike a pertinent negative from the review of systems.

All of this before seeing my first patient and contending with the futility of meaningful use and all those pointless clicks.

The primary care physician is being slowly picked to the bone.

Better to not say a word to the medical student. 

Let her shadow me.  The facts will speak for themselves. 

Another budding radiologist/dermatologist/allergist in the making.

The Fallacy Of Big Medicine

If you listen to the pundits, the future of medicine is big: big medicine, big data.  And indeed the healthcare policy of our nation is couched in the promise of what is to come.  Many dictates of the accountable care act focus on the ability to aggregate and consume a variety of inputs. ICD-10, EMRs, and meaningful use all tie nicely into a beautiful computational orgy. 

Big data, however, has it drawbacks.  One wonders if in usual fashion, politicians and pundits will do more harm then good.

Correlation and Causation

There is a hierarchy in medical data.  Every clinician knows that prospective, randomized, double blind studies are the gold standard.  The reason why, is that lesser models (retrospective and case study), often are only able to show correlation.  Time and time again, we find that clinical decisions based on correlation are faulty.  High homocysteine levels are associated with coronary artery disease but bringing them down with folic acid can be harmful.  Poor dental health may be related to cardiac disease, but good hygiene has little effect on the risk of heart attack.  In a world where the LDL and HDL hypotheses are quickly being disproven, one loses a taste for relying on such logic.

Yet, big data is clearly a correlational model.  One can only compare it to the weakest forms of evidence (case control, open label).  There is no ability to use it in a prospective randomized manner.

Poor studies lead to poor medicine. 

Period.

Garbage In, Garbage Out

I am not a big fan of meta-analysis.  The reason why, is often the bias of the investigator clouds the results.  If you want certain answers, you ask certain questions.  Inclusion criteria can be tricky and bend to the will of those crunching the numbers. 

Big data suffers from the same fundamental issues.  Who knows the political pressures that will be placed on scientists.  If you don't get the answer you want, maybe you have to ask the question differently, query the database more delicately. 

Anyone can produce results, but will they be meaningful.

Faulty Inputs

For years scientists have relied on death certificates to understand causes of death in America.  But as almost any signer of such documents knows, they are often completed in a hurried, haphazard way.  As a physician, I have no reason to care if the cause of death is correct.  Often, in fact, I don't even know the answer.  It's just another paper to fill out: cardiovascular collapse (whatever that means).  A grand majority of times when I review these documents as a medical expert, the cause of death on the certificate is inaccurate. 

Big data relies heavily on ICD-9 and CPT codes.  Providers often manipulate these codes, however, for a variety of reasons.  Want the venous doppler to be covered, say the patient has a DVT (of course you don't know yet because you haven't done the test).  Want the blood tests to be paid for by insurance, say the patient has fatigue.  The EMR doesn't have a code the suitably fits the situation, just use another, who cares if it's not accurate?

Most of the time these data inputs have no real meaning to the clinician and thus only receive a passing thought.  They are another hurdle to providing care, they are to be dispensed with as quickly as possible.

Keeping Our Eye On The Ball

The great task of big data is falling squarely on the shoulders of overburdened clinicians.

ICD-10, CPT, EMR, Meaningful Use, PQRI

Inputting all this data takes huge amounts of time, time that is being taken away from patient care.   Years of practice and training has formed clinicians who strive towards perfection.  These distractions destroy our attempts at mastery.

No one would think of asking the conductor of a symphony to also collect tickets at the front door in the middle of a performance. 

What is gained in knowledge with big data, is lost many times over in faulty, distracted, and poor face to face care.

In Conclusion

We are left with one basic question.

Do we want big medicine, or good medicine?

I'm not sure we can have both.