How doctors became subcontractors

In our healthcare system, the "middleman" is not who you think

Share with your friends










Submit

During my recent podcast interview with Jeff Deist, president of the Ludwig von Mises Institute, I remarked that third-party payers are not, in fact, intermediaries between doctors and patients.  In reality, it is the physician who has become a “middleman” in the healthcare transaction or, as I argued, a subcontractor to the insurer.

Important as it is, this reality is not well recognized—not even by physicians—because when doctors took on this “role” in the late 1980s, the process by which healthcare business was conducted did not seem to change in any visible way.

Continue Reading »

Neither expert nor businessman: the physician as friend.

Arguments against the outcomes movement

Share with your friends










Submit

In a recent Harvard Business Review article, authors Erin Sullivan and Andy Ellner take a stand against the “outcomes theory of value,” advanced by such economists as Michael Porter and Robert Kaplan who believe that in order to “properly manage value, both outcomes and cost must be measured at the patient level.”

In contrast, Sullivan and Ellner point out that medical care is first of all a matter of relationships:

With over 50% of primary care providers believing that efforts to measure quality-related outcomes actually make quality worse, it seems there may be something missing from the equation. Relationships may be the key…Kurt Stange, an expert in family medicine and health systems, calls relationships “the antidote to an increasingly fragmented and depersonalized health care system.”

In their article, Sullivan and Ellner describe three success stories of practice models where an emphasis on relationships led to better care.

But in describing these successes, do the authors undermine their own argument?  For in order to identify the quality of the care provided, they point to improvements in patient satisfaction surveys in one case, decreased rates of readmission in another, and fewer ER visits and hospitalizations in the third.  In other words…outcomes!

Continue Reading »

Five hopeful trends in medicine and healthcare

Enough with the gloom and doom!

Share with your friends










Submit

I feel that I have been spending way too much time as a “chronicler of the decline,” to use von Mises phrase.  The secular trend in healthcare (literally spanning the last 100 years) is one of increasing centralization, consolidation, and reduced choice.  Nevertheless, there are some promising developments that gives me hope for a better  future.

Here are five notable trends, in no particular order:

Continue Reading »

Phronesis

5 must-read articles about what good medical decisions are all about

Share with your friends










Submit

I told you before that I would do my best to avoid bringing up phronesis, but a superb essay by Lisa Rosenbaum, national correspondent at the New England Journal of Medicine, is forcing my hand.

In “The Paternalism Preference — Choosing Unshared Decision Making,”  Rosenbaum calls into question the gradual shifting of the burden of decision-making onto patients in the name of informed consent and autonomy.

The essay begins by examining the issue from the patient’s perspective, but Rosenbaum’s reflection then turns to the role of the physician.  She remarks:

But science cannot answer a question at the core of our professional identities: As information-empowered patients assume greater responsibility for choices, do we assume less?

The answer to that question has to do with our understanding of what constitutes good medical decision-making.  Clearly, the prevailing notion assumes that good medical decisions come after a rational approximation of an objective biological reality, a “predictive analysis” that forms the core of “evidence-based medicine.”

Continue Reading »

From DPC to CPC – part 2

A cardiologist is humbled

Share with your friends










Submit

To summarize W’s case up to March 17, here were the salient features:

  • Baseline signs of conduction system disease
  • Progressive, and now severe, dyspnea on exertion
  • Unexplained relative hypotension, not due to adrenal insufficiency
  • Weight loss and early satiety
  • Hypercalcemia, initially mild, now more pronounced, with suppression of PTH
  • Markedly active urinary sediment with severe dipstick proteinuria, but also microscopic hematuria and calcium oxalate stones
  • Worsening renal function, possibly pre-renal azotemia.

The 50-mile distance separating W from my office made frequent visits impractical, but from March 17 onward I was essentially on daily contact with the patient either by phone or email.

I could not tie everything together, but the thought occurred to me that he might have systemic sarcoidosis with cardiac involvement: hypercalcemia, heart block, shortness of breath, gastrointestinal symptoms.  In fact, I was clearly hoping for this diagnosis as something potentially treatable in what otherwise looked like an ominous illness.

On March 19, however, a 2-view chest x-ray was normal and the light bulb that had gone off in my head a few days before was quickly burnt.

Continue Reading »

From DPC to CPC – part 1

An extraordinary case in a direct primary care setting

Share with your friends










Submit

A couple of years ago, as I was trying to determine the best business model for my practice, I offered direct primary care (DPC) services to a few patients.  Among them was WW, a then 57-year-old man who was well when I first saw him, but who ended up dying a year later in a very sad and dramatic way from a rare condition.

The extraordinary illness that struck W is worth describing simply on account of its rarity and its highly unusual manifestations.  But in addition, it occurred to me that my experience with W may be of particular interest to the growing number of physicians and health care professionals intrigued by, or involved in, DPC as a practice model.  This case exemplified the challenges and rewards of taking care of people with no insurance and with limited financial means.

I hope you will find this “clinico-pathological conference” to be of value.  Although W’s ultimate outcome would likely have been the same under any circumstance, I’m sure his clinical course may have been tackled differently by another doctor. 

Continue Reading »

Feel-good medicine: yesterday and today

Share with your friends










Submit
I’m on summer break but I thought you might enjoy this piece, published a year ago in the August 2014 issue of the Nob Hill Gazette.  The version below is slightly edited compared to the original.

In their recent book titled, Dr. Feelgood: The Shocking Story of the Doctor Who May Have Changed History by Treating and Drugging JFK, Marilyn, Elvis, and Other Prominent Figures, Richard Lertzman and William Birnes chronicle the startling career of Max Jacobson, a physician who specialized for decades in treating celebrities with his personally concocted injections of vitamins, human gland extracts, and high doses of amphetamines.

Operating from a filthy office in Manhattan, Jacobson showed no regard for basic medical hygiene and never obtained a basic medical history from his patients. Yet, over the years, he dispensed untold quantities of his “cocktails” to political and show business superstars suffering from fatigue, pain, or lack of stamina. For some of his patients, such as Cecil B. DeMille, the German-born doctor was a paragon of modern medicine. But others saw their careers and personal lives ruined as they became addicted to the treatments, and a few might have actually died as a result of it. The authors of the book relate instances where, under the influence of Jacobson’s amphetamines, President Kennedy’s behavior became wildly erratic. They even speculate that a motive for his assassination might have ensued.

Max Jacobson’s story might seem like a sordidly entertaining tale from a bygone era. Nevertheless, given our current love affair with medications (one in five adult Americans takes a psychiatric drug, and 70 percent of the U.S. population takes some form of chronic prescription medication), it behooves us to reflect on the professional and ethical failings of Jacobson’s practice to help keep our way of “better living through pharmaceuticals” within healthy boundaries.

Continue Reading »

How experts really decide

(Hint: they don't follow guidelines)

Share with your friends










Submit

I opened my last post with a question I never came around to really answer: How should doctors make decisions?

That wasn’t an oversight.  To try to provide an answer seemed daunting, plus I wouldn’t have resisted the urge to wax philosophical about praxeology or phronesis.  And how sexy is that?  Surely my Alexa ranking would have suffered!

Perhaps sensing my predicament, Dr. Saurabh Jha tactfully suggested a book which I have since ordered and read.  (And what a great call that was.  Thank you, @RogueRad!)  The book is Streetlights and Shadows: Searching for the Keys to Adaptive Decision Making by Gary Klein.

According to his Wikipedia entry, Klein is a cognitive psychologist credited with pioneering the field of naturalistic decision-making, a research endeavor where people’s decisions are examined in real life setting, not under contrived laboratory experiments.

The book, published in 2011 by The MIT Press, summarizes the fruits of his research.  It’s a captivating work.

Continue Reading »

Make decisions, not calculations

How should doctors deal with uncertainty?

Share with your friends










Submit

How should doctors make decisions?

In the last post, we reviewed the conceptual difficulty of applying risk estimates derived from population studies to individuals, and I proposed that medical decisions should NOT be modeled on the following scheme:

  • Step 1: weigh the probability of future pluses and minuses.
  • Step 2: make a decision on the basis of “probability of pluses > probability of minuses.”

Yet that scheme implicitly serves as a rationale for pay-for-performance measures and justifies legal impositions on the content of informed consent procedures (e.g., precise disclosure of risks, probability of benefit, risks of alternative treatments, etc.).

Today, I will add a some perspectives that I think buttress my case.

Disclaimer:   This discussion is not meant to entice you to violate the standard of care, to forego the established procedures for informed consent, to incite you into civil disobedience, or to put your medical license at risk!

Let’s start with two anecdotes:

A few years ago, the New York Times detailed the extraordinary story of Michael DeBakey’s aortic repair operation.

Continue Reading »

Risky decisions

Pay-for-performance, shared decisions, and the science of risk

Share with your friends










Submit

I had a sort of epiphany about risk and medical decision-making last Thursday evening, even though I was particularly tired and in a state of mental fog.

I had been thinking about two recent articles dealing with risk prediction, but I also was preoccupied with risky career decisions I have made, and how these are affecting me and my family (I am pursuing a quixotic version of the “triple threat:” independent physician, apprentice schoolman, blogger).  So risk was very much on my mind.

One of the articles I had read was a recent viewpoint in JAMA by Allan Sniderman, Ralph d’Agostino, and Michael Pencina titled “The role of the physician in the era of predictive analytics.”  The other was a response to that article written by Bill Gardner at the Incidental Economist blog.

In their paper, Sniderman et al. discuss an important difficulty in the medical science of risk prediction.  The difficulty is apparent when one contrasts the notion of population risk with the notion of individual risk.

Continue Reading »