Interview on “The Price of Business”

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A couple of weeks ago I was interviewed by Kevin Price on his radio show “The Price of Business” which runs on Houston’s 1110 AM KTEK radio station.  Also present was Dr. Geetinder Goyal.  We talked healthcare economics, free markets, and direct patient care.  I hope you enjoy it.

Good medicine starts with friendship

Advice from the ancients

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Whenever I have the opportunity to suggest that good medicine is based on friendship, I usually get a nod of approval mixed with a quizzical look.  What’s that supposed to mean?!

At a recent meeting of an editorial board on which I serve,  the reaction to my suggestion was more forceful and perhaps more honest.  The topic of the day concerned patient education, and how hard it can be to move patients to do things like exercise more or eat better.  I timidly proposed that, as physicians, we might want to start by being our patients’ friends.  The physician sitting next to me immediately objected: “I wouldn’t go that far!”

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How to safeguard your career in a treacherous healthcare environment.

Economics, ethics, and philosophy for medical students

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the following post is a slightly edited version of an article kindly commissioned by In-Training,  a website run by and for medical students. The advice I give in the article is based on lessons I learned long after finishing medical school, so I hope you will find this piece of interest, even if you are well established in your healthcare profession.

Dear medical student,

I am honored by the opportunity to offer some advice on how to safeguard your professional career in a treacherous healthcare system.

I will not elaborate on why I think the healthcare system is “treacherous.”  I will assume—and even hope—that you have at least some inkling that things are not so rosy in the world of medicine.

I am also not going to give any actual advice.  I’m a fan of Socrates, so I believe that it is more constructive to challenge you with pointed questions.  The real advice will come to you naturally as you proceed to answer these questions for yourself.  I will, however, direct you to some resources to aid you in your reflections.

I have grouped the questions into three categories of knowledge which I am sure are not covered or barely covered in your curriculum: economics, ethics, and philosophy of medicine.

I have found that reflecting on these questions has been essential to give me a sense of control over my career.  I hope that you, in turn, will find them intriguing and worth investigating.

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How doctors became subcontractors

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

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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.

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Neither expert nor businessman: the physician as friend.

Arguments against the outcomes movement

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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!

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Five hopeful trends in medicine and healthcare

Enough with the gloom and doom!

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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:

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Phronesis

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

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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.”

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From DPC to CPC – part 2

A cardiologist is humbled

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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.

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From DPC to CPC – part 1

An extraordinary case in a direct primary care setting

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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. 

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Feel-good medicine: yesterday and today

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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.

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