Comparative Effectiveness Research–The View from Wachter’s World

Bob Wachter discusses the challenges of implementing the comparative effectiveness research results we have in hand. From the perspective of leading physicians and frequent contacts with a diverse range of specialists and sub-specialists in my tertiary care providing community, teaching hospital I find myself nodding in agreement with Wachter's observations.

Everyone but the citizen's ox gets gored by comparative effectiveness research implementations. I use the term citizen advisedly, taking my cue from Obama; for some number of patients may well feel that they lose out as individuals, even as the polity benefits.

Tough implementation ahead with lots of squabbling before we're done accomplishing a fraction of the result the policymakers are seeking.

Customer-Consumer Confusion and now Patients, too

EP Monthly's "WhiteCoat's Call Room" posts two links and discusses "Patients or Customers"?

Patient, customer and consumer have specific meanings, not accurately used in the posts from Aggravated DocSurg and Detroit Receiving's EM Blog.While I'm in general agreement with many (not all) of the sentiments expressed in the two posts, it's important to get the correct meaning of the terms.

Customer= he who pays
Consumer= he who uses

The definitions are from Princeton Wordnet, but they're the same as what I was taught at Wharton 20+ years ago.

Part of our challenge in forming relationships in the ostensible business (good or service exchanged for value) is that for many users of physician services (i.e., patients) both the patient and physician experience customer-consumer confusion with consequent misalignment of incentives.

Patients will be increasingly demanding of receiving value in their care for value given directly (fee-for-service) or through employer and tax-based services. They will find the employers holding them accountable for "smart shopping" or the government steering in other ways–or both.

My father was a proud physician, he cared only for patients. Were I to view the world as he did, I would be struggling to feed my family. In this year of the 200th anniversary of Charles Darwin's birth, let's remember that it is not only individuals, but also entire species and perhaps professions for whom survival is not guaranteed; one must adapt or die.

Emergency Physicians “When in doubt, they image.”

Or so says Internist Robert Centor at DB’s Medical Rants. He then goes on to offer the predictable rationale of malpractice risk as the driver for this behavior. KevinMD weighs in and cites GruntDoc who advances the economic calculation which suggests there’s little benefit to attention to this phenomenon. A lengthy and continuing exchange of comments can be found on DB’s and GruntDoc’s sites.

At least some emergency physicians order the imaging we do because other physicians want us to do so. The ED has become the defacto “unfocused factory” where the emergency physician is expected to work up the patient to the point that the patient can be admitted to or referred to the specific focused factory for definitive care.

Today our hospitals and physician practices manifest a myriad of focused factories, the chest pain-ACS focused factory, the joint-replacement focused factory, the respiratory distress-COPD-CAP focused factory and I could go on at length. This is exactly what the specalist medical environment wants–indeed insists that the hospital deliver and we emergency physicians respond.

Furthermore, hospitals have come to realize that with approximately half of revenue generated by patients admitted through the ED it makes sense to concentrate resources on the workup of these patients. Thus hospital diagnostic, treatment and support services focus on ED patients–not the least because those patients arrive to the hospital 168 hours every week. Hospitals, including my own, have installed the most sophisticated 64-detector, dual-source CT-scanner in the ED so that we will use them to better define which of our patients require which specialized services.

When physicians stop pointing fingers and start accepting the reality of industrialization of our once professional, cottage practice we may be able to generate intelligent patient-centered alternatives to the financial policy driven managerial practices we presently experience.

Trust: In Healthcare and New Media

A Twitter friend turned me on to Julien Smith and Chris Brogan's Manifesto on Trust Economies. Which got me to thinking of an early morning exchange I had with a panelist at the Health 2.0 Conference in October 2008 in San Francisco.

The panel was a second presentation of the Edelman Report on Infoentials in Healthcare which was held early the second morning of the conference after the previous day's scheduled presentation was mobbed. I found the Edelman Report quite a cause for optimism, mostly because of the observation, that on-line information coupled to expertise scored significantly higher in confidence among infoentials than did on-line information alone. "The most credible source for health information is 'my doctor or healthcare professional' (96 percent)."

This observation on value added by the trusted physician provoked me to comment to the panelist that trust is multilayered and  begins when the parties involved: practitioner (or per Edelman a website or service) and patient/consumer find one another "trustworthy". Trust evolves as the parties experience one another and grows as this experience of trusting serves those involved.

Smith and Brogan's "Manifesto" makes the point explicitly and in rather utilitarian fashion. I've also been reading Robert Solomon & Fernando Flores, building trust in business, politics, relationships, and life since Kent Bottles of the Institute for Clinical Systems Improvement told me about.

I'm further prompted in these comments by Michael Millenson's comments on the Health Affairs Blog about Jay Katz. I loved Millenson's piece because with an experienced essayist's precision, Millenson lays out Katz's skepticism for the practice of medical research and medicine as he knew it in his era with its wholesale abrogation of physician trust for the patient.

Given that Katz in The Silent World of Doctor and Patient was writing during and about an era for which I still hold remnants of a romantic fantasy and confidence in the righteousness of those physicians I idolized either personally or by reputation, Millenson's essay both calls me to finally shed that fantasy and imbued me with the energy to complete this post.

In the practice of medicine, historically trust began with patient and physician finding one another "trustworthy." The sheepskin on the wall, the neighbor's recommendation and the practitioner's physical appearance ("like me" in physiognomy; "better than me" in habitus and often wealth) gave the patient reason to find the physician "trustworthy."

During the twentieh and now twenty-first century, the physician has been explicitly trained to suspend disbelief–presume the patient trustworthy. Certainly we practitioners have also learned to look beyond the bare bones narrative for what the tale may obscure or imply as much as what the patient's recounting discloses; still, the clear theme has been and continues, "The patient tells you the diagnosis if you'll but listen."

Out of this suspension of disbelief and presumption of trust, the physician and patient sought a caring and comforting relationship which in historical terms was about "Curing sometimes, relieving often and comforting always." Or as Francis Weld Peabody put it (J Clin Invest. 1927 December; 5(1): 1.b1–6.) "One of the essential qualities of the physician is interest in humanity, for the secret of the care of the patient is in caring for the patient."

Writing here as a physician trained in the 1970's and the son of a physician who was trained in the 1940's I'd like to fantasize that I still maintain a strong connection to that ethos and the trust that may be developed through "caring for the patient."

Though I lead and teach physicians as my life's work and I engage this issue every day with a hopeful mien; at my core I despair: Few physicians of my acquaintance approach each patient interaction with a suspension of disbelief and a presumption of a trustworthy patient. No, fortunately such suspicion is not universal, but it is widespread, particularly in my own field of emergency medicine. If my reading of general medical journals and many websites and blogs is to be believed, others see it as well. Perhaps you think I'm suffering from the "availability heuristic"?

There are many possible contributors to this state of affairs, perhaps the medical negligence environment contributes, regulatory structures around advising victims of domestic violence, the well-founded and appropriate concern for finding and reporting abused children–complete with a penalty for the physician who fails to do so–all contribute and create an inherent suspicion around many injured patients regardless of the compassion of the practitioner. I'm sure some will dispute these suggested contributors and perhaps you identify a more critical factor I've overlooked. Please add your comments below.

In short, there are environmental as well practitioner (and patient/consumer) contributors to trust deficiencies in healthcare today and in the absence of maintenance, entropy takes over and trust decays.

It certainly has done that in practice and it is unlikely that primary physicians in 15 minute encounter will rapidly rebuild it. A troubling conundrum indeed.

Year End 2008

Christmas photo final6

Hello from Brooklyn where as I write cookies are baking and
hens are laying. Last January we took our first ever family winter vacation to
warmer climes and spent 8 days in Turks and Caicos to general approval. This January,
the family winter vacation plan takes us all to Costa Rico with some friends
for the warmth and explorations. We’re still not certain what the summer of
2009 will bring for either Zoey or Masha. We’ll likely visit Grandma Claire on
LBI at some point; a trip to the North Fork of Long Island for one or more long
weekends is a certainty as we enjoy it a great deal; the pace is reminiscent of
LBI years ago and the food and local wine is wonderful.

 

SFM_SJD_HainesWedding_15112008_CIMG1264
We do look fabulous at
the Plaza Hotel for the wedding of one of my ex-residents and the daughter of
one of my friends. I’m claiming credit for the Shidduch as she met her now husband
when she rotated as a student in our ER and I assured my friend, her father,
that my resident would be a good addition to his family. At work, we opened
additional space in our ER last winter and the patients have come—we’re busier
than ever; still 23 minutes is the median waiting time to see a physician—56
minutes is the national average per USA
Today
(12/14/08).

 

This academic year, Masha is living at home with us and
taking courses at Hunter while planning her next steps. In June, Zoey now
majoring in Physics, computational techniques; moved out of the dorm and into
off-campus housing with five others. One of the guys set the stove alight at
4:00 AM one morning to no one’s delight. In June 2009 Zoey plans a move to
a different house with a smaller group of closer friends so mishaps are less
likely—we all hope.

 

Simone’s farm has seven hens, down three thanks to our cat Chad’s
efforts at thinning the flock of chicks in late spring. Simone again served as
a site coordinator with the Cobble Hill Community Supported Agriculture program
that supports local farmers and supplies us with fresh produce. She continues the
Brooklyn branch of the German Shepherd Dog Rescue, just celebrating its tenth
anniversary, that she helped establish when we were in Philadelphia

 

Three of Simone’s seven chickens are laying and we’ve
enjoyed the eggs and given others as gifts. Ethel, the Buff Orffington held by
Zoey in the photo on the card was the first and still champion layer. Our old GSD
Hillary still hangs on at age 13 and somewhat more than 10 years with us. She’s
been joined by Leo, a terrier mix in sheep’s clothing rescued from a local
shelter.

 

We’re fortunate that our mothers remain active and mostly
well though not without some of the challenges of great age. These family
tidings remind me of friends who are struggling with their health and life
itself. I hope you are taking care of yourselves and enjoying the world around
you. We would love to host your visit to New York in 2009.

Just Recertified–Am I competent, good, outstanding . . . or not so much? Bob Wachter wants to know.

In a year-old post on The Health 2.0 Blog Bob Wachter points to the activities of commercial ventures including Healthgrades, Zagat and Google to begin rating doctors right along with your favorite city magazine. As is typical for his straightforward style, Dr. Wachter puts himself in the position of seeking information for his own care and concludes that he wants all the differentiating information he can get–including Board Certification ranking of some sort. He would prefer a doctor who scored at the 87th percentile to a doctor who scored at the 5th percentile. That sounds like it makes sense–doesn’t it? Seems pretty sensible–a lot of face validity in that opinion–don’t you think so, too?

Not so fast; I’m not so sure it works out so well for all doctors.

In the post Dr. Wachter discusses a presentation by Dr. Kevin Weiss, the president of the American Board of Medical Specialties made to the American Board of Internal Medicine (ABIM). Bob Wachter also reveals that he serves on the ABIM and Google’s Healthcare Advisory Board; I served for nine years on the American Board of Emergency Medicine (ABEM) and I still read the periodic newsletters from the Executive Director there–I have some idea of what’s going on in my own specialty certifying process. I also took and passed my recertification exam this year.

Our board, ABEM, uses criterion referenced examinations rather than norm referenced examinations. I’m not certain our specialty is still alone in that distinction, but at one time we were. While I’m not a psychometrician and I don’t play one on TV, either, I’ve come to understand that our exam is pretty good at distinguishing a doctor who know 74% of the tested material from a doctor who knows 75% of the tested material. The latter will pass; the former will not. As I understand the nature of the exam and the scoring, while it is fair to say that the doctor who knows 100% of the tested material certainly knows more than the doctor who knows 75% of the test material, it’s not at all clear that one knows a third more than the other or that the test can tell that the doctor at 100% knows more than a doctor scoring at 90%; it becomes even less certain as the differences become smaller; consequently, the American Board of Emergency Medicine probably can’t put its diplomates on a percentile scale as Dr. Wachter suggests may be appropriate, at least probably not based on the testing approach in use today. Not to say that the testing couldn’t be changed at some future time.

So Dr. Wachter’s smell test notwithstanding and the people’s desire for physician ratings very much still in evidence, it’s not at all clear to me that the route to the goal is as direct as Dr. Wachter suggests.

Greater transparency in support of better decision-making for patients is a desirable, laudable goal. Reliable physician ratings is probably not coming soon, though city magazines, HealthGrades, Zagat and Google are either already or shortly to begin publishing their own ratings–user beware.

Primary Care Backlash Unfortunately begins with an Emergency Physician

I’m saddened to learn of Jonathan Glauser’s column in the December 2008 Emergency Medicine News from KevinMD. He notes, “With the primary care shortage starting to gain traction within the mainstream media narrative, it’s inevitable that some will lash back against generalists. (via Bob Doherty)”

Jonathan’s a very smart guy and I don’t doubt the experience that underlies the conclusions he’s drawn and the recommendations he’s making in his column, yet, he’s missing the bigger picture and as Bob Doherty’s blog and associated comments demonstrate the data support investment in primary care–not disinvestment. I regret that I can’t support your view, Jon.

Daschle: What Can We Expect Of The Health Czar In Waiting?

Jeff Goldsmith in this Health Affairs blog entry summarizes what we might look forward to in the New Year. I found his pointer to the McKinsey study useful since I’ve been uneasy for years in my support of PNHP’s view of the source of savings in single payer healthcare. Goldsmith’s three key ingredients for a health policy book by a Democrat seems on point:

1–Personal interest horror stories;
2–Debunking of Himmelstein/Woolhandler/PNHP assertion on 31% of health costs due to "administration". (See the McKinsey Global Institute’s 2007 “Accounting for the Cost of Healthcare in the United States” for a more rigorous analysis);
3–Mention of the WHO study ranking the USA 37th in the world in health care.

The piece goes on to discuss the Federal Health Board and why it might work and what political barriers to implementation it could face. I’ve been fascinated for years by the hesitancy to adopt a technocratic approach to the underlying issues of coverage and benefit–the diseases and technology to treat them are arcane. Perhaps at this moment the body politic suffers from sufficient fear of the complexity and of the financial abyss confronting employer paid healthcare so that rationalization whose goal might be improving upon "the failure of the intermediation system to provide sufficient incentives to patients and consumers to be value-conscious in their demand decisions, and establish the necessary incentives or mandates to promote rational supply by provider and other suppliers." (McKinsey Report cited above).

Ah, "incentives or mandates . . . ". Physician, heal thyself.

Hospital Marketing in the Web 2.0 World

So what does this book have to do with hospitals–aside from the title of this post?

I learned of this book because I read Robert Scoble through the RSS feed of his blog and just recently, Scoble interviewed Kawasaki in an 18 minute video. Guy Kawasaki argues the reality of marketing in the era of social media. He makes the audacious assertion that, "Twitter is the most powerful branding mechanism since television." yet this assertion receives independent affirmation in the unrelated efforts of Paul Levy, CEO of Beth Israel Deaconess Medical Center (BIDMC) Boston who in his activity on twitter @paulflevy and in his blog is successfully marketing his hospital through the social web. My hospital’s medical director regularly reads this blog.

Most hospital administrations look at their local market–primary and secondary geographic market areas, usually defined by zip codes. To most administrators Boston wouldn’t be relevant to our hospital’s market in Brooklyn–today they’re right–it’s not. Marketing hospitals today is mostly not far removed from how I learned it in my MBA program in 1988. Yet I believe Kawasaki would argue that the social media Web 2.0 tools are awaiting deployment in Brooklyn. Ten postings on Yelp review my hospital, Maimonides Medical Center and nearby NY Methodist‘s ED was discussed on a community bulletin board.

Kawasaki tells us that if we don’t get out there and brand ourselves–others, typically our most vociferous and perhaps disgruntled patient-customers will and are doing it for us.

In Brooklyn we’re not competing with Paul Levy and BIDMC which is why we can learn so much from what he’s doing; we’re competing with our communities to own our brand and to define ourselves in the marketplace. The Web 2.0 social media tools are the way to go and Twitter is a great way to start; Facebook is not just for your college student. Define yourself, don’t leave it to others to do it for your. See you on the social web. @sjdmd

Engage with Grace

Theoneslide

Engage with Grace is a project I learned about a month ago at the Health 2.0 Conference. Alexandra Drane presented the very personal story of her sister-in-law’s death, at home and in direct opposition to the recommendations of her physicians. About 1000 people in the room and you could hear a pin drop–except for occasional sobs–mine included.

—-
Several dozen bloggers in the health care field and beyond are engaged in a blog rally* this weekend, simultaneously posting the one slide and Alexandra Drane’s post to
encourage conversation about a topic that’s often avoided but every family ought be discussing: How we want to die.
Please try it, using the slide above as a discussion guide. It’s not
that hard to have the conversation with your loved ones once you get
started.


We make choices throughout our lives – where
we want to live, what types of activities will fill our days, with whom
we spend our time. These choices are often a balance between our
desires and our means, but at the end of the day, they are decisions
made with intent. But when it comes to how we want to be treated at the
end our lives, often we don’t express our intent or tell our loved ones
about it. This has real consequences. 73% of Americans would
prefer to die at home, but up to 50% die in hospital. More than 80% of
Californians say their loved ones “know exactly” or have a “good idea”
of what their wishes would be if they were in a persistent coma, but
only 50% say they’ve talked to them about their preferences.But
our end of life experiences are about a lot more than statistics.
They’re about all of us. So the first thing we need to do is start
talking. Engage With Grace: The One Slide Project
was designed with one simple goal: to help get the conversation about
end of life experience started. The idea is simple: Create a tool to
help get people talking. One Slide, with just five questions on it.
Five questions designed to help get us talking with each other, with
our loved ones, about our preferences. And we’re asking people to share
this One Slide – wherever and whenever they can…at a presentation, at
dinner, at their book club. Just One Slide, just five questions. Lets start a global discussion that, until now, most of us haven’t had.Here is what we are asking you: Download The One Slide
(that’s it above) and share it at any opportunity – with colleagues,
family, friends. Think of the slide as currency and donate just two
minutes whenever you can. Commit to being able to answer these five
questions about end of life experience for yourself, and for your loved
ones. Then commit to helping others do the same. Get this conversation
started. Let’s start a viral movement driven by the change we
as individuals can effect…and the incredibly positive impact we could
have collectively. Help ensure that all of us – and the people we care
for – can end our lives in the same purposeful way we live them. Just One Slide, just one goal. Think of the enormous difference we can make together.
(To learn more please go to www.engagewithgrace.org. This post was written by Alexandra Drane and the Engage With Grace team.)


* In case you are wondering, "blog rally" is a term invented this past weekend
.
A blog rally is the simultaneous presentation of identical or similar
material on numerous blogs, for the purpose of engaging large numbers
of readers and/or persuading them to adopt a certain position or take a
certain action. The simultaneous natu re of a blog rally creates the
ironic result of joining the efforts of otherwise independent bloggers
for an agreed-upon purpose. As far as we can tell, this is the first
recorded use of a blog rally — occurring from November 26 through
November 30, 2008, in support of a viral movement called ‘Engage with
Grace: The One Slide Project’ — organized to encourage families to
discuss end-of-life care issues while gathered together for the
Thanksgiving holiday weekend. This particular blog rally also has a
parallel component on Facebook, where many people are donating their
status to bring attention to Engage with Grace.


—-
I must credit Paul Levy, President and CEO of Beth Israel Deaconess Medical Center in Boston whose blog, Running a Hospital is where I learned of the weekend "blog rally". Levy is also on Twitter as PaulFLevy.