Throw Dr. Kildare from the Train


In the last couple of years, I have seen a substantially increased number of retirements among local physicians, including both senior core academic medical faculty at Yale and `private community` clinicians. Many more of my medical friends and colleagues have told me that they plan to retire shortly, even though until fairly recently, they had no intention of doing so. Some of this is in part a result of the switch from paper records to EHRs, some the loss of face-time with patients, some the loss of revenue, and for many, the loss of continuity of care, of being a meaningful part of their patients’ lives. But probably the biggest catalyst for docs to leave the profession has been the profound recent change in the balance of power and authority within nearly all hospitals. The evolution from a medical-centric to an administrative and business-centric environment has rocketed, with little sign of slowing down. The skill-sets to advance in the current environment are organizational acumen and administrative facility, with medical skills of greatly diminished utility and stature. These shifts have been accompanied by a remarkable migration towards incessant bureaucracy, and especially, by a hard push to meet `productivity goals` that are little more than a volume measurement. We receive a seemingly endless flow of changing mandates, protocols and departmental standards as to how now to practice medicine and how to precisely record our proceedings, spelled out down to the finest minutiae. Naturally, there are the required companion meetings in which the changes are presented, so that compliance is ensured. Enthusiasm for and adherence to this brave new world is increasingly rewarded in hiring and promotion criteria and decisions. In a nutshell, the MD as MBA has risen, at the expense of the MD as MD. And Meaningful Use dollars have become `the Precious`, all-consuming and absolute, Tolkien’s (or Wagner’s) ring, the possession of which ultimately drives nearly all decisions, to the goals of wealth and market dominance.

The collateral damage here is that many of my esteemed (and in my judgment, nearly irreplaceable) colleagues are being treated as commodities or clerks by the hospital staff. I have heard numerous stories of now-salaried physicians being required to see many more patients daily than were their norms for many years, in fact sometimes double the previous volume. What if the numbers were not met? In a number of instances, administrators informed the doctors that there would be either a financial penalty or a cutback in vacation time. And this sometimes was willfully blind to complications or special circumstances that required immediate extra attention, at least by any humane and self-respecting doctor. Some of the physicians involved have been fully autonomous and remarkably productive for four or more decades, and are regarded as among the top specialists in their fields nationally. I can only sympathize with their decision not to put up with such superficial and inflexible edicts anymore, without any available recourse. Yet in an age in which quarterly earning reports drive the business model, within the Medicine as Hospital as Business complex, the ongoing evolution seems ominous, at least within the system. Part of the modern Hippocratic Oath is `I will remember that there is art to medicine as well as science, and that warmth, sympathy, and understanding may outweigh the surgeon’s knife or the chemist’s drug.` Where on earth has this gone to?

Dr. Abigail Zuger, an infectious disease specialist in New York City, has written a series of compelling articles in the New York Times in the last two years on a steady and dispiriting beatdown by EHRs. In the aptly titled  `Quantifying Tests, Instead of Good Care`, she described a typical work afternoon spent “doing little but ordering tests, far more than I honestly thought any patient needed.” Unfortunately, since she will be evaluated (and probably reimbursed) primarily on the basis of her test-ordering behavior and patients’ results, she has little choice in the matter. At first blush, at least the results part of the equation sounded fair. Sadly, yet hardly surprisingly, she wrote a recent follow-up article, in which patients’ results are measured on the basis of simplistic metrics that can be used to easily confirm `continuous quality improvement`. In her H.I.V. clinic, a report card was determined simply by the percentage of patients who achieved a benchmark `undetectable level` of the H.I.V. viral load. Her first report card grade was pretty good, hardly great, and was accompanied by a list of her failures by name “and a few generic suggestions for improvement.” But most interesting to me was Zuger’s descriptions of several of her failures, including a representative `Patient A`. Patient A was graded as a big failure, with 11,000 copies of H.I.V. RNA per milliliter of blood. Yet, he came in as a sad loner who trusted nobody, and thrived with her help. His viral load had plunged from several million to 11,000. He had gained 20 pounds, and had rejoined society enough to start to see a dentist. Dr. Zuger considered Patient A as one of her big recent successes, and so would the vast majority of other docs. This grade of failure does not come close to passing the `smell` test.

I have absolutely no problem with performance reviews, which have long been standard not only in the business world, but also are integral in determining promotion to partnership within medical and legal practices. Indeed, some form of merit-based performance evaluation dates to the Roman Empire, which somewhat predates our modern computers. However, if the reviews are based on superficial and often spurious criteria such as Dr. Zuger describes, we will witness some perverse responses. I can foresee two likely outcomes from this type of grading, especially if it actually translates to behavior towards attending physicians and/or salary penalties. First, some of the most mobile (and best) staff will leave. Second, this approach provides strong incentives for hospitals and physicians to skew (`cherry pick`) patient selection, and to select treatment regimens that best achieve a short-term measurement. And again, notice that the quality of the patient’s life is nowhere in sight in these calculations. H. Gilbert Welch, Professor of Medicine at Dartmouth, writes in his recent book Less Medicine, More Health, that in medicine, “true quality is extremely hard to measure.” “What is easy to measure is whether doctors do things.” Although deciding not to do things may generate nothing transparent (or billable), the attentive pass is often the most appropriate, highest quality care.

In a recent Sunday `Week in Review` Op-Ed piece in the New York Times, Theresa Brown elegantly stated “Computer documentation in health care is notoriously inefficient and unwieldy, but an even more serious problem is that it has morphed into more than an account of our work; it has replaced the work itself. Our charting, rather than our care, is increasingly what we are evaluated on.” Although Ms. Brown was describing how nursing jobs have evolved in the age of EHRs, this essential observation equally applies to the jobs of most doctors within larger integrated hospital systems. And so long as health care reimbursements are primarily tied to documentation alone, rather than to actual care, this skew towards the increased importance of administrators and coders, away from doctors and nurses, will only accelerate.

As I wrote above, the Affordable Care Act provided strong financial incentives for hospitals to buy up local medical practices. The central premise was to reduce the high aggregate national medical costs while delivering improved quality medicine. The driver behind this is the recognition that larger, integrated hospital systems can often spend less money on Medicare, by avoiding redundant treatments, and offering a full suite of medical care synergistically. But a study published in December 2015 by the National Bureau of Economic Research casts doubt on the expectation that overall national medical costs will fall as a result of these integrations. The research looked both at Medicare and also at a very large new database drawn from private insurance plans. And it showed that there was very little correlation between total spending on Medicare and spending on the privately insured. In particular, the new findings cast serious doubt on the wisdom of encouraging systematic purchases of local practices and mergers among hospitals. The critical finding was that the merged systems tend to set substantially higher prices in private markets, which often more than offset any savings gained on the Medicare side of the ledger sheet. For instance, the authors found that rates were 15.3 percent higher, on average, in areas with just one hospital, compared to those served by four or more. As Zack Cooper, an assistant professor of health policy at Yale University, and the paper’s lead author concluded, the merged systems could charge these elevated prices because they now faced little or no local competition – they now could exhibit monopolistic practice from a position of enhanced market power.

Unfortunately, where does this leave the physicians whose practices have already been bought by hospitals? It would be very difficult to put the genie back into the bottle, as it were, to undo the changes to patient care protocols already rendered within now agglomerated practices. However, the administration can reverse many of the financial incentives that have pushed private practices into hospital mega-systems, and perhaps even provide incentives to preserve some private practices as independent entities, for those practices that have yet to forfeit their autonomy. This could serve to forestall some of the quasi-monopolistic behavior on the part of large hospital systems, while providing patients with more of a choice in the style of medical care that they wish to receive.