A Stranger in this World

Redefining Value: A Critique of "Value-Driven Health Care"

Sun, 05 Feb 2012 16:52:00 -0500

Everyone in the world is talking about “value-driven health care.” Or so it might seem if you pick up a medical journal or attend a lecture about health care here in Boston. “Maximizing value for patients” is on the tip of every administrator’s tongue and an interest in cost containment is de rigueur for young physicians who aspire to leadership positions in medicine. For those of us who are intimate with the deep dysfunction of our health care system, improving the quality of care is an imperative. And the realization that health care spending robs from public education and burdens American business makes reducing the cost of health care a top priority across the political spectrum. An approach that allows the pursuit of both of these goals—quality improvement and cost containment—seems ideal and, not surprisingly, has gained broad appeal. So why be concerned about value-driven health care? Let’s start with a little background.

The principle proponent of value-driven health care has been Michael Porter at Harvard Business School. In a number of articles and his 2006 book, Redefining Health Care: Creating Value-Based Competition on Results, Porter lays out the foundational arguments for value-driven care. Neither increasing quality nor controlling costs, he argues, are satisfactory aims for health care organizations. Instead he argues for competition based on value, which he defines as “the health outcome per dollar of cost expended.” Drawing extensively on principles of Lean production, Porter says that value must be measured in terms of the patient’s medical needs over the “entire spectrum of care.” Expenditures that do not contribute to creating value for the patient should be eliminated and efficiency in delivering high quality care should be prized. It has proven to be a persuasive argument. In fact, these principles are underpinning huge changes in the health care system, with tenets of value-driven care having been incorporated into the Affordable Care Act. Accountable Care Organizations are an outgrowth of Porter’s philosophy—their goal will be to provide value for patients over long periods of time in all of the settings where care happens.

Despite all of the excitement about value-driven care, there is a remarkable lack of clarity about what “value” means in this context. Moreover, though providing better outcomes at lower costs may be a noble goal for a health care organization, a system organized around competition to achieve this objective is not functional in a market-based health care economy.

First to the question of defining “value,” a topic that has long been the subject of anthropological thought. David Graeber, in his book, Toward an Anthropological Theory of Value, highlights three way that value has traditionally been discussed in social theory:

1. “values” in the sociological sense: conceptions of what is ultimately good, proper and desirable in human life

2. “value” in the economic sense: the degree to which objects are desired, particularly, as measured by how much others are willing to give up to get them

3. “value” in the linguistic sense, which…might be most simply glossed as “meaningful difference”

Porter’s conception of value in health care is probably most consistent with the first definition. He is arguing that quality, efficiency and low cost are “good, proper and desirable” aspects of a health care system. If Porter’s argument is an attempt to define the values that should be at the core of our healthcare system, it is fair to take a closer look at what he thinks those values should be. He sets them out in a 2010 New England Journal of Medicine piece entitle, “What is Value in Health Care?” The answer is encapsulated in a three-tiered hierarchy,

in which the top tier is generally the most important and lower-tier outcomes involve a progression of results contingent on success at the higher tiers. Each tier of the framework contains two levels, each involving one or more distinct outcome dimensions. For each dimension, success is measured with the use of one or more specific metrics.

It’s a bit esoteric. In short, Tier 1 represents health status gained or retained as a result of medical care. Tier 2 outcomes relate to the recovery process. Tier 3 outcomes represent the sustainability of health. Examples of how this applies to specific disease conditions can be seen in the figure below. For breast cancer, outcome measures include survival rate, breast preservation, functional status, time to remission and incidence of brachial plexopathy. One can imagine that for diabetes, outcome measures might include mortality, hemoglobin A1c levels, incidence of blindness, amputation rates and so on. This radical reorientation of care toward patient outcomes is refreshing in health care, where factors like physician workflow and the financial interests of provider and payor organizations have more typically been the organizing principles. But how will we decide what is valuable for the patient? Choosing what weight to assign to the numerous indicators that Porter mentions alone would be daunting. What of those that he hasn’t even thought about?

Porter’s conception of value is decidedly focused on the intensive management of illness. Measures of a patient’s emotional well-being, for example, are absent from his framework. So are thousands of other factors that might contribute to a patient’s sense that her medical care has been “good, proper and desirable.” Personally, I value receiving medical care close to my home and from a person I know and trust. Features as diverse as the availability of interpreters, the delivery of culturally responsive care, a family tradition of seeking care at a particular hospital, the appearance of the physical plant, the amount of a patient’s copay or a hospital affiliation with a medical school can all contribute to a patient’s sense of value in their health care. It’s probably obvious that there is no metric for kindness in Porter’s scheme. One can’t help but wonder, will the pursuit of “value” make us proficient at delivering a certain set of outcomes but leave us blind to the more human needs of our patients?

We should also be aware that Porter’s framework alters the tenor of the relationship between health care providers and their patients. As health delivery organizations are rewarded financially for meeting outcome markers, pressure will grow to reach further into patients’ lives. For many patients this will be helpful. But for those who place high value on activities that are in conflict with the goals of the health care system, their autonomy may be at risk. Imagine the patient who wants to eat unhealthy foods, for reasons of pleasure or culture, despite having diabetes, or the patient who refuses surgery for breast cancer or rehabilitation after surgery. This will have an impact on hospital quality measures. Not all health organizations will pressure or abandon these patients, but some will in order to improve their numbers. Some will avoid caring for poorer, marginalized patients if existing health status and patient background are not used to adjust outcome statistics. There will, in a number of scenarios, be distinct conflicts between taking good care of individuals, managing public health and keeping outcome numbers high. Whether we want our health delivery organizations in this position is something that deserves more attention.

It is also completely unclear how competition based on value, defined as the “health outcome per dollar expended,” will succeed in lowering costs. Organizations can certainly succeed in lowering costs internally using Lean production methods, but in the marketplace, health organizations compete on their ability to make money. Making less money is generally a bad competitive strategy. Here’s what I envision happening: An organization that follows Porter’s guide can become more efficient and improve its outcomes, increasing its margins and creating a more “valuable” experience for patients. This will tend to increase its market share and reputation, which the organization will use to negotiate higher, not lower, prices from insurers. Consider the example of Partners HealthCare in Massachusetts, which receives higher rates than any other provider in the state. As our NPR affiliate has reported, Parters

invest[s] in facilities and staff in ways its competitors can’t. That lets it build its brand and market share, which gives it leverage with insurance companies, which lets it charge them higher prices, which they pass on to consumers — and on and on.

Partners controls two large, Harvard-affiliated academic medical centers, numerous community hospitals and thousands of primary care providers. If any organization can provide value across the “entire cycle of care,” it is Partners. But acting in a rational, self-interested way, Partners has driven the cost of health care up. To expect an organization that functions like a business to compete on their ability to drive costs down just doesn’t make sense. Health care providers operate in the realm of economic value, “as measured by how much others are willing to give up to get” their services.

In the end, the greatest shortcoming of the “value-driven” philosophy is not that it is bad strategy for a delivery organization (it isn’t) or that it will be bad for the patient-provider relationship (it needn’t be, if kept in perspective), but the idea that “the biggest problem with health care isn’t… politics.” This is harmful. Determining the basic values that should animate our health care system is a fundamentally political problem. Porter speaks at the level of the business practitioner, but the allocation of resources in health care requires answers to questions about what we value as a society and how we chose to organize ourselves. The notion that these decisions can be made behind closed doors by technocratic experts is hypocritical if the goal is to create value in the broadest sense. To do this, we must put aside the wishes of health industry executives and ask what “community-driven health care” would look like. It’s possible that our patients will value much of what Porter argues for, but we’ll never know if we don’t ask them.

Sleep/death

Sun, 08 Jan 2012 18:15:55 -0500

Karl Kerchwey once said, to a class of undergraduates, that sleep has power in poetry because it evokes death. Being twenty at the time, I didn’t really understand.

Now I see death frequently. And I work a demanding job. Sleep presents itself as a reminder of choices that must be made each day, about the balance between work, family, friends.

Though I believe he meant something slightly different at the time—that sleep requires surrender to an abyss, uncertain of the future—I think of Karl Kerchwey sometimes when I’m tired.

What's unfair about this?

Fri, 06 Jan 2012 17:16:00 -0500

This photo is making its way all over the social media today- I came across it on Facebook. Initially posted three months ago by a Floridian who identifies herself as “M. Turner” on her website, she describes how she was able to get health insurance through the Pre-Existing Condition Insurance Plan (PCIP) that was created as part of the Affordable Care Act. I can’t speak to the veracity of this particular story, but her struggles with the insurance industry are absolutely reflective of the experience of millions of Americans.

I’ve personally been surprised by the number of comments I’ve come across calling this “unfair.” A number of commenters are arguing that Ms. Turner should not be able to get health insurance because she did not “pay into the system” when she was well. This despite the fact that she could not afford health insurance and her job did not provide it. It is a too common argument- blame those who are harmed by a system that is structured against them. Can it actually be true that fairness requires us to deprive the working poor of access to healthcare?

It seems obvious to me that the real injustice is that the richest country in the world fails to provide basic health services to all of the people who live here. And even when we do provide services, we place great financial burden on individuals: according to her website, Ms. Turner is in a significant amount of debt as a result of her medical care and lost her job because of her illness.

Most Americans don’t realize how easy it would be for them to end up in the same situation.

Teaching TLC... and more

Mon, 31 Oct 2011 11:25:02 -0400

“Teaching TLC,” the cover story of the Boston Globe Magazine this week, is about the Cambridge Integrated Clerkship (CIC), the unique program where I spent my third year of medical school. In the piece, Dr. Ishani Ganguli explores some contemporary challenges in medical education and considers how the Integrated Clerkship can help train more humanistic physicians. She writes about the experiences that my classmates and I had over the course of last year, growing close to our patients over time, and highlights data from Academic Medicine showing that CIC students finish their third-year feeling both less cynical and more ready to take responsibility for patients than their colleagues in more traditional clerkships. I’m very pleased that people around Boston will be reading about the CIC and thinking about innovations in medical education.

A critique of the program raised in the article is that students don’t have enough exposure to inpatient medicine. One expert worries that the CIC “devalues what can be gained [by] being involved in acute care in the hospital, working in a team, [and] coordinating across services.” My response to this is, first, to point out that CIC students have more inpatient exposure than is typically assumed. We regularly take call on the inpatient services and, when our longitudinal patients come to the hospital, we admit them and take care of them there.

I will also concede that there are nuances of inpatient care that I have learned in my fourth year that I didn’t understand previously. But on the numerous acute care rotations I have done since the CIC, I have consistently received positive feedback on my ability to “get my head around a case,” that is, to quickly build a holistic view of a patient. Seeing the same patients at home, in clinic and in the hospital during my third year has made it natural to seek a comprehensive understanding of them and their health. In my view, delaying learning some details of inpatient medicine until my fourth year has been both a worthwhile tradeoff and a natural developmental sequence.

Medical training is so often framed around a particular hospital service or learning to be a particular kind of doctor that the patient experience is forgotten. The CIC gives students a year-long formative experience that is centered around patients. By following them closely, we develop deep empathy with our patients and, more than most medical students, share their experience of their illness. In this way, integrated clerkships allow students to learn to practice in our healthcare system while retaining clarity about its numerous shortcomings.

For instance, I’m quoted in the article saying that CIC students are able to “see how people with complex illnesses keep bouncing around, how they experience fragmentation of services.” Up-close and longitudinal exposure to this problem is essential for medical trainees. We know that five percent of patients account for fifty percent of healthcare costs and that care fragmentation plays a large role in this. If the integrated clerkship model can inspire physicians to address this issue by building better systems for care coordination, its impact will be enormous.

My personal hope is that by exposing students to patients’ lives, to the communities in which they practice and to the limitations of our healthcare system, that we’ll do more than create skilled clinicians who show more TLC. I hope we that can train more socially-conscious physicians, truly capable of addressing the big problems that American healthcare faces.

Connected Health Symposium 2011: Initial Reflections

Fri, 21 Oct 2011 15:20:00 -0400

I’ve spent the last two days at the Partners’ Connected Health Symposium here in Boston. It has been a fascinating event with a number of brilliant people from academia, clinical practice, government and business. The speakers ranged from Atul Gawande, the surgeon and author, to the Crown Prince of Denmark, who spoke about universal, high-quality, informatics-driven healthcare delivery in his country.

To me the broad themes from the conference can be understood as tensions between some big ideas and values:

1. Society vs. individual

We heard much about how health is affected by the larger context in which we live. Among rich countries, less equal societies are generally less healthy. And inequality affects the health of all members of a society regardless of class— meaning that even the richest people have, for example, higher infant mortality in less equal countries. We also heard about behavior change and how information delivery and incentives can nudge individuals towards healthier decisions. The hope is that giving someone facts when making a decision and motivating them through things like social networks (either real or online), that health status can start to change.

The tension for me stems from the fact that while we talked about social determinants of health, we proposed solutions for individuals: food policy seem more critical to combating obesity than smart-phone apps, even if they can count the number of calories in your food. This critique can, of course, be applied to the entire healthcare system—we manage illness in individuals. Connected health technology can help us get one step further up the chain of events between social context and illness. Before we get to the point of managing diabetes, we might empower and motivate people to keep better track of their food and exercise—and technology can undoubtedly help. My worry, though, is that just like with our pills and shots, we’re fighting a battle against social problems that really need to be addressed on a societal level.

2. Innovation diffusion vs. the medical model

I felt a strong tension between people in business and design and those in healthcare. From the product side, people tended to talk about connected health technology according to a diffusion of innovations model. In this view, the principle obstacle to adoption is getting through the curve from early adopters to the majority of users. Those on the delivery side were more likely to favor a paradigm requiring demonstration of effectiveness, especially for unfamiliar products. In simple terms, it seems that the business perspective sees use as the goal, the design perspective sees usability as the goal and the medical perspective sees effectiveness (and, hopefully, cost-effectiveness) as to goal of any intervention. What I take away is that all of these are required— an ideal service would work, be a pleasure to use and actually be used by people. Having cared for patients, and felt the deep moral responsibility that goes along with that role, I found myself nodding along with physicians who want to see evidence before adopting a service.

3. Patient versus profit

There were varying degrees of patient- and profit-centeredness represented at the conference and people don’t sort neatly into groups by background. There were entrepreneurs deeply committed to improving health and physicians talking about “taking control of more of the diabetes space.” We saw products clearly aimed at capturing a market and products aimed at truly improving the lives of patients. I don’t mean to say that people making a difference can’t make money or vice-versa, but my heart is with the true patient advocates who are motivated by a heartfelt desire to make an impact.

Despite these tensions, there was a broad consensus about one thing—our healthcare system needs to change. The conference made a compelling case that connected health technology will be critical in improving healthcare and lowering healthcare costs, even if it doesn’t quite get at the root causes of our biggest health problems.

I’m looking forward to hearing reflections from others!

Occupy Wall Street & Inequality

Thu, 20 Oct 2011 09:55:00 -0400

I’m at a conference this morning and just heard a fantastic talk from Dr. Kate Pickett. She is a social scientist who researches income inequality and its effect on society. She presented the graph above which shows the correlation between income inequality and a number of health and social ills. The index includes low life expectancy, poor literacy, infant mortality, homicides, imprisonment, teenage pregnancy, obesity, mental illness, drug use and poor social mobility. She also has figures that link the prevalence of each individual problem to levels of inequality in a society. The media has been making a fuss about the diversity of causes represented at the Occupy protests, but it seems to me like there’s a pretty obvious unifying explanation.

Igreja de Nosso Senhor do Bonfim (Church of Our Lord of the Good...

Wed, 05 Oct 2011 21:18:00 -0400

Igreja de Nosso Senhor do Bonfim (Church of Our Lord of the Good End) in Salvador, Bahia, Brazil.

In the north of Salvador, on our honeymoon, we visited this church. Devotees here pray to Nosso Senhor do Bonfim who represents both Jesus and Oxalá, a god whose tradition was brought to Brazil by slaves from west Africa. As I understand it, he was the creator of human beings, including people with disabilities—and this may explain why the church has become a destination for pilgrims in need of physical healing.

In a small room inside, hundreds of ill people and their families have posted requests on two of the walls. There are hand-scribbled notes on dirty scraps of paper, small polaroid photographs and bright images from inkjet printers, highlighting the varied reach of Brazil’s economic transformation. The notes describe all kinds of illness— cancers, infections, injuries—and call for the help of Nosso Senhor do Bonfim. The photographs are a showcase of the diverse problems that affect our bodies: thin, frail people, few of whom can bare to look at the camera, show their catheters and tubes, reveal their distended bellies, uncover their bandaged wounds. The walls are a collage of the suffering caused by disease.

The two other walls in the room have a strikingly different tone—they are stories of gratitude to Nosso Senhor do Bonfim. Numerous notes describe recoveries, both miraculous and ordinary, from illness. Some of the pilgrims have hung photos of themselves, back to their normal lives. One of the most moving posts is a high school diploma, placed there by a father who never believed his daughter would survive to be an adult. Many notes also thank Nosso Senhor for a different kind of “good end.” People express gratitude for time with a loved one, for a comfortable death or for emotional healing after a loss.

The problems that bring people to this church are the same ones that bring them to our hospitals. The church gives out colorful bracelets that petitioners wear until they break, which is supposed to make one’s prayer come true. We offer a different kind of bracelet and marshall evidence and technology to fight disease. We, correctly, invest years in training ourselves to care for the conditions that people describe. But too often we forget the basic human concerns that bring people to see us, the concerns that are pasted to the walls of this church: “I hurt.” “I’m afraid.” “I don’t want to die.” “I wish I was like I used to be.” A visit to Igreja de Nosso Senhor do Bonfim inspires close attention to the human and spiritual side of providing medical care.

Our visit also inspired another thought. American hospitals—especially our academic centers— often look like giant, sterile monuments to science. This church has become a tribute to the humanity of the people who seek help there. Wouldn’t it be interesting if our hospitals tried to incorporate that spirit?

Missing longitudinality

Mon, 05 Sep 2011 21:53:00 -0400

This month I’m on my sub-internship, where fourth-year medical students do their best to act like interns (first-year medical graduates) and take care of patients on the medical service. It’s been fun, fast-paced, a lot of work and a steep learning curve. I feel like I’m getting the hang of it and, as my efficiency improves, will be able to really enjoy it.

Still, I already miss seeing patients for longer than a few days. Our patients come to us to have an acute issue stabilized- most of their care is handled in the outpatient setting. I find myself wishing that I could get to know them better and go to their follow-up visits to see how their illness progresses or resolves.

This was the Cambridge Integrated Clerkship model. It not only allowed us to build relationships with patients over time, but it gave us the chance to see the full course of an illness—something that rarely happens in the era of the two day hospital stay.

Medical student indebtedness and career decisions: values matter too

Thu, 28 Jul 2011 14:54:00 -0400

Pauline Chen has a compelling piece on the NYT Well Blog today about medical student debt and it’s unappreciated costs. It draws on a recent publication in Academic Medicine which highlights the diverse drivers of medical student indebtedness. These include an expansion of the medical school’s research enterprise, a lack of accountability on the part of medical school administrators, who can increase tuition to support the research mission, and the advent of medical students who want to live like young professionals not professional students.

Dr. Chen argues that high levels of medical student debt are, at least in part, responsible for the shortage of primary care doctors and those willing to take care of poorer patients. She writes that “looming debts mean eschewing a calling to serve a particularly needy, less lucrative patient population or practice, and instead pursuing a well-compensated subspecialty that caters to the comfortably insured.”

I’d like to suggest that something more complicated is going on. As both articles point out, high medical school tuition acts as a deterrent to students from underrepresented minorities and lower socioeconomic status. Since the 1970s, enrollment of underrepresented minorities in American medical schools has stagnated (see figure). The percentage of students coming from the lowest 40% of the income spectrum has dropped from 27% to 10% from 1971 to 2004. The percentage of medical students from the top 40% of earners has increased from 66% to 75%. Our profession is increasingly made up of people who come from the upper and upper-middle classes.

As this AAMC report points out, “physician diversity contributes to increased access to health care for underserved populations.” The converse is true as well— the less our profession represents the demographics of the U.S. population, the less well we’re able to care for it.

No doubt, students are justifiably concerned with their debt burdens, but it’s frequently forgotten that one can make a good living in primary care or caring for the underserved. Personally, I wonder if students eschew this work because of their loans or if they never really consider it in the first place. A recent study highlights that sustaining a practice in an underserved area requires a deep personal motivation or strong sense of identification with the community. If most students don’t bring these characteristics to medical school, and schools don’t nurture them, it’s no wonder that students choose lucrative subspecialties where their income can keep pace with their peers outside of medicine.

This is all just to say that increases in tuition and debt for medical students are only a part of the problem. They reduce our ability to recruit and train a diverse workforce. This in turn contributes to skewed values within the profession—and it is our values, not the debt itself, that most frequently drives graduating doctors into subspecialties and suburban practices.

Language training for health professionals: an opportunity

Thu, 28 Jul 2011 09:09:53 -0400

During my first few years in medical school, I helped to launch the Harvard Medical Language Initiative (HMLI). The group was created to meet the demand among my classmates for language training during the academic year (it had previously been offered only in the summer for fourth year students). We inherited a Spanish course from the class ahead of us and during my time at the HMLI a committed group of students worked to strengthen that foundation. We found faculty mentors to teach the courses, we worked with the Dean for Medical Education so that faculty could cite their teaching in their promotions portfolios and we worked with the Office of Diversity and Community Partnership to secure grant funding. We expanded to offer courses in Portuguese and Mandarin (covering the top three languages in Massachusetts, after English) and we won recognition for the courses as official Harvard Medical School electives. These all felt like huge accomplishments.

As more of our classmates took the courses, we started to wonder about our impact. We became concerned that graduates might misinterpret finishing the course as a measure of fluency. We read an article in JAMA that highlighted concern about “physicians and medical trainees [who] underuse professional interpreters… substituting their own limited spoken Spanish during clinical encounters.” Could we be contributing to the problem?

We started to design our curriculum to address these concerns. We incorporated more simulated patient encounters, we introduced cultural sensitivity training into the courses, we had Interpreter Services from one of our hospitals train the students on the importance and proper use of interpreters. We tested students more and talked frequently about knowing one’s limits. I dreamed that we could have our students undergo something like Interagency Language Roundtable testing, to rate their proficiency in a language. Funding proved to be an obstacle for the last idea, but I believe that we succeeded in making our students more self-conscious about their language skills.

The busyness of third-year has separated me a bit from the HMLI. A new generation of students is in charge and, I understand, doing a fantastic job. Though I remain concerned about the outcomes from language training for health professionals, I’m still a supporter. Healthcare is a field driven by skills and competencies; it is natural for providers who want to take good care of a diverse patient population to seek to learn another language. The key is that this be taken as an opportunity to train students in cultural sensitivity, interpreter use and critical self-assessment of their language skills. Very few people will come away from a language course with anything close to fluency in Spanish, Portuguese or Mandarin. Everyone, though, can learn to take better care of their patients with limited English proficiency.

Disappointed

Mon, 25 Jul 2011 01:18:00 -0400

In 2008, I drove to New Hampshire and knocked on doors all over the state. I wrote letters to my hometown newspaper in Pennsylvania, arguing that electing Obama would improve our healthcare system. I flew to Washington for the Inauguration. Since then, when friends have argued that Obama should be bolder, I was the one who defended him. This is a conservative country and progress is slow and hard, I would say. Yes healthcare reform should have gone farther, yes the stimulus could have been bigger, yes we need a better financial regulatory law, but the direction of the country, at the very least, was right.

With his offer to cut Medicare and Medicaid, Obama has changed course dramatically. This represents not slow progress, but a giant step backwards. Paul Krugman has explained the negative effect that the Medicare cuts would have. I mentioned recently why I oppose the Medicaid cuts. Here I just want to express my disappointment. We need a President who is willing to stand up for the safety net and explain the vitality of these programs to the American people—not one who starts by offering deep cuts.

The past weeks have made me rethink my defense of Obama. The Republicans clearly think he’s a pushover in negotiations. What if it’s because he has been all along?

On Medicaid Cuts

Mon, 18 Jul 2011 21:38:00 -0400

I didn’t protest when we invaded Iraq: I watched the news with disapproval and detachment from a college dorm room. I don’t even remember the day when the Bush tax cuts were passed. Tonight I’m wishing I had joined the people in the streets.

Events in Washington are highlighting the choices that societies must make about how government raises and spends money. President Obama has put Medicaid on the table, offering up to $100 billion in cuts to healthcare for the poor. This will do real harm to some of the most vulnerable Americans.

Medicaid cuts will be invisible to many. Having spent the last year working at a public hospital, I can imagine the impact that they will have: less preventive care, delays in treatment, a greater burden of illness and more medical bankruptcies. People I care about will lose their access to health care.

The popular rhetoric would say that I want to spend without thinking about the consequences. No—I care about a balanced budget. I only wish we had our priorities straight.

One of my best friends from medical school is spending the...

Sun, 17 Jul 2011 14:51:01 -0400

One of my best friends from medical school is spending the coming year in Liberia working for Tiyatien Health, an organization dedicated to rebuilding that country’s health system after years of conflict. They use a community health worker model that draws on the work of Partners in Health. He’s documenting his experience on tumblr. Check it out:

msyj:

Open Road (Sinkor)

Made it to Monrovia, Tumblr and all!

The trip was significant for:

TSA identifying my stethoscope as a possible threat to national security

Mixed feelings about the large, and loud, groups of volunteer missions aboard my flight to Ghana

Ghost plane (40 of 300 seats filled) from Accra to Monrovia

All the memories of tropical developing countries coming back through sights, sounds, and smells

Realizing the adapter I brought doesn’t have the ground I need for my laptop charger. D’oh.

Responding to comments about social media and medical school

Sun, 10 Jul 2011 13:48:00 -0400

The reaction to my most recent post on KevinMD has been strong. I’ve had posts there that I thought would be more controversial, but the topic of social media in medicine has drawn a lot of commentary. Perhaps I shouldn’t be surprised that online health professionals like discussing what health professionals should do online.

The comments are diverse. The response on Twitter has been very positive. In the brief Twitter style, people have shared the link with: “Agree!,” “Great post,” “Time to get with the program, doctors,” “Go where the people are!” and other supportive remarks appended. Via email I have received several responses from medical students who thanked me for writing the post and agreed with the sentiment. Two people have written to invite me to physician social networks that are in beta testing.

The response on KevinMD has been, for the most part, much more critical. One family doctor talks about how social media has helped his practice and reports that “older docs are losing potential new patients to the younger docs with an internet presence.” Beyond this, though, almost all the comments find fault in my post. It seems to me that the comments hit on two big issues: an adoption issue and a professionalism issue.

The adoption issue is highlighted by the commenter “saynotosocialmedicine.” Regarding the possibility of interacting with patients online, he writes,

“I love tech but if a patient wants my opinions, let her make an appointment for a face to face encounter, the only thing for which I can get paid.”

Sharon Bass adds,

“There are already too many things I am required (by insurance and the government) to do for which not only am I not paid but must do to get the pittance that they will pay. I have about had it and am this close to becoming a cash only office.”

This is a common refrain among physicians. Whether it’s adoption of electronic health records, building more comprehensive services for patients or doing any non-billable activity, many physicians say “that’s not what they pay me for.” They are right, of course. In most places we don’t pay physicians to do what would really be best for patients. ACOs and medical homes will hopefully start to change this, but I’m not entirely sympathetic now. When doctors in the 95th percentile of earners nationwide say things like, “they don’t pay me enough” to improve patient care, I can’t help but be disappointed: wanting to improve healthcare delivery was one of the principle reasons I came to medical school.

Regarding professionalism, commentators took issue with what they read as complaining that I have to show discretion online now that I’m in medical school. I want to first assure them that I am not young enough to have had my Facebook habits change because of medical school— I actually joined as a first-year medical student because my classmates encouraged me to do so. I was, even then, past the phase of my life when most of the possibly inappropriate photos of me were taken.

Regardless, my principle point was to highlight the difference between how social media is treated by medical school faculty and how it is used by patients. Medical students are getting warnings to stay away from social media instead of instruction about its responsible use. Openness to the possibilities of social media is rare. Instead of scare tactics, we need good teaching, role models and creative thinking about how social media might help our patients.

Lastly, I don’t think that physicians are always good judges of what is and isn’t professional behavior. Doctors have the standing of the profession in mind, in addition to the interests of patients. So while the comment, “Having a position of trust and authority in society means showing self-restraint in public” is well taken, I think there is a question of degree. In my post I referenced pictures of medical students “drinking” not “drunk” and “dancing” not “blowing up a condom over one’s head.” It’s frankly ridiculous that these were conflated in the comments. Standards for professional behavior are cultural and always in flux; exaggeration doesn’t help us reach clarity on the issue. Additionally, physicians who want to protect the standing of the profession (or their standing within it) may call behavior “unprofessional” if they find it threatening to their status. I would rather reserve the term for behavior that is harmful to patients. That’s the standard we should be teaching in our medical schools—for behavior online and off.

The Pager

Sun, 26 Jun 2011 21:59:00 -0400

On our first day of the Cambridge Integrated Clerkship, every student had a pager on their desk. We knew they would be there—the central idea of the clerkship was that students could be reached at any time when our patients came to the hospital. Still, it seemed to me a strange and antiquated device, only slightly less odd than a typewriter or rotary phone, and it was hard to imagine carrying the pager for an entire year.

At first it was novel. Wearing a pager on my belt was a sign that I had arrived in the clinical world, that the first two years of classroom work were over. When I put it on my nightstand, it was a pleasant reminder of the responsibility that my work demanded. As a group, we learned which ringtones we liked (I prefer the obnoxious loud beep, a sound that can’t be confused with a cellphone receiving a personal call) and how to carry the pager when out of the hospital (I was among the last of the students to realize that I should move the pager to my pocket at social events). We learned the etiquette of paging (always include name, role and return phone number) and the nuances of the computer program that allowed us to be notified when our patients came to the hospital.

Then the pages started to roll in. There was the daily 7 AM barrage of pages, as the hospital system alerted us to patients who had appointments that day. There were predictable pages throughout the morning, letting you know about unexpected visits: pediatric patients with ear infections or moms-to-be who had moved up their appointments. And then there were the truly urgent pages, the pages that would change your life for the next several days. These included pregnant patients in labor and patients who were seriously ill. It could be worsening heart failure or emphysema, a small bowel obstruction, appendicitis or an overdose that brought my patient in. I would come early and stay late to help care for them and to round with the obstetrics, medicine or surgery team. These were tremendous learning opportunities: we could often help the inpatient teams with the past medical history and they would teach us clinical medicine. I developed close relationships with many of my patients because I came to the hospital when my pager told me to.

At times this seemed like a burden, in part because I no longer had the assurance of a full night’s sleep. Worse, though, was that when my pager went off, it frequently meant that something bad had happened to someone I cared about. Through page after page, I learned to find meaning in accompanying a patient during an illness, whether or not our interventions could change the course of it.

For an entire year we carried our pagers, and the stories of our patients, with us. We never knew when a page would be a simple problem: “Mr. X, visiting clinic Y with a complaint of wax in the ears” or when it would be the next, or the last, chapter in a patient’s progressive illness. If it wasn’t serious, I wouldn’t let the page interrupt my regular schedule. If it was serious but not urgent, I would finish my day in clinic or on service and go find them. If it was urgent, I would go, even if I was home at night. We learned to triage and figure out when patients needed us there. We learned to be responsible for our patients by being responsible to them.

On the last day of the clerkship, I left the pager on my desk for the next student who would carry it. Before I turned it off, I sent it a page: ”Hello, I am your pager, take good care of me. It’s going to be a wonderful year.”

Walking out of the hospital for the last time as a third-year student, I reflexively reached down for the place on my belt were the pager always sat—a habit I developed to assure myself that it was still there. I had a moment of panic when my hand didn’t find it. What if something happened to one of my patients? I felt a mixture of relief and sadness—relief that I had made it through the year, sadness that I wouldn’t know.

Do global payments work?

Thu, 23 Jun 2011 23:23:00 -0400

“I don’t care who is paying for healthcare—what matters is how we pay for it.”

This is the hopeful argument that I made in a conversation with a friend less than a year ago. The friend was trying to convince me of the cost-controlling merits of a single-payer model and I was trying to argue that it was less important to have a single insurer to control costs (notwithstanding the obvious benefit for access and equality), than to move away from the fee-for-service model. Align the incentives in such a way as to discourage over-spending and… voila, reduced health care costs!

It turns out I was wrong. Or at least the Attorney General of Massachusetts thinks so. In a report released yesterday (pdf), Martha Coakley’s office puts forth a harsh critique of global payment in Massachusetts. Her staff found that global payment arrangements have actually been more expensive than fee-for-service plans and have contributed to the growth in healthcare costs. True, these plans are early in their existence, but they don’t look as promising as I once thought.

The problem isn’t that payment reform itself is a bad idea, it’s that it doesn’t address the unique factors that have led the U.S. to pay twice as much for healthcare as other developed countries. In our private insurance system, factors like prestige and market share are the principle determinants of what health care organizations charge. In a market where no one knows the true value of the product, all of the private actors have incentives to increase costs—and they do it based on market power.

Coakley suggests addressing this “historic market dysfunction” with the following:

1. Promote tiered and limited network products to increase value-based purchasing decisions.

2. Reduce health care price distortions through temporary statutory restrictions until tiered and limited network products and commercial market transparency can improve market function.

3. Encourage consumers to select a primary care provider who can assist consumers in coordinating care based on each consumer’s needs and best interests.

4. Promote coordination of patient care through primary care providers by recognizing the need to improve funding of care coordination, including the infrastructure necessary to coordinate care, and by giving providers timely access to relevant patient data regardless of their size or payment methodology.

Some of these steps are (slowly, painfully) underway. I wonder, though, if the state will have the stomach to “reduce health care price distortions through temporary statutory restrictions” (presumably by regulating health insurance premiums).

If the government of the Commonwealth of Massachusetts can’t take action to restrain healthcare costs in the private market, I worry even more about the rest of the country. This is the direction we’re all headed. And it looks, increasingly, like my friend was right—a single-payer system would be much better at both controlling costs and guaranteeing access.

Image from Minnesota Historical Society.

Louis Menand and the Purpose of Medical School

Sun, 19 Jun 2011 12:25:00 -0400

There are, according to Louis Menand, three different ways to understand the value of higher education. In his recent article in the New Yorker, he assigns numbers: Theories 1, 2 and 3. Theory 1 is that the purpose of higher education is to sort members of society to their appropriate roles. In this mode of thinking, college is an extended and demanding audition for employers who need more than a standardized test to determine who is appropriate for a job. In Theory 2 the purpose of college is to expose the young members of a society to ideas and values that make them better citizens in whatever careers they decide to pursue. This is an essentially democratic philosophy of higher education. Theory 3 argues that advanced societies have a number of technical roles that need to be filled and that higher education should provide students with the skills to fill these roles. As Menand points out, this argument underpins the Obama administration’s current push to strengthen community colleges. The article is well written and thought-provoking and it suggests the challenge of similarly trying to articulate the purpose of medical school.

Of Menand’s theories, Theory 3 is the most obviously applicable to medical education. Medical school prepares students to fulfill a societal role, namely the delivery of medical care. The advent of so-called “mid-level providers,” nurse practitioners and physicians’ assistants, has challenged the notion that medical school is the only route to this special role, but, in many ways, society still grants medical school graduates a privileged place in the delivery of healthcare.

Theory 3 begs the obvious question: what are the skills that one needs to be a physician? This is where much of the debate in medical education circles occurs. As an example, I vividly remember a disagreement between a family physician and intensivist, both of whom are prominent medical educators. One felt that medical student evaluations in a particular context should be weighted toward cultural sensitivity and interview skills with the other feeling that they should focus on mechanistic understanding of pathophysiology. Another example is the debate about when suturing skills should be taught and if every medical school graduate (consider a psychiatrist) even needs to know how to suture. Do doctors need policy, public health and health systems skills? The debates rage because of the amazingly diverse work that physicians do. Still, equipping people with the skills to care for the ill seems to me like one of the noblest goals of medical school.

Theory 2, that the role of education is to expose students to a set of ideas and values, has a different application in medical school. The goal is not to produce a diverse and engaged populace, but to create a cohesive class of people, a profession. As a result, it feels more accurate not to say that students are exposed to different values, but that they have the values of the profession impressed upon them. As a result, many students find medical school intellectually stifling compared to their liberal arts education.

So, is professional cohesion a legitimate goal of medical school? Does society benefit from medical professionals having shared values? The answer, for me, depends on the value in question. Patient confidentiality is a value that I am glad that most physicians share. But professional norms like the strict hierarchy in medicine can stifle innovation and positive change. It seems inevitable, to a degree, that medical school graduates will have a shared sense of identity, so I support efforts to incorporate ideas like openness to critique and social justice as professional values.

The sorting of medical students (Theory 1) into different specialties is a necessity in our modern, complex healthcare system. Medical school grades and standardized test scores determine whether students can match into the most competitive specialities. Whether these grades and scores reflect a student’s true ability as a clinician is an open question. A bigger problem is that the sorting process does not adequately reflect the needs of the society that graduates are meant to serve. The shortage of primary care doctors and psychiatrists and abundance of medical students seeking spots in high-paid specialties is evidence of this. Sorting is an important function of a medical school, but it’s one that can be vastly improved.

Menand’s framework is applicable to medical education, with his Theories seeming much more like three explicit Goals of medical schools. Still, it’s a helpful framework for understanding the debates in medical education. What do you think? Are there other purposes of medical school that the framework leaves out?

Illustration: Barry Blitt from the New Yorker

Link: Wellness Rounds

Sat, 18 Jun 2011 17:03:00 -0400

Link: Wellness Rounds:

I just came across this blog by Dr. Mary Brandt at Baylor College of Medicine. She shares health and wellness tips for busy medical students, residents and physicians. Check it out for some ideas on staying healthy when your schedule is constrained. It’s a nice reminder about the need for (and possibility of) balance, even when free time is short.

Are pit crews enough? Here's what my health insurance costs:

Fri, 10 Jun 2011 14:47:00 -0400

These are the rates for my student health insurance coverage for the coming year. I’m newly married, so my spouse and I will be enrolling together. That means that the total cost of health insurance for our family of two will be $7,522. Even though I’ve been paying $3,000 a year for my own insurance, $7,522 inspired some sticker shock. Our care is pretty heavily “managed” in this plan, allowing only three appointments per year outside of the University Health Services, so this seemed particularly expensive to me.

But the truth is that $7,522 for two people is probably below average. Health costs are rapidly approaching $20,000 a year for a family of four. In our case, though, we don’t yet have the benefit of an employer covering 60% of those costs.

That we find ourselves at the financial mercy of our healthcare system is a small irony since I am a part of that system. Knowing that average health care costs have doubled in the last nine years, I am worried about how much our insurance will cost next year. I have heard many prominent physicians say that it will fall on my generation of doctors to address this problem. So what does the future hold?

Some are hopeful. Atul Gawande’s Harvard Medical School graduation speech was about the potential that working in teams, like pit crews, has for improving health care and reducing costs. I agree with him. My friend and classmate Ian Metzler wrote on the The Health Care Blog this week about the need for education, improved clinical judgement, decision-support, institutional leadership and payment reform to help make care less expensive. He is also right.

But will all of this really “bend the cost curve?” What makes us think that these savings won’t simply lead to higher margins for providers, health systems or health insurers? Until we address the enormous cost of a private insurance system, either through stricter regulation of insurance premiums or through a public health insurance plan, we’ll have a limited impact on costs.

We also have a deep problem in our national consciousness. Too many of us, including myself before medical school, proceed with the notion that medicine should be able to fix anything and prolong our physical health indefinitely. We are willing to try obscure and expensive treatments with marginal benefit. As a society we have to accept the limits of what medicine can do. We need to come to better terms with our mortality and the inevitability of physical break-down and emotional loss.

For a long time, I wanted to believe that our problem with healthcare costs could be solved with technocratic expertise. But the fact is that our problem is deeply political and cultural. Young doctors need to realize this: working in teams like a pit crew is a start, but what we really need is to change the direction of the race.

Green space and well-being

Thu, 09 Jun 2011 14:41:00 -0400

There are many things to love about Cambridge, Massachusetts. Cambridge Health Alliance, the city’s public health system, which takes care of a diverse and underserved patient population is high on my list. Memorial Drive is near the top too. I have been riding my bicycle home from Boston along “Mem Drive” this past week and I’m rejoicing that it’s there. Just a few minutes from my house, it’s a bike path along the Charles river, where I nearly forget that I’m in a major metropolitan area. I love watching the crew teams row along the river, and there are bridges scattered along the ride that access many parts of downtown Boston. What a joy it is to live here!

It turns out that I’m not the only one who feels this way. There are a number of studies that look at the connection between green space and well-being. Jolanda Maas and colleagues, for example, found a compelling link between the percentage of green space within 3 kilometers of a person’s home and self-reported health. The labels on their graph below are a little difficult to read: the Y axis is the percentage of people reporting that their health is average, poor or very poor, and the X axis divides them into groups based on the percentage of space within 3 km that is green, according to a land use database (pdf).

This included people living in urban, suburban and rural areas. They found an even stronger correlation between green space and health when only urban areas were included. Importantly, the authors controlled for socioeconomic status, which has a strong role in determining whether people live in neighborhoods with more or less green space—this represents the effect from the green space alone!

Another study looked at how green space affects our ability to respond to stress. They found that green space reduces the impact of a stressful life event, with people who live near green space reporting fewer health complaints and better general health after events like the loss of a loved one, a serious illness or the end of relationship. It’s impressive the impact that green space can have.

Given my experience, I had assumed that much of this benefit was the result of being able to get outside to exercise. It turns out that it’s more interesting than that. This study found that people who lived near green space reported better health even though they exercised less than people who did not live near green space. So why did they report better well-being?

It likely has to do with all of the other experiences we have in parks. Safe public spaces contribute to a sense of community, which is very much linked to well-being. In fact, people who live near green space are less likely to report that they feel lonely or socially isolated.

I don’t know of data to support it, but I also have a Thoreauvian belief in the restorative power of nature. Having grown up along the Delaware River in rural northeastern Pennsylvania, there is still nothing like a walk in the woods or a kayak trip to improve my sense of well-being.

So, the relationship between green space and well-being is clear. The inequality in the distribution of green space in American cities is also obvious. Combatting that inequality should be a top priority for urban policy-makers who care about improving the emotional health of their citizens.

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References:

Maas J, van Dillen SME, Verheij RA, Groenewegen PP. Social contacts as a possible mechanism behind the relation between green space and health. Health & Place. 2009;15(2):586-595.

Maas J, Verheij RA, Groenewegen PP, de Vries S, Spreeuwenberg P. Green space, urbanity, and health: how strong is the relation? J Epidemiol Community Health. 2006;60(7):587-592.

Maas J, Verheij RA, Spreeuwenberg P, Groenewegen PP. Physical activity as a possible mechanism behind the relationship between green space and health: A multilevel analysis. BMC Public Health. 8:206-206.

van den Berg AE, Maas J, Verheij RA, Groenewegen PP. Green space as a buffer between stressful life events and health. Soc Sci Med. 2010;70(8):1203-1210.

(Photo of the Charles River from Freefoto.com)