Random Thoughts from a Restless Mind

“We often think of medicine the way we think of math. We go through the diagnostic process and at the end we get an answer.”*

The modern era of computer-assisted medical diagnosis and computerized medical records began at the University of Vermont in the early 1980’s. I was a medical student at UVM from 1982 to 1986, and my professor Larry Weed, M.D. is occasionally credited as the “father” of computerized medicine. Dr. Weed and I engaged in several epic “battles”, publicly disagreeing about the place of computers in the down and dirty acts of medical diagnosis and treatment. My problem, then and now, was the very premise upon which he based both his work and his conclusions, that the education and experience of a living, breathing doctor was not a match under any circumstances with the power of mathematics in a beeping, buzzing computer. And this was in 1983!

Fast forward to, say, 2003. The term “outcome-based medicine” is starting to be in vogue, the new darling of both the academic intelligentsia and the Beltway policy wonk set, an infatuation that rests on the notion that this concept is somehow new. A cognitive breakthrough. Revolutionary. A way of thinking that will surely improve medical care in the United States while simultaneously saving countless Billions of dollars. If only we would embrace the power of math–the answer’s right in front of us–we would surely succeed! And yet “outcome-based medicine” isn’t really all that new. Dr. Weed used the example of serum lipids and heart disease, medicine vs. cardiac bypass surgery, with years survived as the outcome and diagnostic data as the input to his programs. Heck, the granddaddy of all medical trials, the Diabetic Retinopathy Study, was nothing if not “outcome-based medicine” and it was published in 1978!

“In math, you can check your results by flipping to the answer key in the back of the  book. Medicine is rarely that certain”. When doctors treat a patient the “answer” is the outcome. Did my patient get better? Does he see better after I removed his cataract? Did she live? We evaluate the input on the left side of the “equation” only when the output, the outcome, arrives on the right side of the equal sign. Unlike math where the laws of the equation remain ever constant, in medicine the equation takes place in the black box of a real, live, patient.

“We make our diagnoses based on likelihood and risk.”* On the front side of the equation, where data and diagnosis are the input, doctors are in many ways number crunchers or risk managers. Here it is possible that Dr. Weed’s computers might come in handy, but even here the softness of the data, the input, weakens the power of his math. Did the patient give his entire history to his doctor? Did he forget something? Did he tell the truth, or did he relay what he WISHED was the truth?  Did the doctor hear everything the patient said? Did she have enough time to ask the next follow-up question? Was every sign that would make the diagnosis more secure present at the time of THAT particular exam? Were the right tests ordered and were the results all conclusive and consistent enough to place all of the information in a tight silo of clinical characteristics so that some medical math might apply?

There is a certain arrogance in the notion that our education and our experience are sufficient to make a diagnosis, sufficient to choose and implement the correct treatment, whatever either may be. It is, however, an arrogance built on decades of results, each year bringing better outcomes than the last. It is difficult to quantify and validate this position because it is difficult to evaluate the nuances built into both sides of the medical equation, the diagnostic input and even the outcome output. In math a “2″ is ALWAYS a “2″, no matter where one finds it in an equation; the quadrantic equation never lies, and it is always solved if you follow the rules. In medicine a “2″ is only sometimes a “2″; it is just as likely to be a “2ish” on both sides of the equation, and it is startling and maddening when you realize that this is usually the case.

The arrogance of medicine, built on history, is exceeded only by the arrogance of those who would impose strict math on the practice of medicine. For these people, the Beltway policy wonks and omniscient pundits, a “2″ is always a “2″. Why shouldn’t it be? That’s the way it works in the budget and on Wall Street. Look what happened when people wished that “2″ was really a “4″ when they signed their mortgage papers! If only we could get doctors (and hospitals) to follow these strict guidelines on how to take care of diseases A, B, and C. We could have better, healthier people and spend less money! All of this is true, of course, as long as a “2″ is always a “2″. I hate to sound all mysterious and “in the group” and all, but have you noticed how few people who feel this way about the practice of medicine have ever actually practiced medicine?

We are imperfect beings, both we who are doctors and we who are patients. Until we have diagnostic tools like that of “Bones” on the original Star Trek, that magic hand held wand he would sweep over the stricken on the Enterprise, it will be impossible to look at medicine as we look at math. We will always be uncertain to some degree about everything that is on the left side of the equal sign. Every “2″ necessarily “2ish”. Did we get the right diagnosis? Did we get the right result? Did we get the best possible outcome? “Uncertainty is the water we swim in. Often we can’t know if the answer was right, only if it was right enough.”* Medicine is not math because the answer key at the back of the book will always be printed out of focus, slightly blurred and not sharp.

Is that a “2″? Dammit, Jim, I’m  doctor, not a mathematician!

*Lisa Sanders, M.D., New York Times Magazine, 4 October 2009

When did I become the bad guy?

Dirty Rotten Scoundrel, M.D. Apparently that’s me, and for the most part pretty much all of my physician colleagues if you listen to the President, Members of Congress, and various and sundry pundits from all sides of the political spectrum. There is a over-riding assumption of ill-will and mal-intent when the public is asked about doctors and how doctors behave in our modern medical system. Everyone talks about bad behavior, how doctors are at the root of many (most?) of the “problems with healthcare” in the United States, looking out for themselves first and always, rather than looking out for the best interests of their patients.

The stories told and the statements made are really quite amazing. Mind you now, there are really never any statistics offered that stand up to scrutiny, but the stories are just SO good and SO important that they just must be told. And told again. And again and again until through the sheer volume of the telling they just MUST be true. Like the recent statement by President Obama that Pediatricians would much rather remove a child’s tonsils than treat an infection with antibiotics because they, the pediatricians, would be paid so much more for doing the surgery. This one is pretty hurtful for countless reasons, none the least of which is the fact that neither the President nor any one of his minions is aware of the fact that pediatricians do not perform ANY surgeries, and that pediatricians do not garner any income whatsoever when an OTOLARYNGOLOGIST  removes a child’s tonsils. Recent discussions in pediatric, infectious disease, and otolaryngology circles about the fact that childhood infections have RISEN in the decades in which tonsillectomies have declined, and that perhaps we are doing TOO FEW tonsillectomies now seem rather quaint and pointless in the face of such blatant political pandering. After all, how important can decreasing childhood infections be, really? We’ve got a healthcare system to save!

Is it really true? Do all doctors, or even most doctors, or even a measurable minority of doctors REALLY put their own economic well-being first? Is the first level of decision making in the office truly “which treatment will make me, the doctor, more money?” Could this possibly be the case? I really don’t see it.

In the U.S. becoming a doctor has always been a rather difficult task. American medicine has always been a true example of America as a meritocracy. Our doctors have traditionally been among the brightest of our citizens, students who excelled at every level of their education simply in order to qualify for the privilege of suffering through the pain of a medical education. Those who excelled in their medical school and post-graduate years started out with the best jobs in the nicest locations, or became the academicians who did the ground-breaking research that produced the dazzling array of medical advances that serve us today. A very large percentage of each town’s best and brightest became physicians.

Why? Why did so many of our brightest young people go into medicine? The men and women who are in the primes of their careers right now, did they do so in order to become rich? Was that a reasonable expectation, and were they told how to do this in school? Not to my memory.

Once upon a time, around the time that most of our doctors now in their prime were in grade school, the doctors in a town were held apart from other citizens–seen as different for accepting the calling of medicine. There was an assumption of goodwill born out of the experience that the doctor would be there to take care of you whenever you needed him. A high degree of respect and deference was granted those doctors, whether they were pediatricians or otolaryngologists  or any other type of doctor. Physicians were well-off but they were not wealthy unless they were born to wealth. Being a physician was actually considered one way for a child of wealth to give back to the community. The wealthy in town were merchants or the owners of the factories. Doctors lived in nice houses in nice neighborhoods, but they did not live in the NICEST houses or THE neighborhoods. They often belonged to a country club, but not THE country club.

Doctors of that time, and indeed doctors up until relatively recently, had two very powerful incentives to work hard. In a free market where one is paid for doing work and for doing it well, the more hours you worked and the better you worked the more money you made. It has always seemed that it is easier to find the private practitioner, the doctor of any specialty who works for himself, when an emergency arises at 3:00 AM don’t you think? But more than that, the harder a doctor worked, the more he put aside his own time (and that of his family), the greater was the respect he earned in his community. Hard to value in dollar signs, but clearly valuable enough to create the archetypical American doctor, on call for his patient night and day. In return for devoting your talents to medicine, and in return for devoting years to the toils of becoming a doctor, and in return for placing your time at the disposal of your patients, your doctor recieved a very comfortable living as well as uncalculable respect.

With the exception of the 1980’s during which a small minority of doctors did, indeed, become truly wealthy from practicing some kind of medicine, doctors really did NOT, and do NOT get rich from their jobs. Some time  in those 1980’s things started to change as more and more of our nation’s healthcare was purchased by the government or by insurance companies that took their cues from the government. All of a sudden the doctor was suspect, guilty of gaming the system at every turn. The medical record was no longer a tool to be used in the ongoing care of a patient but was now a legal document, the trap in a perpetual game of “gotcha” as third party payers and malpractice lawyers started to grind away at the reputation and goodwill of our doctors.

Why? Why did this happen? What am I NOT seeing in my offices and in the offices of every physician I have ever known that makes this so? The short answer is that I am not really missing anything at all. There really is no greater incidence of greed and graft on the part of physicians than ever in the past. It’s a ruse, a strawman.  What is greater now is the benefit to be gained by individuals and institutions when all of that goodwill, that assumed respect accorded our doctors is slowly eroded, when doctors can then become a target that diverts attention from any number of more culpable groups.

Might this trend bear fruit? Might this, in fact, be the route that we take to controlling the healthcare economic problems in America? Aye, perhaps, but this is likely to be yet one more instance where we have the opportunity to see the genius of Henkel,  There Ain’t No Such Thing As A Free Lunch. Or perhaps this, from the Esteemed Physician in ‘Atlas Shrugged’: “Let them discover the kind of doctors that their system will now produce. Let them discover, in their operating rooms and operating wards that it is not safe to place their lives in the hands of a man whose life they have throttled. It is not safe, if he is the sort of man who resents it…and still less safe, if he is the sort who doesn’t.”

You might miss me, the eye surgeon Dirty R. Scoundrel, M.D. and my colleagues Snide Lee Whiplash, M.D. the otolaryngologist, and Boris and Natasha Karloff, the husband and wife pediatricians. You will most certainly miss our children and the rest of the best and the brightest of their generation, none of whom are likely to be there to answer your sick call at 3:00 AM. They will most likely be home asleep in the NICEST house in THE neighborhood, tired after an evening at THE country club.

For they will not have become doctors.

The eminent philosopher Yogi Berra has captured the essential problem with the current fascination among our legislators and government bureaucrats with Electronic Medical Records (EMR or EHR). “In theory, there is no difference between practice and theory. In practice, there is.”

In my mind I have an image of the well-intentioned men and women who are developing the next generation of EMR. I see them as this generation’s equivalent of  a pre-Foundation Bill Gates, or Steve Jobs before the black mock-turtle tee shirt. All nerdy and earnest, focused on the software solution to a problem they’ve read about. They peer out at the world beyond their screens, convinced of their ability to solve a problem they view from 30,000 feet, perhaps dreaming of becoming wealthy should they succeed.

I also have a picture in my head of the legions of un-elected bureaucrats in state capitols and in Washington who have latched onto this notion of EMR as the panacea, the magic solution to the American “Healthcare Crisis”. Equally earnest, white-paper educated omniscients convinced that a technical solution is all that is missing from the equation. They deal each day in the business of spending tax revenue and the legislative give and take that eventually results in a state or federal budget.  Their time is spent with eyes glued to their laptops and their Blackberries, only seldom establishing eye contact with another of their kind ,and only then if absolutely necessary.

In THEORY this EMR thing is a no-brainer, isn’t it? Who wouldn’t think so? A true EMR is a system of record keeping for medical data in which all of the information is entered digitally and stored in hard drives instead of paper charts. Every time a patient is seen by a doctor or a nurse-practitioner his entire medical record is there for the viewing. No lost pages. No missing data. No struggling with the abysmal handwriting of the busy specialist who saw him for an emergency at 4:00 AM. What’s not to like about that?

In THEORY a universally applied EMR should also create some economic advantages in our healthcare system as well. We would theoretically need fewer billing assistants since all of the charge information would flow automatically from the medical record to the billing system, and from there straight to the payer. There would be few, if any billing errors since the coding and reporting requirements for each insurance company (or the federal government) would be built into the software. Since all of the information about medical outcomes would now be instantly available we would now be able to evaluate competing treatments and determine objectively which ones work and are therefore worth their cost to provide.

Unfortunately it turns out that Yogi Berra is not only a philosopher, but in this instance he is also a genius. You see, in PRACTICE all of this theory falls apart because of a rather messy and unpredictable variable in the system that the EMR designers and the all-knowing bureaucrats just can’t remove from their programs or their systems: all of the patients and all of the healthcare workers are PEOPLE. People who are sick and become patients. People who don’t want to be sick and try not to be patients. People who come to work fresh and adequately caffeinated, and people who are really patients that particular day and don’t know it, spilling their Starbucks on the keyboard.

Computers and the software that runs computers reduce work and increase efficiency in their optimum usage. They enhance the experience of all who encounter them “in the wild” when they fulfill their potential. At the same time that we have all of this talk about the urgent need to get every doctor’s office and hospital computerized coming out of one side of the collective mouths of the “reformers” we also hear out of the other side of the need to improve the patient’s experience when she goes to see her doctor or when she is in the ER. Those same bureaucrats and policy “experts” scampering through the legislative ant hills who extol the virtues of computerized efficiency also demand more time for patients from doctors and nurses, time  spent one-on-one in providing medical care. Not too much time, though; these budget-watchers  also bemoan the existence of so-called “concierge” practices, the ultimate expression of patient-centered medicine, because this model reduces the pool of doctors available to provide care.

The only conclusion that one can reach is that none of these EMR developers or policy developers has ever been a patient in an office or a hospital with an EMR!

The most important entity in the exam room or in a hospital room when an EMR is in use is the computer. The bigger the institution the more this is true. Mandatory questions must be asked in sequence and data entered in order. Imagine your doctor or her nurse as the best-educated data entry clerks in America and you get the idea. And it doesn’t matter whether it’s a computer and a keyboard or some sort of handheld gadget, the eyes of the doctor is on her screen, NOT her patient. The doctor has a relationship with her computer; the patient has a relationship with the back of the doctor’s head.

And you know what, it takes time to enter all that stuff. Much more time than it takes to jot down a couple of notes or a little data. Where will that time come from? Well, either it comes out of the time devoted to looking and listening, or it comes from decreasing the number of patients a doctor can see each day. Fewer employees necessary to run the computerized office? Really? What other customer service business has successfully reduced the number of people involved in providing that service to the satisfaction of its customers? It’s also really expensive to buy and implement and maintain an EMR. We’re talking about Billions of dollars up front and every year hence. Where will this money come from as doctors and hospitals struggle to remain afloat?

The EMR fails “in the wild”. It fails in PRACTICE to do either of it’s most important tasks; it neither increases efficiency nor does it improve the experience of the user. An EPIC fail (pun most definitely intended for you Epic users).

In the end the only winners in this EMR game at the present time are regulators and third-party payers. When we put all of the advantages of EMR in THEORY  into PRACTICE the losers, once again, are patients and their doctors.   With the present state of technology we will spend more money to buy systems that will decrease our efficiency and reduce the quality of experience that both our patients and doctors will  have when healthcare is provided. And we haven’t even touched on the difficulties of maintaining the confidentiality of all of that information, or whether or not you can really pigeon-hole all of those messy, unquantifiable individual patients into tidy little  treatment groups.

I have another picture in my mind, a picture of Yogi Berra in his doctor’s office. Yogi’s getting on in years you know. Probably has a couple of medical problems; probably taking a couple of medicines, too. Can’t you just see him, all ears and nose and those huge glasses underneath a vintage Yankees hat?

“Doc. DOC! Who ya lookin’ at? Hey. HEY DOC! I’m over here!”

It’s become quite fashionable to call oneself “patient-centered”. It’s rather trendy, in fact. Large, quite famous medical institutions now trumpet their new “patient-centered” care initiatives. The hiring of a “patient experience officer” is front page news in Cleveland. The airwaves are choked with advertisements from doctors and hospitals alike, beaming with pride and anxious for you to know that now it’s “all about you, the patient.”

What it really turns out to be is LIPSTICK ON A PIG.

It’s the same hospital with the same staff and the same processes. The same doctors are in the same offices and get paid the same way. A new paint job and new curtains cannot hide the fact that you wait just as long sitting in the same, old chairs in the same old waiting room. No amount of  advertising or re-branding is going to magically change a 1990 Mercury Sable into a brand-new Mercedes 500SL, and if you close your eye  you still know which one is taking you for a ride.

Since when is “it’s all about the patient” news? Isn’t that the way it’s supposed to be? Do the doctor and the nurse have a job because a patient needs their care, or is the patient there so that the doctor and the nurse can have jobs? How many times have you wondered if that big, beautiful new $100 Million hospital wing is being built to handle all of the patients who must be turned away, or if the hospital will now embark on a campaign to find patients to fill that new, superfluous edifice? Or worse yet, if the $100 Million addition is simply a way to launder all of the “revenue in excess of expenses” generated by the “non-profit” hospital?

Medicine is the ultimate consumer service business. Even more so than any other service business because the people who bring you medical care have been entrusted by a patient to do some version of the next right thing for that patient; they have been trusted to put the care of the patient before their own care and feeding. We do a wonderful job of curing disease in the United States, but we don’t do such a great job of caring for patients, lost as we are in our zeal to care for diseases. Patient-Centered Medicine means looking at the curing of diseases from the patient’s viewpoint rather than the doctors’ or the nurses’ or the hospitals’.

Patient-Centered Medicine is all about the patient’s EXPERIENCE.

Enter Skyvision Centers, a unique take on eyecare built from scratch centered around the patient experience from the ground up. Two eye doctors, an ophthalmologist and an optometrist, left a very successful practice (where very high quality eye disease care is still being offered) to start something new. Something radical. Something truly focused on the patient experience from the very beginning. We had nothing but our names and our reputations. No patient lists. No accounts receivable. Heck, in the beginning we didn’t even have an address! All we had was a blank piece of paper with “Skyvision Centers” written on it, and a picture of a patient in the middle. We built our business around that patient and her experience.

Benchmarks? Sure! We went out and benchmarked Nordstrom’s and the Canyon Ranch Spa and the Ritz Carlton to learn about the best practices in customer service. We studied the mechanics of the Toyota manufacturing methods to learn about flow processes, accuracy, and safety. We built an office that allowed us to maximize our efficiency in a setting that looks and feels more like a boutique hotel or retail setting, with lobbies rather than waiting rooms.

Every staff member went on a customer service “field trip” where we ate lunch at a Holiday Inn and dinner at a Ritz Carlton. We witnessed three of our staff members experience a makeover at the Almay counter at Dillards, and then watched three other staff members ENJOY a makeover at the Bobbi Brown boutique at Nordstrom’s. We checked into a room at the Holiday Inn to have a standard hotel experience, and then checked in and spent a night at the Ritz Carlton. All of us. The non-doctor staff and their spouses stayed on the concierge floor, the docs in regular rooms.

And then we brought it all together and made it Skyvision! Our goal is for each patient who comes through the door to have an experience that is more like the Ritz Carlton than the Holiday Inn. More like Nordstrom’s than Dillard’s. We measure every step of the patient experience and constantly evaluate our customer service just like we evaluate and measure our medical outcomes. We agonize over each sub-par visit or less than stellar service evaluation.

Why? Well, why NOT? Where does it say that providing the best possible medical care with the best possible outcomes has to be coupled with less than the best possible experience? That the most important person in the process is anyone other than the patient? We’ve all seen the check-in process at a Holiday Inn and at a Ritz Carlton. They both work, but they sure feel different, don’t they? Why is it that the majority of check-in processes at medical offices and institutions feels more like a busy airline ticket counter during a storm than the front desk at Canyon Ranch? If the cosmetics cost the same at Dillard’s and Nordstrom’s (you know, like your co-pay for a visit), why is it that you feel so much better after shopping at Nordstrom’s?

We all took a financial bath in the first four years of Skyvision Centers. Hey, starting from scratch is hard! In the end, though, we created what is one of those very rare creatures, a true Patient-Centered Medical practice. It should make you wonder how much better your experience would be if all of those busy practices and all of those hospitals building their new wings took some of the money they are spending telling people that they are “patient-centered” and actually tried to put YOU in the center. We’re pretty much an open book. We’re happy to be the benchmark. Heck, we’ll even go along on their “customer service field trips”! This Patient-Centered Medicine is more fun to provide, too.

But until they do, until all of those folks advertising their all-new, all-you, “Patient-Centered Medicine” spend some time looking at the experience of receiving medical care from the viewpoint of the patient, all of us who are those patients had better pucker up.

The pig just got her make-over.

I have been pretty generous in sharing my thoughts about some of the ills of our American Healthcare system, especially with regard to the barriers erected between physicians and patients. I find the various proposals now before our legislative bodies in Washington to be rather curious, even offensive. Since when does the United States of America adopt wholesale an economic solution from another country? Especially another country that is in some way otherwise riding the considerable coattails of the U.S. economy?

The “baby with the bathwater” approach in the halls of our Capitol and the editorial offices of our leading media outlets (WSJ excepted) is about as wrong-headed as you can get.  What we need is an AMERICAN solution to the challenges that we presently face with the economics of healthcare in the U.S., using our present system as the foundation.

Not surprisingly, I have some thoughts!

1) Malpractice tort reform. See my thoughts in “Tort Reform = Healthcare Reform”. Effective reform will dramatically reduce the scourge of defensive medicine with its attendant costs and risks to patients. Defensive medicine represents 15-25% of all medical costs in the U.S. That’s 15-25% of $2 Trillion. Do the math.

2) Tax Reform #1: Remove the tax deduction for employer-offered health insurance. Provide a 100% TAX CREDIT to the lowest 60% of wage earners for the purchase of health insurance. Provide a progressive TAX DEDUCTION for the upper 40% of wage earners.

Tax Reform #2: Remove the tax deduction for advertising as a business expense for Hospitals. If we are concerned about unnecessary increased utilization of medical resources why are we allowing advertising by hospitals? For that matter, remove the tax-exempt status of any hospital or  provider that advertises. How is it appropriate to allow a hospital system to advertise to increase revenue, deduct that advertising as an expense, and still be not-for-profit? If it looks like a business, acts like a business, and sounds like a business, tax it like a business.

3) Insurance Reform #1: Reverse all of the for-profit conversions of previously not-for-profit health insurance companies. Who was the genius who thought THIS was a good idea? I don’t remember insurance premium increase that were quite so massive when all of the Blue Cross/Blue Shield plans were not-for-profit, do you? And while there were $Million execs in the non-profits I don’t recall any $10, $20, or $100 Million execs. Removing the need to answer to the stock market will create companies that will compete quite nicely with the for-profit companies without the horror of a government run system. Let the equivalent of NGO’s compete with the United Healthcares of the world.

Insurance Reform #2: Remove state-level coverage mandates and create a minimum federal set of mandates for comprehensive insurance policies. A REAL minimum. REAL medically necessary items. No Viagra or artificial  insemination coverage. Allow cross-state competition for the business. Real competition always drives prices lower.

Insurance Reform #3: Mandate high-deductible catastrophic health insurance for all. Real insurance, the kind that protects against a life-altering financial death sentence, not the pre-paid service plans that we now call health insurance. See Tax Reform #1 to see how it can be covered.

Insurance Reform #4: Allow insurance companies (Medicare and Medicaid included) to discriminate IN FAVOR OF people who make healthy lifestyle choices (eg. no nicotine, no DUI, etc.). We are all so afraid of the stick that we refuse to allow any use of the Carrot.

4) Freedom of Speech/Restraint of Trade Reform #1: Abolish, once again, direct-to-consumer pharmaceutical advertising. There was a quantum leap in the utilization of all sorts of medications immediately following the 1997 rulings that allowed DTC pharmaceutical marketing. If it is so obvious that our ever-increasing levels of spending on medical care is a threat to the very existence of our fair Union, then DTC drug marketing is a version of yelling “FIRE” in a crowded theater.

Freedom of Speech/Restraint of Trade Reform #2: Begin a return to the professionalism of yesterday by prohibiting all forms of advertising by, or for, physicians. The AMA gets a lot of criticism, most of it well-deserved in my opinion, but the court and FTC rulings that prohibited the AMA from censoring physicians who advertised was a seminal event in the de-professionalism of doctoring and medicine. Doctors and other medical advertising was, is, and always will be wrong. While we’re at it, do the same thing for lawyers and the practice of law.

5) Public Health. Finally, and most importantly, go to the true root of whatever “Crisis” we may have here in the United States, be it a “Healthcare Crisis” or a “Healthcare Finance Crisis” or what have you. We as a people are not healthy; certainly not as healthy as we ought to be. We are not healthy because of some wrong-headed previous Public Health decisions (simple-carbohydrate based diets, abolition of school phys-ed programs, tort-fearing closures of playgrounds, etc.). We are not healthy because our ability to treat the diseases that result  from poor lifestyle choices (cigarette smoking, alcohol abuse, preventable accidents, etc.) is SO GOOD that we are able to keep more and  more unhealthy people alive longer and longer, paying ever more to do so along the way.

This is where true leadership can make a difference. Remember JFK and the President’s Council on Fitness? I do. 8 pull-ups in the fifth grade for me. Sweden identified saturated fats from whole-milk products as a significant cause of heart diesease in the 70’s; a full court Public Health press for low-fat dairy brought about a dramatic decrease in cardiac deaths in the 80’s. Polio, measles, smallpox and whooping cough were once the leading killers of children in the U.S. but are now historical footnotes due to Public Health initiatives.

We lead the world in per capita alcohol related accidents and deaths, losing young lives by the thousands each year. We have ever more increasing numbers of truly obese citizens who go on to suffer the diseases caused by that obesity, and we pay ever more for their diabetes, hypertension, strokes and heart attacks. These lifestyle choices are root causes for our increased expenditures on Healthcare, much more so than all of the targets of Beltway demagoguery like insurance company expense ratios and pharmaceutical company profit margins. A solution to this issue, more than all of numbers 1 through 4 combined or any other proposal yet floated, is the true crux of the solution to any “Crisis” we may be facing. Everything else is only there to buy time. Time to get healthy.

There are no votes to be had in making Americans healthier. Nothing but hard work on every side of the equation. Who will stand up and do the hard work? Who will lead?

Who will have the guts to not only say that the Emperor is naked,  but also drunk and fat and puffing away our economy.

In “Residency Training and the Modern Physician” I wondered if I was as dedicated as my friend Bill, the general surgeon who left our dinner to attend to a youngster with appendicitis despite the fact that Bill was not on call. Bill was trained in such a way that he doesn’t see any alternative but to answer that call, day or night, on call or not.

I got my answer today.

Skyvision is closed today in observance of Independence Day. It’s a vacation day for both doctors and staff. Disease, however, respects neither the calendar nor the clock. I received two emergency consults in two separate hospitals, but I was reasonably certain that I could see both patients and still be able to join my wife and youngest for a planned late afternoon activity. Sure enough I was headed home at 3:30 or so, the afternoon shot but still in time to hop in the car at 4:15 with Beth and Randy. Severely under-caffeinated I decided to treat myself to a sweet iced coffee at the local mini-mart on the way home.

“Doc, doc…hey P___, there’s the doc I told you about. He’s the eye doctor who comes in all the time. Tell him what just happened.” Unbelievably an elderly gentleman had literally just lost his vision in one eye, not ten minutes before I walked in. This is roughly the eye-guy equivalent of a cardiologist seeing someone clutch their chest. P___ is a resident of a retirement home about 300 yards from the Mini-mart, on foot, with no family near. I bundled him into my car, stopped quickly at home to let my wife know where I was going and to wish her and Randy good luck on their adventure, and drove over to my closed office to try my best.

The diagnosis is bad; the treatment was as successful as it can be. I walked in to the Mini-mart for an iced coffee and a lottery ticket, hoping as always that THIS time there’d be some good karma in this particular visit. Time will tell if the good karma surrounding my new patient in his time of misfortune will make him one of the 5% of people who recover from this very bad problem.

I’ll be just as happy if the good Karma goes to him and not my lottery picks as I was to pick up the check when Bill had to leave dinner early.

The law of unintended consequences is alive and well in medicine.

One of my closest friends, my best friend in Cleveland, is a General Surgeon on the other side of town. We were medical school classmates a lifetime ago at the University of Vermont. Although we live in the same city we have done a terrible job of getting together over the years, consumed as we have been with the various duties of fatherhood, husbandhood, and doctorhood. We finally managed to get together for dinner at  what may be the best restaurant in Cleveland, Johnny’s Bar; it’s certainly the best “guys’” restaurant. It figured to be a perfect guy-getaway: my entire family was out of town, and Bill was NOT on call.

As fathers will do we spent the lion’s share of the time we were together talking about our kids. None of my progeny seem destined to follow their old man into medicine, but Bill’s two older kids are hell-bent to be doctors.  He wondered aloud whether they really knew what they were getting into, whether they really understood what it means to be a doctor and what they would go through to get there.  He also mused about the difference in both  the practice of medicine today in comparison with  medicine as it was practice when we decided to be doctors, as well as the apparent difference in the attitude and approach of recently trained doctors. Being old guys we naturally commenced whining and complaining about the newly minted doctors and how different they are from us and our generation. (Note to self: quit acting like an “old guy”)

How are new doctors different you ask? What is it that makes them different and how did that happen? Well, in order to answer that question it would probably be helpful to describe what it was like to be a doctor and to train to be a doctor “back in the day”. There was a time when only doctors possessed medical knowledge, when the canon of disease and disease treatment was the sole purview of those who had gone to medical school and trained to be doctors. Weird, huh? No internet around to google a disease or come up with a novel treatment in order to play “gotcha” at an office visit. Nothing but true quack remedies in the publications of the day, unless it was an article on some amazing cure discovered by a doctor.

Doctors served long apprenticeships in training, spendings years of their young lives as indentured servants, working brutal hours for what would be much less than minimum wage if such a thing existed. This rite of passage not only served to teach the newly minted doctor all that was known about his particular specialty (almost all doctors were men back in the day), but it also served to ingrain certain habits and skills that were characteristic of the profession. Among the most important of these was the ability to perform at a very high level when fatigued or just after being awakened, and the knee-jerk reflexive response to do just that whenever a patient was in need. Every time. The long, endless hours of patient care in training developed generations of doctors who simply didn’t know that there was any other choice but to go to the side of their patient whenever they were needed, day or night, every day and night. I think I’m like this, but my friend Bill most certainly is.

Patients responded by according enormous respect to doctors. A doctor, ANY doctor, was someone to look up to no matter who he was or what kind of doctor he might be. Answering the phone with “this is Doctor White” instantly set the tone for the conversation.

What kind of medicine, what kind of healthcare, and what kind of doctor did we get from this system. This was the day of the paternalistic doctor, the time when patients said things like “you’re the doctor” when asked their opinion about a treatment. Even though there was much less to know the gulf between what the patient knew and what the doctor knew was at least as immense as it is in today’s world of endless complexity. The relationship was not adversarial, though, but was rather very cordial and respectful in part because the doctor behaved as a professional, putting his patient before essentially everything including his own family. To be truthful this lead to some pretty dysfunctional physician families in the days before divorce, and a  pitifully high divorce rate among medical families once divorce became more common. But the primacy of the patient and the profession remained through all of the societal changes occurring around medicine in the 60’s, 70’s and 80’s.

What happened? Why do old guys like me and my friend Bill feel that new doctors are different? What is different about them and how did this happen? Somewhere in the 80’s there was a shift in how Americans viewed their doctors. No longer was the first instinct to trust, to respect a doctor simply because he (or she, now) had earned a degree. It became a little less OK to get up in the middle of the night, to leave the dinner table to take a call once the level of appreciation of the sacrifice involved declined. Add in a steady decline in income and a steady increase in bureaucratic headaches that took time away from doctoring and it was harder to feel good about putting your patient first. Yet doctors of a certain age continued to do just that because, frankly, it was what they had been trained to do and it was all that they knew.

If you talk to most doctors over the age of 40, and certainly any doctor over 50, you will hear them lament that younger doctors do not place enough emphasis on being a doctor. That newer doctors are selfish, too concerned about themselves and their lifestyles and their own comforts. Talk to a patient at 2:00 AM? No way–I’ll be too tired tomorrow. See a patient at 1:00 on a Saturday or on a holiday? Sorry. That’s family time. Is this all bad? Well, from the standpoint of the physician’s family it’s probably a very good thing, and who can blame the young physician if you think about it. Why should they put the patient first when in their minds they no longer get the respect and appreciation for doing so? When they are constantly second guessed by the Google-empowered, and paid less to boot. But if you are a patient and you call YOUR doctor it’s a little less of a good thing.

Why do doctors like Bill not adopt this attitude? I think it goes back to the traditional residency training that doctors of our generation endured. As a general surgical resident Bill routinely put in 100-120 hour weeks learning to function at a high level when tired and learning about how diseases progressed as you watched continually over time.Even more importantly the instinctive reflex to respond when called was indelibly ingrained. In residency training nowadays, not so much.

In the late 80’s I think it was, there was a very famous case in New York, the Libby Zion case. Young Ms. Zion was brought to an ER and was under the care of an intern heading into her second day of work without sleep. A medication error was made (Ms. Zion neglected to mention an illegal ingestation and the intern failed to consider the possibility) and Ms. Zion died. Now, Ms. Zion was the daughter of a rather famous publisher in New York and the case became a cause celebre. The intern was vilified, the hospital was sued, and calls rang out for reform of the medical training system that left a patient under the care an intern who had been awake and working for more than 24 hours. The well-known effect of fatigue on performance was judged to be the cause of the error and a sea-change in how doctors are trained resulted. Every state now has explicit laws that limit the number of hours a doctor-in-training, a resident or intern, is allowed to work in a day and in a week.

Was that it? Is that why Libby Zion died? Because an intern was awake for more than 24 hours and still at work? Did the system fail Libby Zion and rob the Zion family of their daughter? These are important questions because the work rules that have resulted from this case have contributed to the kind of doctoring we are now getting from our newest trained doctors. I believe the system did INDEED fail Libby Zion, but NOT because her intern was working more than 24 hours without rest. In my opinion the system failed because the other doctors who were supervising the young intern left her alone. Her resident, fellow, and attending failed to engage the case as they were obligated to do under the residency system, leaving an intern to fend for herself in a complex case. The senior doctors in the system failed their intern, a systemic failure that was, and would be, independent of the number of hours worked by the intern.

In came the “Do-Gooders” and “Know-Betters” to solve this problem and prevent any other Libby Zions from coming to harm at the hands of an overworked, under-rested intern. We are now training new generations of doctors who never learn what it is like to work under the pressure of fatigue. They never learn that reflex of going to your patient first, last, and every time because they never get called to do so–they have turned over the care of that patient to their relief. Our residency training programs are now turning out medical shift workers who punch a clock and put in their time. Patients don’t stop being patients and diseases don’t respect either the clock or the calendar, but in their zeal to correct the (wrong) problem with medical training that contributed to Libby Zion’s death the crusaders have removed one more cornerstone from the foundation of the practice of medicine: doctors don’t stop being doctors after office hours.

The law of unintended consequences is alive and well in medicine. Reform has come  although it is still quite an open question as to whether this has really made medicine in training programs any safer-the senior residents and attendings still need to show up to back an inexperienced, albeit well-rested  intern. A trend toward less respect for doctors and therefore less satisfaction while practicing medicine is now augmented by a training regimen that teaches our residents that they work on a clock. When they close the clinic door they leave not only the office but their patients behind. Not surprisingly this leads to a public with less respect for doctors and medicine. And on it goes.

So how did our dinner end? Although Bill was not on call the child of an OR nurse was in the ER with appendicitis and she insisted that Bill be called to do the surgery. Mid-way through the veal Bill left with a touch of sadness at the interruption but with no apology. We are, after all, the same age, doctors and surgeons of the same vintage, and Bill knew that I would understand.

I’ve never been happier to pick up a tab.

In any discussion or debate about a “Big Idea” the quality of the discourse depends in part on the accuracy and specificity of the definition of terms, as well as the amount of agreement among the participants as to the actual question or idea that is under consideration. When the discussion is proceeding with the goal of establishing a solution to a “Big Problem” or crisis, it is also useful to have performed a root cause analysis of the crisis so that one can assess whether the “Grand Solution”  is targeted at the true problem or simply aimed at a symptom of that problem (hey…I’m a doctor…I can’t help myself with the medical analogies). In short, in order to avoid the all too common trap of “talking past one another”, participants in this type of discussion must agree on premise and definition before embarking on the journey.

Unless, of course, the participants are politicians, government bureaucrats, or other creatures who feed with them and upon their offerings.

We are being bombarded with articles, speeches, broadcasts, and Tweets about the “Health Care Crisis” in America. In my reading there seems to be at least a dozen separate discussions occurring under this heading, mostly due to the fact that the above two rules about premises and definitions are being ignored, either inadvertently or willfully. So why don’t I offer up a couple of definitions that will allow us to explore the root cause of this so-called “Health Care Crisis”? Who knows? Perhaps a solution might arise.

Loosely defined terms allow a type of linguistic abuse in “Big Idea” discussions; this abuse usually involves some sort of secondary gain (money, power, legacy). The more loose the definitions the more abuse made possible. What is meant by “Health Care” and what should the definition really be? At present “Health Care” when combined with the term “Crisis”,  means the cost of providing health care. “Health Care” is properly defined as the provision of medical care, cognitive, diagnostic, and procedural, that actively prevents or cures disease.  I think anyone who has been paying attention would agree that we might very well have a “Health Care COST Crisis” in America right now. It’s really expensive to provide  health care to  everyone who needs it in America.

Do we have a “Health Care Crisis” in America? Are our hospitals, our doctors and our nurses providing inadequate or bad care? Pundits, politicians, and plain old people on the street point to the fact that the United States does NOT have the highest life expectancy among developed countries and say that the answer must be “yes”. They point out the regional discrepancies in treatment protocols and health care expenditures and say that this is proof that healthcare providers are not providing the best care possible. I would argue just the opposite. The actual “Health Care” that is provided in the United States is superior to that provided anywhere else in the world. I will show in a minute that this is actually part of the “Cost” problem.

These same people  then point to the fact that, at any one time, some 47 million Americans are without “Health Coverage”, what we call health insurance, and that this lack of financial coverage preventing them from gaining access to health care is causing  preventable deaths. These preventable deaths explain the lower life expectancy of Americans in comparison with, say, Swedes. It turns out that this, too, is a canard. A red herring. Americans without “Health Care Coverage” do in fact have access to health care, and access to “Health Care Coverage” or health insurance does not appear to affect life expectancy.

No matter how you slice it this discussion or debate comes right down to the most basic definition, which then establishes the most basic root cause of the problem. We do, indeed, have a “Health Care Cost Crisis” right now in America, but it all stems from the undeniable fact that we have a “HEALTH CRISIS”, and it’s getting worse. Our people are more and more unhealthy and our phenomenal ability to care for their diseases is allowing them to live unhealthy lives longer. This  allows us to spend more money on keeping them alive.

The Eight Americas Study published in the People’s Library of Science examined life expectancy in America and the factors that influence it. (http://www.plosmedicine.org/article/info:doi/10.1371/journal.pmed.0030260) The population of the United States was divided into 8 cohorts based on age, race, county of residence, race-adjusted income, and cumulative homicide rate. Cause of death was recorded and variables such as whether or not the individual had health insurance were tabulated. The difference between the longest lived cohor  and the shortest-lived is 35 years! The results are as surprising as they are counter-intuitive. While income is a weak factor underlying this difference neither “Health Care Coverage” nor access to health care is a factor.

“The eight Americas analysis indicates that ten million Americans with the best health have achieved one of the highest levels of life expectancy on record, 3 y better than Japan for females and 4 y better than Iceland for males. At the same time, tens of millions of Americans are experiencing levels of health that are more typical of middle-income or low-income developing countries… The health disparities among the eight Americas cannot be explained by single causes of death such as homicide or HIV. Nor are the largest sources of disparity in children and the elderly. The mortality disparities are most concentrated in young and middle-aged males and females, AND ARE A RESULT OF A NUMBER OF CHRONIC DISEASES AND INJURIES WITH WELL-ESTABLISHED RISK FACTORS.” (emphasis added)

Yes, we have a Health Crisis in the United States. It is a crisis born of preventable injuries and disease (vehicular accidents, alcohol-related homicide, diabetes, heart disease) with actionable underlying causes and risk factors (alcohol abuse, tobacco use, obesity). We have aided and abetted this Health Crisis because we do NOT have a Health Care Crisis; it is precisely our ability to treat many of these diseases that keeps many unhealthy Americans alive. We bear the financial consequences of this Health Crisis as a nation.

The solution to this problem becomes rather clear once we have the appropriate definition of the problem and once we identify the underlying cause of the problem. It appears that we cannot afford to pay for all of the health care that will be necessary to keep Americans alive if we continue to go on with things as they are; we have a “Health Care Cost” problem. The root cause of our financial problem is that a large percentage of Americans are not healthy; we have a “Health Crisis” and this is largely due to problems that can be prevented. No amount of “Health Care Reform” that involves changes in how we pay or who ultimately pays for healthcare will solve our “Health Care Cost Crisis” unless we solve the underlying problem of unhealthy Americans. The solution to this problem is a PUBLIC HEALTH  strategy that will improve the health of Americans, and it is here that funding and reform should occur.

Now, when this inevitably  fails to occur because there is no near term secondary gain to be had  we can have a discussion about the “Leadership Crisis” in America.

I’ve been thinking a lot about health care recently. Real health care, not Health Care as in “Health Care Crisis” or “Health Care Reform”, but the kind of health care that is provided by doctors and nurses and all kinds of other health care providers. You know, like making sick people better, and keeping healthy people healthy. The kind of health care that old guys like me (I’m 49, in case you were wondering) got from pediatricians like Dr. Roy in Southbridge, MA in the 60’s, or like my sons get from Dr. Gerace in Westlake, OH today.

I did a lot of thinking about this some 5 or so years ago, too, when I developed the concepts that eventually resulted in Skyvision Centers. My mini-epiphany at that time is that medicine is the ultimate consumer service business. At its core medicine is about one group of people providing a service to another group of people who either want or need that service. It’s the most intimate type of service, too. One to one. Face to face. You and me.

There is a remarkable lack of difference between doctors (and hospitals, for that matter) when you look at the outcomes that arise from that service– how many people get better after receiving medical care for their illnesses. The difference between the top 1 or 2% of doctors and the 50th percentile in terms of real medical outcomes is remarkably small, and much smaller today than it was in the days of my Dr. Roy.

Sure, there are differences in how people arrive at getting better. Some very instructive studies from Dartmouth have shown dramatic regional differences in the U.S. in how much money is spent on treating heart attacks, for instance. By and large, though, the same number of people get the same amount of better no matter where they are treated or from whom they received that treatment, and the quality of those treatments is several orders of magnitude greater and better than it was in my youth.

So what was it about Dr. Roy that people in my generation seem to have so much trouble finding in medical care today? If the treatment of diseases is so much better now why do so many people complain about medical care today? Why is it that Dr. Gerace has people lined up waiting to see him while other doctors don’t? Why do people rave about their experience at Skyvision Centers and complain so bitterly when they need to have a consultation at some of the most famous medical institutions in Cleveland?

I think it’s because Dr. Roy, Dr. Gerace, and I were all, once upon a time, caddies.

Seriously. We spent the earliest part of our working lives on the lowest rung of the service ladder, providing one-on-one service for a single customer. Because of that I think each of us realized that what really sets doctors (and hospitals) apart is what a patient experiences when they visit. The most successful doctors and the most successful medical practices are those who have realized that the central character in the play is the patient. The most successful caddies never forget that the most important person on the course is the golfer. The job of the caddy is to help the golfer perform a well as possible (maximize the health of her game) while at the same time making sure that she has a wonderful experience on the golf course.

Ben Stein wrote a recent column in the NY Times about his first real job; he was a shoe salesman. Imagine, at 17 years of age, selling shoes. Days filled with all manner of customers and handling the foot of each and every one of them. Customer service and sales is “learning the product you are selling, learning it so well that you can describe it while doing a pirouette of smiles for the customer and talking about the latest football scores” no matter who that customer might be. Tinker, tailor, soldier or spy, junior partner or janitor. Be they humble or haughty, gracious or grating. Totally focused on that one customer in front of you in order to provide them that service. The same can be said for any front line service job. Waitress in a diner, car mechanic, you name it.

My first summer job was caddying, and I caddied for parts of each summer through medical school. As I think about it now after reading Stein’s article it’s amazing how many parallels there are between my first job as a caddy and my career as an eye surgeon. I toted the bags for one or two golfers at a time; I usually have a patient, patient and spouse, or parent and child in the office. I was a better golfer than almost all of the men and women for whom I caddied; I know more about the eye than every patient who visits, google notwithstanding. In both circumstances my success was/is determined by my customer’s (golfer/patient) outcome, their “score”, as well as their view of the experience. Even a career-best round doesn’t feel quite as enjoyable if it took place over 6 hours in the company of a surly caddy!

I’ll tell the story of how this turned into Skyvision Centers another time; it’s a neat story and I love telling it. For the moment, though, I have a little experiment for anyone who might be listening, and a modest suggestion for the powers that be in medical education (who most assuredly AREN’T listening). The next time you visit a doctor ask him or her what their first couple of jobs were. See if you can predict which of your doctors or dentists or nurses had what kind of jobs before their medical career based on the kind of experience you’ve had in their offices or institutions.

Let’s add a little time to the education of the folks who take care of our medical problems, especially our doctors. How about 6 months selling shoes at Norstrom’s. Or a year of Sunday mornings slinging hash at a local diner. Better yet, let’s get all of those pasty white interns out on the golf course with a bag on their shoulder and a yardage book on their hip, golf hat slightly askew and Oakleys on tight (for the record, even people of color end up “washed-out” after a year of internship). Let ‘em learn how to take care of a customer without the huge advantage of all that medical knowledge. We’ll take the best of them and turn them loose in offices all across the land. Those who can’t hack it, the ones who can memorize the history of Florsheim but can’t bring themselves to touch a foot, who are scratch golfers but can’t bring themselves to congratulate the hacker who sinks a 30 foot double-breaker, those we’ll hide in the lab, or put them in huge, anonymous medical centers, one more anonymous member of an anonymous team hiding under the brand umbrella of some “World Class Clinic”  where one-on-one customer service never really happens.Because the ultimate consumer service business is medicine.

Just ask a caddy.