The Pace of American Medical Training

In his commencement address at Kenyon College in 2005, the late author David Foster Wallace told the story of two young fish swimming along. They pass an older fish swimming the other way who greets them: “Morning boys. How’s the water?” As they swim on, one of the younger fish responds to the other, “What the hell is water?”

Feeling and appreciating your body of water takes experience, maturity, and occasionally someone else making you aware of your daily surroundings. It was not until a few years into my career as a Family Medicine physician that I realized the furious pace at which American physicians learn to swim, insulated in a system that operates in stark contrast to that of other countries around the world.

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What kind of young physicians is our system creating?

Six months into my first year of residency, I was on a rotation with an energetic Orthopedic Surgeon. Our residents looked forward to our time with him. Residency training is a time for young physicians to drink from a fire hose of information during long work hours, learning not just clinical medicine but also the business of healthcare. As we stood outside the exam room preparing to see the next patient, the topic of medical malpractice came up. He stated, “Every time I walk into a patient room, I see the patient in front of me, the insurance representative on the right, and the malpractice lawyer to the left.”

At morning report following nights on call in the hospital, we would present each admitted patient to our Attending Physician who taught us clinical pearls and also regaled us with stories regarding malpractice cases that had arisen from similar situations. He helped us refine our documentation and ensure our trail of charting and medical care would back us up in the event of a lawsuit.

Several times faculty physicians reinforced my plan to order studies to ensure a life-threatening condition was ruled-out. Many could have been reliably excluded with physical exam signs or patient risk factors, but I had been trained to rely on technology to definitively prove my clinical hunch. I have never been the subject of a medical malpractice lawsuit, but I practice as if I have.

So each month, I gathered nuggets of information from my professors regarding medical business practice, detailed documentation, and using technology to prove diagnoses. These lessons all slowly seeped deep into my practice habits. And, much like an older brother repeating a parents’ teachings to a younger impressionable sibling, I taught these to junior residents and medical students.

Then came several stints in a rural health center in Kenya and a three-month course in tropical medicine put on by the London School ofHygiene and Tropical Medicine in Tanzania and Uganda. My classmates were from the United Kingdom, Australia, Germany, Tanzania, Uganda, and even Botswana, among other countries. Out of the 57 young physician students from around the world, I was the only American. Through work in the resource-limited health center in Kenya and a subsequent year of teaching medicine in East Africa, and discussions with my tropical medicine classmates, I started to see my water more clearly.

Fear of medical malpractice lawsuits and defensive medicine are unique American system attributes. The private fee-for-service system without a firm foundation of public care is an American trait. Patient cost sharing having no basis on the actual cost of care makes the US health sector unlike any other. Mountains of educational debt following medical school are only found in the American system. The large pay increase that first year as an independently practicing physician after postgraduate training is a massive incentive only present Stateside.

How do these elements affect healthcare delivery in one of the strongest economies on the planet?

In the documentary film Escape Fire, former Centers for Medicare and Medicaid Services Administrator Donald Berwick says he does not blame anyone in the American system for doing what they are doing. Hospitals fill hospital beds because they are incentivized to do so. Physicians enter lucrative sub-specialties at times partially motivated by the need to pay off educational debt, and many go straight through medical school and residency eager to absolve that debt. Seventy-six per-cent of American physicians graduate medicalschool with an average of almost $190,000 of educational debt. Can we blame them for sometimes seeking more profitable specialties and blazing straight through training? I finished training as quickly as possible at the age of 29 with just over $200,000 in debt and no savings, and then entered practice in the fee-for-service system. And the path of least resistance was to follow the volume-based carrots laid out by my predecessors.

The lessons of older physicians are percolating down to breed younger physicians with similar attitudes. And that should be concerning. What were once young idealistic physicians, are now caregivers entering a post-Affordable Care Act system with the same views as a physician who was raised in the fee-for-service scheme. 

How do we incentivize young physicians to enter the right mix of specialties and shape them to serve an aging population in a changing system?

We must start by addressing the cost of medical education. Without the heavy debt burden, financial incentives lose their power. Next, improve the pay during postgraduate training, while encouraging, through funding or built-in time away from the home institution, extended breaks in training if the physician so chooses. This time away could be used for international rotations, administrative or policy placements, or exploring research opportunities that interest them. For example, young British physicians take months, sometimes years, away from their postgraduate medical education to work with non-governmental organizations (NGOs) or in academic settings in low-income countries. During this time out of their comfort zone, physicians have more time for self-reflection while pursuing personal interests. This may very well extend the length of training, but without debt creating the race to finish, this would be less bothersome to young physicians. In fact, many young physicians start out craving these seemingly extracurricular experiences, but there is currently little time or support for what would be key to a physicians’ personal and professional growth.

When the system of education changes to encourage outside perspective gathering experiences, our system may well end up with physicians whose incentives better align with the most important healthcare player of all: the patient. That physician will be more confident in her physical exam skills rather than relying on technology, which will in turn lower costs in the most expensive healthcare system in the world. That physician will be more in tune with herself and the need to care for herself before caring for others, thus lowering chances for burnout and improving longevity. That physician will be more empathetic to patient needs, leading to higher quality care.

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One must smell poverty to recognize the stench of inequality. You have to be confronted with true hopelessness to detect suffering. You must feel, at some point, uncomfortable to identify vulnerability.

Learning medicine takes years of study, sacrifice, and repetitive pattern recognition. Caring for another human takes a self-awareness that requires an intimate full sensory appreciation of your surroundings. And only with these skills sharpened, can the leaders of our health system take that vital swim alongside their patient.    

Health System Reform?

The bill was signed today. The Republicans are offering amendments in the Senate, which will likely be futile. Was this really health system reform? That was the initial goal, but ended up as health insurance reform. Was the change in nomenclature simply a change in course to only reform one part of our system? Or was it just a cloak, a change in the title instead of the substance, to settle down the masses? Our entire system needs reform.

Where were the medical liability reforms? Where was the change from an employer-based system, to a system of individuals buying portable insurance? Where was the overhaul to allow Medicare to negotiate with pharmaceutical companies for cheaper drugs? Not only did we not just accomplish health system reform, but we did not accomplish it in the manner promised us by the candidate Obama.

Worse than anything, watching the debate on C-Span Sunday night made me think - this was not the way it was meant to happen. Democrats ignoring Republicans. Republicans shouting on the House floor. Instead of legitimate open-minded debate, we saw political theater at the primetime showing. Democrats wrote the bill with little Republican assistance, and there was little teamwork to produce this sausage.

Some of my fondest memories throughout my medical training have come during heated debate at American Medical Association meetings. The back-and-forth, usually led by my liberal-leaning fellow medical students and physicians-in-training, and generally enhanced by the fatigue that comes from a day of discussion and panels and meetings, topped with a touch of wine, generally led to a powerful consensus: Our healthcare system needs a life-saving operation. While the views of my friends out in the pacific northwest typically didn’t align with those of my own more conservative camp from Texas, we almost always found common ground. Each time we ended with a heightened sense of mutual respect for the others’ views and goals, and our friendship grew. What harmony.

Where was this agreeable attitude amongst our Congress? Have the last few administrations and elections, and most importantly the media, this effectively polarized our country and its leaders?

In the end, what are we left with? Health system reform (or was it health insurance reform?) that was passed - squeaked by the House, and Reconciliation that will survive the Senate only with the help of the Vice President’s vote. And to slap the exclamation point on the end, the Vice President demonstrated powerfully just how much of an accomplishment he felt this was.

This entire debate has left me confused about what “side” I’m on in this debate, in this polarized country, where everyone is forced to choose. Black or white. For the uninsured or against the uninsured. For lawsuits or against them. Expensive medication or cheaper medication. Tax Cadillac insurance plans, or not. And finally last night I was asked, “Can anyone really be just ‘for’ or ‘against’ healthcare reform?” Brilliant question.

No. The answer is no.

The 2700-page bill, the health system, the debate, has many aspects, many working parts. You can support parts, and want revisions to others. Truthfully, our system needed a change. Not only a facelift, but a transplant – in most areas. We needed drastic changes, but in this climate severely lacking in compromise and the ability to work in the grey zones, this wasn’t politically possible. (Whether that’s the media’s fault, or the fault of the politicians themselves, I’ll let you be the judge.) In the end, I want what’s best for the patients in our country. I want for everyone to have access to quality healthcare. And if that makes me liberal, then I guess I am.

And finally, my favorite quote from the grand finale Sunday night comes to us from Paul Ryan, Republican from Wisconsin: "The philosophy advanced on this floor by this majority is so paternalistic and so arrogant - it’s condescending.” This debate has forced me, and many of us, to reach deep down and ask what we believe and why we believe it. At my core, I believe the government is not itself the answer to our greatest problems – and if that makes me conservative, then I guess I am.

So, if you’ve had trouble picking between the two sides in this debate, don’t worry: You don’t have to, and you’re in good company.

Christmas List for the Healthcare Policy Nut: Beans and MRI's

While the Senate attempts to pass its version of health system reform and the CBO completes its tally, the debate centers around one final question: Are we going to decrease the cost of our system?

On first blush, we say no. Even Democrats admit this. Dr. Atul Gawande, author of Complications, the book that once inspired my focus on studying for the MCAT, is left to compare our healthcare system to that of the agricultural gains in the early 1900’s in the most recent New Yorker. The farmers were inefficient and resistant to change. Along came the USDA and a few initiatives that at first were feared as the “government takeover” of the agriculture industry, but instead proved to assist the farmers in increasing efficiency and supply, thus decreasing costs for the average American and increasing profit for the farmers who followed the evidence-based recommendations.

Dr. Gawande was also the part med student, part policy wonk who set out (along with a few others) to design President Bill Clinton’s attempted health overhaul in the early 1990’s. While some contend that then Student-Doctor Gawande and the other higher-ups, including Hillary Clinton, got too bogged down by the many policy details to produce a timely bill, others will say that President Clinton simply didn’t handle the political situation as well as he could. In conclusion, Dr. Gawande may know a thing or two (or three) about controlling costs, but I find it hard to believe that the cotton industry can relate to patient care. The diversity of agriculture industry hardly compares to the art of medicine and the intricacies of bedside medicine, although his praise of the many pilot projects in the current Senate bill that will be put into action should they be passed into law may well be what we need.

It’s time to figure out how to cut costs in our healthcare system – one that currently has the ability to bankrupt even a middle class family, yet still leaves our country ranked number 37 by the World Health Organization based on many “quality” measures. A few friends asked me my views on this whole debate when it all began, so here we go:

Transparency
When you go to the grocery store to buy beans, you go to the bean aisle to check out the different beans. Let’s say you decide you want black beans, and then look at the different types of black beans. Do you want organic? Do you want the cheapest? You peruse the labels, and based off of quality, perhaps off brand name, or maybe just based on cost alone, you select your can of beans. All the information you needed was on the label, and you made your decision. When you went to your last doctors’ visit, or when you signed up for your health insurance at your last benefits renewal day, how easy was it to comparison shop and to make your decision based off of quality and cost? Healthcare shopping these days is in a class of its own. In what other sector do you buy a product without first comparing it to other similar products, and the prices of each?! None. This is where the first element of decreasing costs comes into play: Transparency.

We must have an easier mechanism for which to shop for health insurance and medical care. If you could compare the different health insurance companies side-by-side in an easy-to-read format, and had more options than just what your employer offered you (thus, on the individual market), the insurance companies would be forced to compete on a larger scale. They would compete for each individual’s business, rather than competing for bigger companies’ business, to whom they sell big bulk non-personalized plans. That’s how your HR team at your company works. They shop around to the different insurance companies and find you the health insurance plan that will cost them the least, yet still offer you the standard services. And they get a discount by buying bulk. But your health needs are very different than those of your colleagues, so why wouldn’t you like a health insurance plan that offers you only what you need – no more, no less?
If we all shopped on the individual market instead, the insurance companies would be forced to offer a higher quality, more tailor-made product, at a lower cost to you. I don’t know much about economics, but economies of scale are a wonderful thing. But what if you had this type of smooth-sailing shopping experience at your doctor’s office…

Quality and Competition
Before you go shopping for your next best and cheapest pap smear, we have to figure out how to measure quality. Physicians’ quality should be measured – surgeons, family docs, and psychiatrists. Hospitals’ quality should be measured. Nursing Homes’ quality should be measured. This raises a few eyebrows among the physician community for many reasons. How will quality be measured? What if a surgeon takes on a very sick patient, for a risky surgery, in hopes of helping that patient? Will the measurement be “risk-adjusted?” This will have to be done carefully to ensure that hospitals don’t keep the sick out, and only take on healthy patients, for fear of hurting their quality “score.”

Quality must be measured, but there need to be many stake-holders who decide HOW we do that. This will be a delicate task, and our success will depend on how we decide to measure quality. What if I as a Family physician have a patient that does not take his Diabetes medication as recommended, or does not follow the diet he knows he should, and thus his Hemoglobin A1c (a measure of the average blood sugar over the last 3 months) is extremely high? If that hurts my quality ranking, then I should not be incentivized to kick my patient out of my practice. That brings us to our next topic.

Personal Responsi… Care and Pay for Yourself!
With the intervention of the third payer (health insurance), the contract between the physician/provider and the patient has been lost. Most health insurance plans pay for care, and you as the patient simply pay a “co-pay,” or a set fee, no matter what the cost was to the insurance company. This may be great if it’s a $1000 MRI. You paid a $100 co-pay no matter how much your MRI was, but what if you had to pay the entire fee? Would you have comparison shopped like you did for your black beans? This could have the potential to greatly reduce costs! The cost variation on certain imaging tests like MRI’s is great – but you would never know it, because you’ve never shopped for an MRI. You just paid your $100 co-pay and went to the closest place.

Even Jason Furman, President Obama’s Deputy Economic Director agrees with this (according to a recent WSJ ‘Cost Control’ Op-Ed). Where were his suggestions in the Senate bill? Imaging centers would be encouraged to publish their list of services and have the best product at the lowest cost to attract business much like in other sectors.

Defensive Medicine
It’s real, whether you like it or not. Physicians order tests for the phantom lawyer who might sue them in the future. An Orthopedic Surgeon I worked with once told me, “When I walk into a patient’s room, I see the patient in front of me, the insurance adjuster sitting on this side of them, and the lawyer on that side.” His point was that with every single patient he considers the medico-legal ramifications of what he’s about to order, or not order. While I as the Resident physician, learn to put together the puzzle pieces of each unique patient’s case, practicing the art of medicine, I am constantly reminded by the older, wiser physicians that my physical exam and history clues will not matter if I don’t have the (sometimes) expensive diagnostic or laboratory test to prove, to document that that patient did not have a life-threatening pulmonary embolus (PE). It doesn’t matter if their oxygen saturation, heart rate, and respiratory rate were all normal, if they left my ER without the CT Angiogram that proved for once and for all that they did not have that PE, then that is a lawsuit waiting to happen. So I order the CT Angiogram – just in case – to defend my potential future case. That’s defensive medicine.

The Pacific Research Institute, a think tank out of California, published a large report a few years back that claimed that our medical malpractice system in the U.S. costs our country greater than $800 billion each year! Medical malpractice suits end up not in front of a jury of the physicians’ peers, but rather a jury of the plaintiff’s peers, and the southern region of my great state of Texas is one of the most plaintiff-friendly areas in the nation. Even if the case doesn’t make it to trial, there is money expended in lost wages for the parties involved.

Now, in any medical malpractice case, there are economic damages, such as lost wages and hospital bills, that a monetary value can easily be placed upon, and non-economic damages that are more subjective such as “pain and suffering.” If a physician made a mistake, the economic damages might include bills from a prolonged hospital stay. When that guy spilled hot McDonald’s coffee on his lap and won millions for his anguish, those were non-economic damages. Are you with me?

In 2003, Texas passed Proposition 12, adding Tort Reform to our already lengthy state constitution. The new law enacted limited non-economic damages only, to $250,000 per entity per case. There was NO ceiling placed on economic damages. So, if you stayed in the hospital for millions of dollars longer than you should have, you could still be compensated for that full amount. Because of these reforms, in just a short six years, the medical malpractice climate in Texas has without debate improved greatly. Before this law was put into play, physicians in higher-risk specialties such as Neurosurgery, OB/Gyn, Orthopedic Surgery, and Emergency Medicine were paying up to $50,000 or $100,000 each year just for medical malpractice insurance! That same Orthopedic Surgeon I worked with said that since this law went into place, his malpractice insurance premium dropped from $49,000 each year to $19,000 each year. And the amount of medical malpractice insurance carriers in Texas has increased from three to over 20, increasing competition. And the amount of medical malpractice lawsuits has dropped significantly. Many plaintiffs’ attorneys aren’t taking cases any more unless they know there’s clearly been some wrong-doing. The opportunity for exorbitant profits for plaintiffs’ attorneys simply isn’t there anymore. The John Edwards of our state, who made their millions by suing physicians, could still win cases on behalf of patients, yet not with their big personal (subjective) payday.

There are physicians and hospitals that make mistakes, and there must be recourse. And there still is. In Texas though, we now have fewer frivolous suits and for that our state is more attractive than ever for physicians. Our state medical board at one point had a 12-month back-log on processing applications of new physicians coming into our state after these reforms took hold, and now our physician workforce is growing fast to serve the patients in our state. What if similar reforms were considered at the federal level?

Were those in power in D.C. not lawyers themselves, and were the trial lawyers’ associations not one of the most powerful (and by powerful, I mean, give the most money to lawmakers when they run for office), we may just be considering this crucial part of health system reform as a part of the 2,000-plus-page bill before the U.S. Senate. But there is nothing in these bills other than a few million dollars to study some small pilot programs. How about looking at the data in Texas over the past six years?

Cook-Book Medicine, Government, and Check-Out
It’s time to expand the amount of information available to the public about costs, and to put more of those costs into their hands. Physicians, hospitals, health insurance companies, and pharmaceutical industry – everyone will be measured based on quality outcomes and cost, and the information should be available to all who seek it. Maybe, just maybe, the government can have a role here, in facilitating the discussion and research that will bring us to our grand solution many years down the road. The government should not however, develop their own “best practices,” and their own cook-books for physicians to follow. Physicians train for years, a minimum of seven years from the start of medical school to finish, to even begin to master the art of medicine. Let’s harness that skill, and use it to increase the quality of care delivered in our country. And let’s measure that quality, so that competition will help our sector decrease costs on its own without managed controls from academics or technocrats.

Without the above measures, or at least significant steps towards including these, we will not see substantive strides towards lowering the costs and increasing the quality of care delivered in our country.

It’s time to buy your beans. You chose the cheapest beans. I chose the more expensive beans for reasons important to me. I knew the price, and I was willing to pay the full price for it. We both knew the quality, because of the information we had available, and we made the best decision for each of us at that time. And our system won, because the beans companies competed for our business.

Poltically, for the Democrats to cling onto any sort of mandate in 2010, something has to pass. Thus, we’re left to hope for one of two things: that we’re either granted more time next year to consider further health system reform before the leadership decides to ram sweeping legislation on a politically unpopular, yet extremely difficult and intricate topic, through our Congress, OR at the very least that Ms. Pelosi and the conference committee participants have shopped for beans lately.