Stepford doctors

Ever since variation was declared to be an enemy of medicine there has been a multifaceted unrelenting effort to constrain the autonomy of clinicians.

In an article in the Medical Humanities journal titled “Stepford doctors”: an allegory GM Sayers described this trend creeping towards the ultimate creation of a workforce of Stepford doctors. 

From the paper:

The Stepford Wives, a novel by Ira Levin, provides the theme for this allegory. The men of Stepford belong to the Men’s Association. Their wives are “perfect”, in that they do nothing other than clean, cook, preen, and provide satisfaction without argument for their husbands. They are, furthermore, content with their lot, and believe that their previous interests and freedoms were self indulgent.

Applying the allegory to hospital medicine, Sayers wrote:

In the hospitals, doctors were pooled and moved like pawns to fill clinical slots, by masters who controlled both board and pieces...

The masters were not doctors; they were experts in managing time, costs, and doctors. They had not studied medicine, bioethics, or humanities; they were devoid of empathy. They did not treat patients, perform operations or do clinical research. They did not break bad news or get consent from patients for surgery. Nevertheless, they knew what sort of doctors they wanted—‘‘Stepford doctors’’. These were not ‘‘excellent’’ doctors, but ‘‘good enough’’ doctors, who would devote themselves to the masters’ objective of expediency, and the masters’ duty to balance the budget.

It is not completely clear how the masters changed the thinking and acting of so many doctors, but they did. Some of the doctors accepted the superficial plausibility of the reasoning that informed the masters’ demands. Some of the doctors themselves became masters, and they persuaded other doctors that the way the masters saw medicine was the way medicine should be.

 

The article was published in 2006 and might be considered dated but the premise is even more relevant today. In the words of the author: “This allegory cannot be concluded because it is on going.”

Are internal medicine’s core values effectively applied in today’s hospitalist practice?

Hospital medicine has changed. The change has been brought by business and regulatory pressures rather than the core values of internal medicine. Internal medicine’s core values are timeless.

Phillip Tumulty was famous as one of internal medicine’s great teachers. He was a lead faculty member in the department of internal medicine at Johns Hopkins for over 20 years. He published an article in JAMAInternal Medicine in 1977 in which he laid out some of the core values of internal medicine. Tumulty, an exemplar of internal medicine if their ever was one, had these things to say (paraphrasing from some of the points he made):

An internist is meticulous in the application of expertise in history and physical examination.

An internist develops a “referral practice” which leads to distinction among peers. (In other words, an internist is a specialist).

An internist “must not nod, nor grow bored, but sustain his enthusiasm through constantly searching for the unexpected in the seemingly obvious. Its occasional discovery in a patient’s problem hitherto passed over as routine brings self renewal.“ In other words the internist’s professional satisfaction feeds on being able to spot zebras in the morass of “bread and butter“ problems.

The internist should not be regarded “merely as some useful indispensable medical work horse, ably attending to the daily clinical chores.“

Tumulty summarizes his points this way: “some may say this is all very well but only as an idealistic concept of a kind of clinician and care that is no longer practical. I agree; it is indeed a concept of excellence. However, in the care of the sick, should one plan for less?“

Are the pressures and expectations placed on hospitalists today aligned with these core principles and values of internal medicine as articulated by Tumulty?

Is evidence based medicine the same as science based medicine?

 In its original notion, yes.   In its widespread popular distortion, no.  Harriet Hall explains.

 

 

Very low utilization of advance care planning (ACP) CPT codes among hospitalists

From a recent study:

We analyzed advance care planning (ACP) billing for adults aged 65 years or above and who were managed by a large national physician practice that employs acute care providers in hospital medicine, emergency medicine and critical care between January 1, 2017 and March 31, 2017. Prompting hospitalists to answer the validated “surprise question” (SQ; “Would you be surprised if the patient died in the next year?”) for inpatient admissions served to prime hospitalists and triggered an icon next to the patient’s name. Among 113,621 hospital-based encounters, only 6,146 (5.4%) involved a billed ACP conversation: 8.3% among SQ-prompted who answered “no” and 4.1% SQ-prompted who answered “yes” (for non-SQ prompted cases, the fraction was 3.5%; P less than .0001). ACP conversations were associated with a comfort-focused care trajectory. Low ACP rates among even those with high hospitalist-predicted mortality risk underscore the need for quality improvement interventions to increase hospital-based ACP.

The last sentence is a non sequitur. The codes are an unreliable measure because many, I would wager most, ACP discussions are not billed with these particular codes. Many hospitalists don’t even know they exist. The codes, 99497 and 99498, were not even included in the fee schedule until 2016 so they were brand new at the time of the study.

Ten years ago similar codes were proposed under the Affordable Care Act but spurred fierce debate around “death panel” fears. Those provisions were dropped before final passage of the law. What’s interesting is how these provisions were slipped in out of most people’s awareness, with no public debate to speak of, seven years later. Political winds change and people are easily distracted.

Only the American Association of Physicians and Surgeons, (AAPS), a relatively minor player in the larger physician community, seemed to mind. They argued that the codes, which pay more than ordinary CPT codes, would incentivize doctors to talk patients out of life prolonging treatments. That’s an oversimplification, of course, because some ACP conversations produce decisions for more care, not less.  That said, the intent of the measure is to reward doctors for giving less care toward the end of life.  It creates the perception of a conflict of interest though based on the data above the measure has had minimal impact.

The public debate about the proposal in 2009 was confused. The idea of the “death panel” (merely an inflammatory term for an advance care discussion) was nothing new. We had been having those discussions for decades. Moreover, the pre-existing ordinary CPT codes already rewarded doctors for long discussions through the provision that a higher level of service could be coded if greater than half the encounter time was spent in counseling or care coordination. Nobody on either side of the debate seemed aware of those facts.

Atul Gawande on the electronic medical record

Atul Gawande has a piece in the New Yorker titled Why Doctors Hate their Computers. The title is deceptive. In the first place doctors don’t hate computers (I’ve never met one who did, have you?). In the body of the paper Gawande doesn’t even seem to attempt to make that case. He does point out how doctors hated the way in which they were forced to adopt health information technology and the culture that went alongside. But, though he talks around it (and he talks a lot around it) he fails to answer the question of why. Is there something wrong with computers themselves in the current state of development? Is it the way policymakers and administrators have forced the implementation? Or is it that docs just need an attitude adjustment? He implies a little of each. Overall the article is incoherent.

Gawande has thrown together a mishmash of anecdotes, unreferenced claims and quotes from supposed experts. And the qualifications of these experts? Well, consider this one:

Gregg Meyer sympathizes, but he isn’t sorry. As the chief clinical officer at Partners HealthCare, Meyer supervised the software upgrade. An internist in his fifties, he has the commanding air, upright posture, and crewcut one might expect from a man who spent half his career as a military officer.

Hmmm. A commanding air, an upright posture and a crewcut. I think I’m afraid of this guy. He seems to think doctors have too much autonomy and a bad attitude to boot. He says:

“But we think of this as a system for us and it’s not,” he said. “It is for the patients.” 

Emphasis his.

Meyer just gave himself away. He’s operating on the idea that the interests of doctors are opposed to the interests of patients. It’s an ethical question worth pondering but not a great starting premise. Gawande seems to accept it uncritically. A little further on Gawande says of Meyer, also uncritically:

Gregg Meyer is understandably delighted to have the electronic levers to influence the tens of thousands of clinicians under his purview. He had spent much of his career seeing his hospitals blighted by unsafe practices that, in the paper-based world, he could do little about.

Evidence based medicine, particularly its third pillar (the importance of the expertise of the individual clinician) opposes such a top down approach. Does Gawande see anything wrong with Meyer’s line of thinking? If he does he doesn’t say so.

It’s style over substance:

Jessica Jacobs, a longtime office assistant in my practice—mid-forties, dedicated, with a smoker’s raspy voice—

As if that’s supposed to be a convincer in some way. But what does it mean, exactly? That she’s got savvy? That her dedication to her work has taken its toll? It’s left to our imagination.

Gawande fails to even come close to making the case that doctors hate computers, let alone answer the question of why, but he does point out some of the negative consequences of the EMR. Maybe this is progress, because it would have been nearly forbidden speech about a decade ago.

Medical decision making for unbefriended older adults: an AGS position statement

From the document:

Policy Recommendations

1.National stakeholders should work together to create legal standards regarding unbefriended older adults that could be considered for adoption by all states.

2.Clinicians, health care organizations, and other stakeholders should work proactively to prevent older adults without potential surrogates from becoming unbefriended.

3.Clinicians, health care organizations, communities, and other stakeholders should develop innovative, efficient and accessible approaches to promote adequate protections and procedural fairness in decision making for unbefriended older adults.

Clinical Practice Recommendations

4.Medical decision making for unbefriended older adults should include adequate safeguards against ad hoc approaches and ensure procedural fairness.

5.Clinicians should consider non-traditional surrogate decision makers for unbefriended older adults.

6.Clinicians should assess medical decision-making capacity in a systematic fashion.

7.Clinicians and healthcare institutions should develop and standardize/systematize methods to make decisions for unbefriended older adults in urgent, life-threatening situations.

8.Clinicians and healthcare institutions should ensure that patients with long-term incapacity have longitudinal access to a decision-making surrogate who is familiar with the patient's medical condition and specific circumstances.

9.When applying the best interest standard to unbefriended older adults, institutional committees (such as an ethics committee) should synthesize all available evidence, including cultural and ethnic factors, during deliberations about treatment decisions.

Health care team members’ perceptions and attitudes about emergency only hemodialysis (EOHD)

Concerns for what we today refer to as social justice seemed to dominate the responses in this small qualitative study.  

Why are patients not forthcoming? Is it because we’re addressed as “Doctor”?

Here are some findings from a recent JAMA Network Open study:

Importance Patient failure to disclose medically relevant information to clinicians can undermine patient care or even lead to patient harm.

Objective To examine the frequency of patients failing to disclose to their clinicians information that is relevant to their care and their reasons for doing so.

Design, Setting, and Participants Two national nonprobability samples were recruited to participate in an online survey, one using Amazon’s Mechanical Turk (MTurk) from March 16 to 30, 2015 (2096 respondents), followed by one using Survey Sampling International (SSI) from November 6 to 17, 2015 (3011 respondents). Data analysis was conducted from September 28 to October 8, 2018. After dropping respondents meeting the exclusion criteria, the final sample sizes were 2011 (MTurk) and 2499 (SSI).

Main Outcomes and Measures The primary outcome measures were self-reported nondisclosure of 7 types of information to their clinician (eg, did not understand instructions, medication use) and reasons for nondisclosure (eg, embarrassment, not wanting to be judged).

Results There was a total of 4510 overall respondents. Of 2096 respondents, 2013 completed the MTurk survey (96.0% completion rate) and 2011 were included in the analysis. Of 3011 respondents, 2685 completed the SSI survey (89.2% completion rate) and 2499 were included in the analysis. The mean (SD) age of the participants was 36 (12.4) years for MTurk and 61 (7.59) years for SSI. Both samples were predominantly white (MTurk: 1696 [84.3%]; SSI: 1968 [78.8%]). A total of 1630 MTurk participants (81.1%) and 1535 SSI participants (61.4%) avoided disclosing at least 1 type of information. Disagreeing with the clinician’s recommendation (MTurk: 918 of 2010 respondents [45.7%]; SSI: 785 of 2497 respondents [31.4%]) and not understanding the clinician’s instructions (MTurk: 638 of 2009 respondents [31.8%]; SSI: 607 of 2497 respondents [24.3%]) were the most common occurrences. The most commonly reported reasons for nondisclosure included not wanting to be judged or lectured (MTurk: 81.8% [95% CI, 79.8%-83.9%]; SSI: 64.1% [95% CI, 61.5%-66.7%]), not wanting to hear how harmful the behavior is (MTurk: 75.7% [95% CI, 73.5%-78.0%]; SSI: 61.1% [95% CI, 58.5%-63.8%]), and being embarrassed (MTurk: 60.9% [95% CI, 58.9%-62.9%]; SSI: 49.9% [95% CI, 47.8%-52.1%]). In both samples, participants who were women (MTurk: odds ratio [OR], 1.88 [95% CI, 1.49-2.37]; SSI: OR, 1.38 [95% CI, 1.17-1.64]), younger (MTurk: OR, 0.98 [95% CI, 0.97-0.99]; SSI: OR, 0.98 [95% CI, 0.97-0.99]), and with worse self-rated health (MTurk: OR, 0.87 [95% CI, 0.76-0.99]; SSI: OR, 0.80 [95% CI, 0.72-0.88]) were more likely to report withholding information.

Conclusions and Relevance Many respondents in these surveys intentionally withhold important information from their clinicians and were most likely to do so when they disagreed with or misunderstood their clinician’s instructions. A better understanding of how to increase patients’ comfort with reporting this information may improve the clinician-patient relationship and patient care.

At only one point in the body of the entire paper is the word “doctor” used, which is in the methods section where the authors described the survey instrument:

The survey defined “health care provider” as “any medical care giver, such as a doctor, physician's assistant, or nurse.”

Nevertheless Ron Harman King, writing a piece for Medpage Today, says the findings of this study “jolted” him into the idea that we should drop the title “doctor.” The piece is wrong on so many levels I don’t know where to start. Here’s my attempt to triage my reactions into a reasonably coherent post.

King starts with theatrical language to introduce his premise:

A recent study published in JAMA1 has jolted me into considering a crazy, radical idea. The article's title is, and I quote, "Prevalence of and Factors Associated With Patient Nondisclosure of Medically Relevant Information to Clinicians." Whew, can't wait to see the TV mini-series…

Even more chilling were the common reasons respondents gave for keeping secrets, in descending order: Patients didn't want to be judged or lectured. They didn't want to hear how harmful their behavior is. They feared embarrassment. They didn't want the clinician to think they're difficult patients. And they didn't want to take up more of the clinician's time.

No one I know of who is in touch with real medicine would feel jolted or regard as chilling the findings of this paper. It’s been well known throughout the history of medicine that patients lie, withhold information and withhold their feelings.

Then comes the non sequitur:

Which provoked my crazy, radical idea. Maybe it's time to take a long-standing healthcare tradition, wrap it up into a 40-gallon contractor-grade trash bag, and cart it out to the dumpster in the alley. That is, perhaps it's time patients stop addressing physicians as "Dr. So-and-So."

What does it mean if you drop the title “doctor”? It’s a pretense. It means pretending you don’t have superior knowledge and judgment that might help the patient. It’s part of a broader movement in medicine which was driven for years mainly by consumerism but is more recently gaining traction within the profession itself. It seeks to abandon all notions of expertise and completely democratize the transactions among patients, families and all members of the healthcare team. Is this a good thing?

Are specialists ruining medicine in the US?

Jamie Koufman seems to think so.

Her solution? Let primary care docs be the gatekeepers who control access to specialists. Didn’t we try that in the 90s with managed care? It didn’t work.

In case you didn’t know, over a third of ER docs are industry puppets

I am a close follower of the Emergency Medicine Literature of Note blog. The author, Ryan Radecki, takes a skeptical approach to surrogate endpoints and is generally careful to avoid conclusions that over reach the data.

He seems to have violated his own rules, however, in his approach to this report on industry gifts to physicians. From the paper:

Objective

Characterize the frequency and magnitude of all categories of publicly reported financial payments made to emergency physicians (EPs) in the United States (U.S.) in 2017.

Methods

This cross-sectional study of the 2017 Centers for Medicare and Medicaid Services Open Payments Database was exempt from Institutional Review Board Review. We calculated descriptive statistics of the frequency, type, and amount (medians) of general, research, and ownerships transactions made to EPs from industry, described regional differences of median payments to EPs, and characterized the drugs or devices most commonly associated with transactions.

Results

In 2017, among 40,899 practicing U.S. EPs, 14,447 (35.4%) received 51,870 general payments from industry totaling $12,870,832. The median per-physician payment was $18.30 (interquartile range [IQR], $13.63–$60.90). The most frequent transaction was food and beverage (89.6%), though most payments by dollar amount were related to speaker and consulting fees (74.5%). Antithrombotics were the most frequently drug or device associated with transactions. Only 35 (0.08%) and 20 (0.05%) EPs had research and ownership relationships with industry, respectively. A significant difference was observed in median payments per physician across all U.S. Census regions (p  less than 0.01) except when comparing Northeast and West (p = 1.00).

Conclusions

Over one-third of U.S. EPs had general payments from industry in 2017, while less than 1% of EPs had either research and ownership payments during this time period. Consistent with previous research, most payments to EPs are of low monetary value. Antithrombotics remain the most frequent drug associated with payments to EPs.

The vast majority of the gifts were small: lunches and dinners. There’s been quite a bit of research showing that even small gifts such as these influence physicians, largely out of their awareness. The problem with this research, extensive as it is, is that it is based on soft surrogate endpoints. Virtually nothing is known about the extent of the influence, let alone any downstream effects that might impact patient outcomes, for good or harm.

But Radecki’s post says this:

It’s CMS Open Payments Database time again, updated for 2017. Sadly, it turns out you or at least one of your closest colleagues is a witting or unwitting puppet of the pharmaceutical industry: a full 35.4% of practicing U.S. emergency physicians received payments from industry last year.

Clearly out of keeping with his usually cautions approach. Doesn’t the issue deserve more nuance?

Physician-assisted suicide and euthanasia: a medical student perspective

There’s hope.

Obfuscation of the language: assisted suicide and euthanasia are now medical assistance in dying (MAID)

Medical Newspeak.

Not challenging science is anti-science??

But I thought science was inherently self-challenging. To Dr. John’s credit, though, he does make some good points about the thought police. They’re everywhere in medicine.

Doctors in the US make too much money

---according to a policy wonk at one progressive think tank. So, says he, we must apply pressure from all sides to break up the cartel and reduce doctors’ pay. The fact that patients generally like their doctors doesn’t help.

Conflict of interest concerns misdirected: JAMA report

Another of the articles in JAMA’s theme issue on COI makes a case that the focus of concern has been wrong:

Much current research and debate involving conflicts of interest in medicine focus on the appropriate level of physician interaction with firms in industries related to health care, such as pharmaceutical and medical device companies. The influential article by Brennan et al1 that led academic medical centers to take the lead in tackling problems caused by conflicts of interest focused almost exclusively on interactions between physicians and pharmaceutical companies. The 2009 Institute of Medicine report Conflict of Interest in Medical Research, Education, and Practice also limited its coverage of conflicts to interactions between physicians and pharmaceutical, medical device, and biotechnology companies. The American Medical Student Association “scorecard” grades conflict of interest policies at medical schools purely on the basis of how they regulate physician-industry relations.

Although these interactions may influence physicians in ways unrelated or even detrimental to patient care, only a small percentage of physicians have substantial financial relationships with pharmaceutical or device companies.2 In contrast, every physician is paid for providing patient-directed services via a system set by the physician’s practice group and supported by insurers, government, individuals, and others who reimburse for care. While a minority of physicians receive direct payments from industry, the average primary care physician sees roughly 2000 patients per year who are, directly and via insurance, billed an average of $5000…

The nearly singular emphasis on physician-industry relationships has been way out of proportion, a point I have been making for years on this blog and in other forums.

Appealing to patients’ altruism to reduce low value care: surprise surprise, it doesn’t work

Not only that, it results in lower physician ratings.  From a recent paper in JGIM:

Objective

To determine whether altruistic appeals reduce hypothetical requests for overused services and affect physician ratings.

Design

Experimental survey using hypothetical vignettes describing three overused health services (antibiotics for acute sinusitis, imaging for acute low back pain, and annual exams for healthy adults).

Participants

U.S. adults recruited from Research Now, an online panel of individuals compensated for performing academic and marketing research surveys.

Interventions

In the control version of the vignettes, the physician’s rationale for recommending against the service was the minimal benefit and potential for harm. In the altruism version, the rationale additionally included potential benefit to others by forgoing that service.

Main Measures

Differences in requests for overused services and physician ratings between participants randomized to the control and altruism versions of the vignettes.

Key Results

A total of 1001 participants were included in the final analyses. There were no significant differences in requests for overused services for any of the clinical scenarios (P values ranged from 0.183 to 0.547). Physician ratings were lower in the altruism version for the acute sinusitis (6.68 vs. 7.03, P = 0.012) and back pain scenarios (6.14 vs. 6.83, P less than 0.001), and marginally lower for the healthy adult scenario (5.27 vs. 5.57, P = 0.084).

Conclusions

In this experimental survey, altruistic appeals delivered by physicians did not reduce requests for overused services, and resulted in more negative physician ratings. Further studies are warranted to determine whether alternative methods of appealing to patient altruism can reduce overuse.

Though this study is not very “real world” it makes sense, especially the finding of lower physician ratings.

An argument against low value care based on ineffectiveness is fine and patients ought to be able to respect it.  But an appeal to altruism sends a message that you can’t whole heartedly advocate for them as individuals. Imagine you are accused of a crime and your attorney says “I’ll work hard to represent you but please keep in mind the interests of ‘the people’ in these proceedings.”

Jump into the political fray or you’ve made the wrong moral choice and are guilty of harm

And be sure you line up on the correct side. Berwick.

Your patient wants to leave AMA. Now what?

There’s an interesting article in the Journal of Hospital Medicine on what to do when a patient wants to leave the hospital against medical advice. After reading and rereading it I had to disagree with the conclusion but it took me a bit to get there because the article, with its confusing use of terms, is a masterpiece of obfuscation. The most obvious example is the oxymoronic use of the term “AMA discharge” in the title and throughout the article. If a patient leaves AMA it's not your decision. How is that a discharge? Put another way, if you discharge the patient you are making a statement that the patient is medically ready to leave the hospital. A discharge order can only mean the patient is leaving in accordance with, not against, your advice. Why, after all, would you enter an order for something that is against your own judgment?

Another example of language confusion is the authors’ statement that leaving the hospital AMA can be a process of informed consent. Quoting directly from the article:

Because all competent patients have the right to decline recommended inpatient treatment, the ethical and legal standard is that the physician obtain the patient’s informed consent to leave…

Consent to leave? That’s an inappropriate use of the word. Consent leads to adherence with the physician’s recommendation, which in this case would be to remain in the hospital. In the AMA situation the patient’s decision to leave is a demand, not a consent.

Getting past all the confusion, there were a few good points. When the patient leaves against your advice you don’t have to destroy the rapport. It doesn’t have to be an adversarial transaction. But the authors go beyond that principle by stating that when the patient leaves AMA not only should it be handled as a regular discharge but that you should not even document that the departure is against your advice. Again, form the article:

The solution to improve quality is straightforward—avoid designating discharges as AMA…

Treat all discharges similarly. Avoid designating an inpatient discharge as AMA.

That is where I have to disagree.

There's more to unpack. The authors make frequent mention of shared decision-making. Indeed shared decision-making is a is a core principle of evidence-based medicine but it is just one component. The AMA departure sometimes pushes shared decision making to the level of absurdity. How does it apply, for example, if the patient with an actively evolving myocardial infarction wants to leave the emergency room? What if the patient just swallowed antifreeze because he ran out of his beverage of choice? Where does shared decision making come in when the patient’s choice means almost certain harm? Some patient preferences and choices are simply wrong.

Finally there's the matter of legal protection. The authors make this statement:

Although clinicians may presume that the AMA designation provides protection from liability, the claim is not supported by the available literature.14,15 In these studies, which reviewed relevant case law, defendants prevailed not because of the physician’s AMA designation, but because the plaintiff was not able to prove negligence.

That’s a misrepresentation of the cited articles. Both articles (see here and here) contain statements to the effect that the AMA designation may indeed afford some legal protection.

So what should we do? Why not consider each case on its individual merits? If the patient wants to leave prematurely but the risk is low it may be reasonable to capitulate and enter a discharge order. In other situations where the patient's choice is clearly ill-advised and the risk is high a discharge order may be inappropriate and the departure should be documented as being against medical advice. Even in such cases try to work with the patient to help formulate a follow-up plan and, if appropriate, provide medication prescriptions. Assure the patient that you are not angry, respectfully ask that they reconsider and assure them that they are welcome to return. Clearly advise them about the danger of leaving but don’t threaten them or imply adverse insurance consequences.

The dark side of cost-conscious medicine: Martin Samuels

The hospital of tommorrow

Hospitalists will be obsolete as the hospital care team continues home care via telemedicine and putting patients to death will be considered patient centered. Read the rest.