Lessons from a Family History

Given that my wife and I are highly overeducated physicians and Ashkenazi Jews that have been thinking about our family plans, we decided to go in for pre-conception Genetic Counseling.  Although neither of us have strong family histories of genetic diseases, we know enough (too much?) to know that we are at risk and would benefit from any advanced knowledge.  So far the experience has been very pleasant (because we haven't gotten any results yet) and quite instructive, teaching me a few lessons about health care.

Lesson 1: Glad it wasn't a physician
You can imagine that trying to get two doctors to a doctor's office during business hours takes just a little of scheduling wizardry.  I must compliment BIDMC's OB department for getting us in quickly and taking us back on schedule.  We were met by a genetic counselor who took both of our family histories and placed them on a pedigree.  While we do not have very large families, this is still a time-intensive detailed process. However, I felt that it proceeded very quickly and efficiently as our counselor was able to only ask necessary questions.  It was upon this realization that I was glad I was not speaking to a doctor.  Not that I have anything wrong with doctors, but I know that in order to justify certain levels of billing for a visit, they have to ask a lot of inane and useless questions.  (The family history normally falls in this category, for how is the family history of 95 year old woman going to help me figure out what is going on today).  Those useless questions are externally imposed by payment regulators, and while they seem harmless, are incredibly wasteful.  Now imagine all those useless questions for two people!  Needless to say I blocked out 2 hours for this visit and I was glad that we were out in 1 hour including blood work.  Had it been a doctor I can imagine it probably would not have gone so smoothly.

Lesson 2: What is the family history?
Now, not to knock it again, but in my field of Internal Medicine the family history often feels like an obligation, tacked on for billing purposes and not really helpful to diagnosis or management.  We satisfy the requirement by asking at least one question "No one in the family has cancer, right?" But then I got to thinking about information in an ideal medical system.  Although I have not seen this implemented, we have the ability to link medical records together for the purposes of keeping a true family history.  For example, let's say that both you and your mother see doctors who have an integrated medical record.  She could be in New Jersey and you in Boston, but information knows no geography.  Now, if our record knows that she is your mother, then could it not also import her medical history into your family history?  Could this be repeated for entire family trees, making the family history a truly useful part of the history?  I know, I know, HIPAA, privacy, etc., often unnecessary hurdles to good care and information.  We could still maintain privacy in a number of ways: having the information queried but not present (i.e. you could "ask the record if anyone had colon cancer without identifying who exactly had it").

And yes, I checked with my wife before posting this.

Missing the Point?

I guess this counts as a meta-blog as I am commenting on an article over at Kevinmd.com.  Dr. Riner, an Emergency Medicine physician, former president of the American College of Emergency Physicians, and payor consultant reports on the limited utility of trying to keep patients out of the emergency room as a form of cost containment.  He presents data that suggest that deferring emergency care is dangerous, ineffective and does not save any money.  I have no grounds to disagree with his argument as presented.  But as an internist and hospitalist on the receiving end of the Emergency Room, I think he misses the point.  The savings is not in keeping people out of the Emergency Room, it is in keeping them out of the Emergency Room as a way of keeping them out of the hospital.

Given the unique financial incentives and horrid liability that ED doctors face, they have a very strong incentive to admit patients to the hospital.  The hospital is the dangerous, expensive vortex patients enter which drives such high cost in our society.  The Emergency Room is merely the largest portal into that vortex.  The problem, then, lies not with the Emergency Room, but rather with a primary care system ill equipped to care for complex patients outside of the hospital.

I cannot speak for others, but when I refer to keeping patients out of the Emergency Room, it is always in conjunction with keeping them out of the hospital as well.

I do agree with the Dr. Riner that trying to save money in the Emergency Room (like trying to save money in a primary care office) misses the point entirely.

PGP: Physician Group Practice or Pretty Grim Progress?

A recent Perspective in the New England Journal of Medicine by Gail Wilensky comments on the "sobering" results of the Physician Group Practice demonstration projects.  Dr. Wilensky references the full article and comments that while some disease metrics were improved, costs were rarely decreased, and patients were not kept out of the hospital/ER (which is why costs were not reduced).  At first blush, there should be at least some recognition that health outcomes were mildly improved for roughly the same cost increase as the control population.  That is to say, even if the care management programs were not the panacea that Medicare hoped, there was improvement.  That being said, I do not find it terribly shocking that these programs had such limited success.  We have seen time and time again that you cannot just wrap around a broken primary care system and except great results.

Guest Blogging for Primary Care Progress

A guest spot at Primary Care Progress looking back at how my medical education has led to me a career in Primary Care.

Is Anyone's Time Valuable?

Cross-posting from my work at the SGIM Forum, page 4 & 14.  Here I take at look at a recent article from CNN looking at waiting times in doctor's offices.

Dinner out!

Well, I survived my meals out, difficult after my new dietary restrictions.  Thank you both to Zander and Allan for your kindness today.  A special thanks to Roger Berkowitz of Legal Seafood fame for sending us this delicious (and healthy!) dessert!

Need, Want & Would Like

In many discussions over what is ideal primary care, it occurs to me that there is a bit of a definition problem worth certain words people throw around.  I am not taking about Patient Centered Medical Home, Care Cycle, and Quality measures.  Rather, I am referring to three very simple words:  Need, Want & Would like.  I would like to propose operational definitions for each of these words, to better guide solution design for health care.  And perhaps other things about which I am less qualified and therefore less apt to comment.

1.  Need.  Cannot do without; Necessary (in the Necessary/Sufficient paradigm).  An example:  Someone with a new Drug Eluting Stent in their coronary arteries NEEDS dual anti-platelet therapy (perhaps Aspirin and clopidogrel).  Without, chances of death are unreasonably high.  That is a need.  People NEED health care over their lifetime.

2.  Want.  Desiring something enough to give something up for it (or pay for it).  This falls under the common law doctrine of no consideration, no contract.  If you want something, you are willing to pay for it, in money, time, trade, opportunity cost.  For example:  Last year I wanted an iPad, so I bought it.  Wants are not needs, although sometimes it feels like a want has to approach need status before one will pay for it.

3.  Would like:  Desiring something, but not enough to pay for it.  I would like an iPad 2.  But I am not willing to by one yet.  If someone gave it to me free, I wouldn't throw it away.  The difference between Would Likes and Wants comes at payment time.  If you'd rather walk away without paying, it is a Would Like.  You don't value Would Likes enough to pay for them.  Remember that.

There is definite confusion of terms.  I have noticed in health care, and in most situations in which a government is handing things out seemingly for free (whether it is your parents and an iPhone or the Federal Government and Medicare dollars, Really big Wants often get upgraded to Needs, and almost every Would Like is considered a Want.  It is a way of getting things without paying for them.  In this environment, showing weakness is a strategy for gain.

In the world of the marketplace, of producers and negotiation (aka the real world), the opposite is true. Needs get dressed down as Wants, Wants as Would Likes, and I Wouldn't touch that with a 10 foot pole!  This too is a way of paying less for things.  In this environment, hiding weakness is a strategy for gain.

So when deciding on things in your life, first figure out if you are in the government world in the real world, and categorize your priorities accordingly.  But even more so, when designing solutions (for healthcare in this case) really figure out what everyone means, and agree upon the definitions above (or some other standardize set).  Enough with the grandstanding and positioning, just figure out how to get what you need, pay for what you want, and accept what you would like.

Games, a solution for health?

In this week's New England Journal of Medicine, Volpp and colleagues (article linked through the title of this post) comment on the use of immediate incentives to improve employee health through redesigned health benefits plan.  This space has fascinated as it combines two of my areas of interest: health, specifically the delivery of superior health care, and games, specifically PC games.  How did I draw this conclusion?

In the article, the authors comment that adding immediate upside incentives will cause behavior change toward the incentive.  This is what I have tried to explain to the non-gamers around me... you keep pushing the button, ultimately because there is a reward for what you do.  In my preferred case, completion of some task which is fun in its own right, leads to the continuation of a narrative which better be interesting!  Games that lack either a fun mechanic or a decent story tend not to make it into that "classic" realm.

Similarly, benefit design has historically been designed with no incentives (no game mechanic) or worse, perverse incentives (a truly evil game).  The narrative reward--better health, has theoretically always been there, but not quite as explicit as it could be.  One interesting company, Redbrick Health has been doing just what is described in the article, adding a game layer to the world, a brilliant line I have borrowed from Seth Priestbach.

Writer's Block

This is an interesting blog post idea, I know, but I have been experiencing some serious writer's block recently and I hoping to baby step my way out of it.  Currently on my To-Do list I have several pieces to write, some past deadline, some in collaboration with heavy hitters in my field, and some I just find fascinating.  However, between switching from Residency to "real" life, with its attendant risks, intervening vacations, rewards and change of pace; having homework again in the form of board studying sucking up my creative time; and attempting to return my body to a state of pre-residency vitality, has really sapped my ability to create written words.

There is another possibility which is far more terrifying to me.  I am concerned that in my transition to my new careers, both inpatient nocturnist work and outpatient entrepreneurship/start-up work with Iora Health, has made me too happy.  I am actually quite content with my work, excited to do it every day, with a firm belief in both what I am doing in the short term, and its possibility for long term positive effects.  In short, I have lost the strong emotional trigger in the form of frustration that led to so much previous writing.

I hope that I can mature a little and find a new muse which allows me to write.  I am hoping that my enthusiasm for a better world, separated from my frustration from living in the current world, will be enough to keep me writing.  Because I do NOT want to have to go through residency again just to stay in the game!

Resident Night Perks

I received this in the mail unexpectedly from the "Drew Crew" a group of very motivated high school students from around the country who traveled up to Framingham to learn about becoming a physician.  Through National Youth Leadership Forum's Resident Night Program, I was given the opportunity to talk with them for 90 minutes or so.

Drew Crew- you are the best!

Day 3 on the Juice Fast

"Hey Andrew, you want to go to Birch Creek on a Juice Fast with me?" started a conversation with may dad a few weeks ago. It is now day 3 without solid food and about 4 hours of daily exercise. The most surprising thing, I am not hungry. Each day begins with a Barley drink, five mile "walk" (to the top of some high point in the catskills), breakfast juice (two for men!), 2 hours of exercise with a protein smoothie in between, a lunch juice, more exercise and a lecture, a cup of bouillon, then a dinner juice. The even more surprising thing, is that I cannot stop thing about Corned beef. All the foods in the world I am not eating, and it is the salted cured meats that my brain desires.... Watch out Michael's, here I come!

PCP=Paperwork Completing Physician?

About 6 months ago, while on an inpatient cardiology service, I tried to do something nice for my patient and my patient's intern... I wrote a requested prescription for a wheel chair to save my intern a few minutes.  She went home, wheelchair delivered, everything fine.

Flash forward to today.  As I set to graduate residency (tomorrow) I have been tidying up some of the paperwork for my clinic.  I received a fax today from a medical supply company requesting that I fill out a form so that they could get paid for this wheelchair.  6 months later.  At first I struggled to remember details of the scenario, aided by our excellent medical record.

So why has it been 6 months?  I can only imagine that it has taken 6 months for the company to track me down to sign this ridiculous form (of course required by Medicare), was because her Primary Care Physician (PCP) either does not exist or refused to sign the form.  They eventually looked me up and found my information.  Interestingly, the form is addressed to me as though I were the patient's PCP.  (I am not, despite providing primary care for many others).

PCP, could it actually mean Paperwork Completing Physician?  This is usually the person to which forms are directed.  The one physician who is supposed to "know the patient best," which is doctor code for "deal with the problems/paperwork I don't want to."  It is an interesting role that has been created by the medical system, and surprisingly is not being filled.  Who would want to be ultimately responsible for all of the paperwork, necessary and otherwise?  More importantly, in this scenario, the paperwork did not directly benefit my wheelchair bound patient at all.  Rather, as I confirmed, the company needed my signature to be paid by Medicare for the wheelchair they had already provided.  My first thought, if they are dependent on my signature to get paid, do I get a cut?  Is it fraud if I ask, but perfectly acceptable if I do it for free? Would paying me to sign the form somehow change my behavior?  What would happen if I refuse to waste my time on this matter?

Effectively the company issued my patient a wheelchair on credit, certain that I would answer questions on a form for them in a manner that allows Medicare to pay.   I am curious on what assumption or faith this credit is based.  Perhaps their experience that doctors will eventually sign whatever you put in front of them if they believe it will help their patients.  And the purpose of all of this paperwork?  Fraud protection.

This minor situation is typical of the entire fraud/fraud prevention problems inherent in insurance, especially government insurance.  First, it is assumed that everyone trying to obtain insurance payments is a criminal attempting fraud.  Few are, but the costs of this assumption are staggering, and likely outweigh the costs of actual fraud.  The difference, of course, is that waste to prevent fraud is not embarrassing to a government official, whereas smaller losses due to fraud are inexcusable.  Second, the assumption that putting a physician signature on a form changes anything is ludicrous.  I wrote a small statement that I met this patient once and that the above were true to the best of my recollection, but that 6 months have passed.  How is that better?  It is certainly wasteful, that this company has had to extend credit for 6 months and that I have wasted my time. But does creating physician paperwork bottlenecks benefit patients or physicians?  If not, should we put up with it?  We already do enough to make the healthcare system work, you know, the diagnosing and treating part.  Attaching our signature to paperwork so others can be paid is wasteful, does not achieve the attending effect, causes anger and burnout, and ultimately costs patients what they want--time with their doctors.

And we wonder why we have a shortage of PCPs.

On Managing Innovators

I have been reading Alfred Sloan's My Years with General Motors on the advice of a mentor who referred to it as the exception to his rule of not reading business books.  I find it very interesting thus far, mostly waiting for car names I recognize, watching out for now canonical management points as they evolve, and generally appreciating Mr. Sloan's writing style.  On page 78 I came across the following letter from Mr. Sloan to one of his engineers, working on a new style of car and not finding success after a recent launch:
Dear Kettering:-
It is most important in our opinion that your mind be kept free from worries foreign to the development of the air cooled car and other laboratory work. 
In the development and introduction of anything so radically different from standard practice... it is natural that there should be a lot of "wiseacres" and "know-it-alls" standing around knocking the development.
In order that your mind be completely relieved as to the position of the undersigned... we beg to advise as follows:
1st. We are absolutely confident in your ability to whip all problems in connection with the development of our propos[al].
2nd. We will continue to have this degree of confidence and faith in you and your ability to accomplish this task until such time as we come to you and frankly state that we have doubts... you will be the first one to whom we will come.
We are endeavoring in this letter to use language such as will result in complete elimination of worry on your part with respect to our faith in you and this work and if this language fails to create this result, then won't you kindly write us quite frankly advising in what respect we have failed?
Due to the fact that criticism are bound to continue... would it not be well for you to agree with us that at any time you have occasion to pause and wonder about our faith and confidence in you... that you pull this letter out of your desk and read it again.

Wow.  Just, wow.  Talk about permission to try and fail, to succeed and know that you have either the full confidence of your leadership, or their explicit promise to find you as soon as they begin to waiver.  How much time must have been saved without Mr. Kettering having to wonder what others thought of him?   Management of innovation can be difficult, but I will list this amongst the great examples.

Schutzblog.com

Thanks to the sage advice and guidance of John G. Norman, Schutzblog.com lives on its own domain.

Thank you John!

"When you are facing in the wrong direction, progress means walking backwards."

Here I link to this year's Edge Question: WHAT SCIENTIFIC CONCEPT WOULD IMPROVE EVERYBODY'S COGNITIVE TOOLKIT?

Given that earlier today I was told I am right on the edge of a big transition in life (6 weeks of residency remaining!) this article hit home.  One answer in particular from a Physicist Nigel Goldenfeld starts off with the quotation above.  Really just a perfect way to summarize how I feel about a few things these days.

Fun Theory

This is a bit of cool marketing from Volkswagen (the same folks that introduced me to Nick Drake), sent on by a colleague. It is a competition to positively change behavior using fun. Given all the challenges we have in healthcare, there is something to this as a design principle. This ties in nicely with my general love of games as as a method of fun and education.

Why Work Doesn't Happen At Work- Crosspost from TED

Jason Fried gives an excellent presentation on why work is so difficult to accomplish... at work.  I have to say that returning to the hospital this week on Cardiology feels like his description magnified.  One could argue that the entire day of a medical intern or resident is to be interrupted, with the intern having the additional challenge of having to complete baseline paperworks tasks.  Enjoy...

The Problem with Scale

Below is a very interesting look at the relative scale of our federal budget versus sums of money that any of us will ever see or understand.

Guest blogging!

Check out my guest spot on Progress Notes, the blog of Primary Care Progress.  Primary Care Progress is a grassroots organization started here at Harvard Medical School in the wake of changes (elimination actually) of the primary division at the medical school.  Fortunately, it has evolved over time and is working to promote primary care education and careers by bringing together a community of students, residents and practicing physicians.

-Better link for the Gawande Article about Iora Health.

Days 3 & 4: Excellence in Action

Sorry for the delay, I have been so deeply engaged in class (and doing the homework) that it has been hard to come up with a central idea for a post. Then it occurred to me that the topic is excellence, and how it differs from perfection. We been looking at a variety of organizations that focus on excellence through action and iteration. While this may seem obvious to those of you not in health care, specifically academics, we tend to operate on the precautionary principle... Know every possible risk before taking a step. This obsession with starting perfect is what has hindered so much value. But where does it come from?

School. In order to be a doctor in America, you have to get a lot of test questions correct. It is actually the single biggest requirement for medical school entry: good grades. While most of us hang on to humanity through this mechanical process, we do become quite perfection-centered and risk averse. Not exactly the type of person we would expect to be an innovator. Wiser thinkers than I have opined on how to reform school, but this is a root cause of our slow starts in health care, and one that will pay dividends in ways we cannot imagine.

Back to school!

The Forest for the Trees

Day 2 of Value Based Health care. 
Today was a particularly enlightening day as it focused on a big success story in primary care and another in employer based health care.  I also had some foreknowledge of the organizations which helped enrich the cases for me.  One thing that I did notice is that we as health professionals might have a tendency to hold the delivery of health care to the same standards as our actual therapies.  While high standards in and of themselves are a good thing to have, working with humans in a complex social, medical, business, regulatory and legal environment is tricky to do and even trickier to study.  It is important to remember the current state of health care delivery innovation.

Infancy.

Current research projects, ideas and companies in changing the way health care is delivered are remarkably young.  Given the restrictions placed by government regulating practices, insurance, payment, and their own involvement via Medicare/Medicaid, that there is any innovation at all amazes me.  The key takeaway here for me was to celebrate what is actually being done, and what it can lead to, rather than lament the shortcomings of the research methods used to validate the success of innovations. 

It actually strikes me that perhaps our current research methods to "prove" that medicines are effective, are themselves the problem.  We are using the wrong tool for the wrong job, and the implicit suggestion is that reality must be broken down and remade so that it fits within our current research methods.  Perhaps innovation of research methods are actually required to deal with the chaotic business of health care delivery. 

This class is quite exciting, and the level of debate is quite sophisticated.  I am very fortunate for the stars to have aligned so that I may be a part.
More tomorrow!

First day of Business School

Today I had the pleasure of starting a one week seminar at Harvard Business School entitled "Value Based Health Care Delivery Intensive Seminar.". Taught by health care strategist Michael Porter, author of Redefining Health Care, it is a collection of about 80 business students, medical students and health care providers brought together to learn about how focusing on value across the entire care cycle of a disease cane improve health care delivery. This is a unique opportunity to learn an approach to innovation in health care delivery. From the first day's events, each day wlll consist of two case discussions, for which Harvard Business School is well known. The Case Method is an interesting way of working through material that draws on a written case and experience from the class. The professor's job is to draw out and organize the discussion, rather than provide the information. It is *very* different than medical school.

Continuing the theme of the small world of Health care, I am sitting next to a friend of a friend that I have not seen in years, and know at least 5 more people in the room by name or face.

More each day...