Malpractice Reform

Defensive medicine and tort reform are frequently discussed as inseparable twins. Many doctors claim defensive medicine is the systemic evil causing health care costs to run rampant. The latter, tort reform, is the holy grail of health care salvation. Both views are wrong.

Rahul Parikh, MD is a physician who largely agrees with me. In a recent article over at Salon.com Dr. Parikh addresses the fallacy of tort reform.

In contrast to many of my colleagues I attribute defensive medicine to physician incompetence or ignorance. In short, physicians practice “defensive” medicine primarily because they haven’t the knowledge to actually understand the relative likeliness of disease states in particular patient populations. From my own experience at a tertiary care childrens’ hospital I recall pediatricians ordering monthly MRI scans to follow children for “static encephalopathy.” When I inquired one day as to why the response was “just to be sure.” Disquieting. My colleagues in the primary care specialties order tests for diseases with remote, absurdly remote, possibilities. They do this so they can “be sure.” They order tests as a huge battery of unnecessary studies rather than sequentially. They order tests they can’t interpret since they had no meaningful clinical suspicion. They attribute this to “defensive medicine.” It is not defensive. It’s wasteful.

Then we have tort reform. Obama is right to decouple tort reform from health care reform. Proponents of tort reform cite decreased malpractice as the primary metric. They then theorize that decreased malpractice costs will allow health care costs to decrease. Needless to say the reasoning is flawed. There are few, if any, good studies liking malpractice costs to health care costs. In short the pundits are using the wrong metric. Until tort reform can be clearly shown to decrease health care costs then it amounts to little more than an additional route to profit for physicians and liability carriers.

These are complex issues poorly understood by most physicians.

As patients each of you can control health care costs. Simply ask your physician “what is the likelihood that I have the disease you’re looking for?” If the likelihood is very low then look elsewhere- for a diagnosis and health care. If your physician can’t explain, clearly, how (s)he will interpret the test results then look elsewhere.

It’s your health. Take care and take charge.

Sleep and Safety

I don’t want you to take care of me if you’ve been awake for 16 or more hours. It doesn’t matter how smart you are or how good you feel. There’s clear evidence that your cognitive and motor skills are beginning to deteriorate at that point. Yet medical education still refuses to admit this limitation to the delivery of modern health care.

Ironically, it’s the senior physicians, the attending physicians, who are more likely to perform well while fatigued. It probably has to do more with the better pattern recognition skills in experienced physicians rather than a lack of fatigue effect. Yet, it’s the attending physician who is home in bed while the least experienced physicians and medical students provide you with care in the middle of the night.

It’s been many years since the residents were limited in the number of hours that they are permitted to work- either consecutively or in aggregate per week. Yet no one can show a change in outcome associated with the limitation. Part of the reason is that residents in some programs are actively encouraged to “fake” the number of hours they record in their log books. In such a circumstance there would be no detectable result from a “reduction” in work hours since there is effectively no reduction.

The reductions proposed by the Institute of Medicine (“IoM”) are a welcome and necessary step for reducing patient harm. The IoM report also reiterates the need for those attending physicians to actually supervise residents. Again it’s an issue of safety.

So what should you do?
1) Ask who the “doctor” is. Is he/she a “real” doctor or just a resident?
2) Where is the attending? Will the attending learn about you and the planned care before the therapy starts?
3) Is the physician rested? Or, has he/she been working the permitted 30 (you read that right thirty) consecutive hours?

It’s your health. Take charge and take it seriously.

You’re Fat- Yes, You

A recent article in the Los Angeles Times poses the question “Are you fat because your doctor didn’t tell you?” I’ll buy the possibility that some mildly overweight patients might not actually know that they’re fat not just “fluffy.” I’ll also accept that some patients underestimate their degree of obesity.

Yet it’s impossible to put a patient’s failure to recognize obesity on the treating physician. If you’re overweight, by any amount, ask your doctor about it. But only ask if you’d like to commit to reducing your weight and gaining a healthy lifestyle. Your doctor cannot follow you around and limit your intake or increase your activity. If you can’t or won’t commit then you’ll only frustrate both of you.

It’s your health, take it seriously and be responsible.

If You Have to Ask…?

A while back I shared my experience as a patient. Journalist Royce Flippin had a similar experience and uses it to discuss the need for transparency in health care pricing.

Very few patients ask about charges prior to receiving care. Notice I said charges not cost. These are not the same. Charges are the exorbitantly inflated amounts providers “charge” for things like band-aids, tongue depressors, facial tissues, and medications. The transparency accompanying “list” pricing would allow patients to compare services and seek real value in health care. Knowing that the guy next to you in the waiting room paid half what you did would encourage fair pricing and stop the traditional usurious pricing.

As we head toward health care reform remember to insist that your legislators allow real market forces to be active.

It’s your health care. Take it seriously and take charge.

Le Treatment

Guy Sorman over at Medical Progress Today writes about the experiences Sara Paretsky and her husband had under French health care.

Although the care appeared “reasonably priced” Sorman nicely summarizes how the care Paretsky’s husband received is subsidized by everyone including Americans. In essence the French government runs health care. Much of the profit and entrepreneurism is removed, limited, or prohibited. The cost to employers of health care limits the employability of unskilled laborers and hence pushes unemployment up (approximiately 10%).

The bottom line is that health care always has a cost. The idea that having insurance will solve costs is pure folly. Limiting bureaucracy and “middle men” might lower costs. Even if those costs are limited with what would we replace the 15% of GNP that health care constitutes? Could shrinking our economy by 15% be good?

There are some things each of us could do:
1) Always ask if the diagnostic study or treatment will actually improve your lifespan or lifestyle.
2) In the case of diagnostic studies always ask if the study will alter therapy.
3) Always ask if the doctor receives any payment related to the diagnosis or therapy beyond what you and your insurance company pay for the immediate visit.

These questions, and others, will allow you to make a positive impact on your own health care costs.

It’s your health take it seriously and be active.

http://www.medicalprogresstoday.com/spotlight/spotlight_indarchive.php?id=1819

Choice?

Insurance is not the answer. Thousands of people have “coverage” through Medicare or Medicaid (yes I know only one is an insurance program). Payment such as offered by these programs may barely cover a physicians expenses. In essence the only way a physician may provide care under these programs is by not paying him or herself.

Physicians are abandoning these programs at an alarming rate. “Coverage” that’s not accepted by any physician is smoke and mirrors. Its benefits are purely illusory.

As consumers of health care each of us needs to be aware of the value of the care we receive and how it’s paid for. After all, if your physician doesn’t accept your insurance does it have any value?

It’s your health care. Take charge.

Government Health Care

Government health care? First, do no harm By: Daniel J. Popeo appeared in the Washington Examiner several months ago. It has some good points but many more bad ones.

American health care is littered with physician self interest and an overwhelming sense of patient entitlement. Physicians and advertisers convince patients that the “latest and greatest” treatment is the best. They work to sell more expensive therapies despite the proven usefulness of traditional, less expensive modalities. The complex relationship between physicians and industry substantially compromises health care integrity by causing a conflict of interest. The conflict may cause physicians to recommend expensive therapies.

As consumers you should always ask your doctor:
1) Will this let me live longer?
2) Will this help me live better?
3) Will this test change my therapy or diagnosis?

It’s your health care. Take responsibility.

Does Our Health Care Suck?

Today, I’ll share a personal experience. Several years ago I injured my shoulder. I “toughed out” the pain for about a week with motrin then finally asked a friend who was an older orthopedic surgeon. He asked several questions then placed his thumb on my shoulder and pushed gently. He asked, “Is that where it hurts?” I winced and said, “Exactly.” He told me what it probably was and offered two or three other less likely possibilities.

Then, the important part, he said there’s an operation for this but you probably don’t want it. He said no reputable surgeon would operate for several months. He noted that good surgeons would advise rest and gentle physiotherapy for 3 months then re-evaluate.

I felt better. I used the motrin for three more months rest the shoulder. After 4 months it still hurt and I had some limitations of movement due to pain. I broke down and saw an orthopedic surgeon rather than just a quick “curbside” discussion. He asked almost the same questions as my friend had. He pressed in the same place and offered the same diagnosis. He didn’t take and xray, CT scan or MRI. Then he sent me for physiotherapy and told me to come back in three months.

I was reminded of this recently when I read the story of journalist T.R. Reid’s shoulder injury. Reid’s experiment shows clearly what happens when doctors co-mingle interests in personal finance with theirs requirements for fiduciary responsibility for your health care. Many times it’s you, the patient, who suffers.

What does all this mean? Like we’ve said so many time, take and active role in your health care. Ask questions and demand answers.

It’s your health care. Take charge.

Caring

I teach physicians to communicate effectively. I’m not sure it works. Every now and then I am encouraged.

The two most common complaints I hear from my mother about physicians are:
1) He doesn’t listen. (Mom won’t see women physicians- no idea why.)
2) The front desk staff are idiots.

The most effective tool a physician has is her ears. The ability to take the time to listen, seriously listen, with genuine interest and compassion is rare. This is what I teach my students. That’s why the new book by Dr. Wendy Harpham caught my attention. She shares her experiences as a patient and physician.

Read Dr. Harpham’s book and change the way you think about your doctor. It’s your health care. You have the right to demand a standard of health care.

Disclaimer: I have no relationship financial or otherwise to Dr. Harpham, Amazon.com, Steve Majewski, or The American College of Physicians. It’s just a great book.

Stimulus or Health Care

Health Information Technology for Economic and Clinical Health Act, or HITECH, is a part of the American Recovery and Reinvestment Act (ARRA) of 2009. HITECH pours $19 BILLION into the economy but only for health care information technology. As you might expect this kind of money is an amount that gets attention even in Washington. It also makes potential vendors come creeping out of the woodwork. Many of the products have no track record of effectiveness yet the possibility of federal funding will compel many hospitals and practices to adopt an electronic record if it can be adopted for at a cost less than the federal grant.

The problem is that there is little evidence that the electronic health record actually improves care to a specific individual. Certainly there are theoretical advantages but so far no clear evidence of benefit. However, the aggregate data from such records may be more valuable than the individual benefit. Finally data regarding the effectiveness of diagnostic and therapeutic modalities may be accumulated. In this way worthless testing and treatment may eventually be eliminated.

Keep watching. Ask your physicians how she keeps and stores your records. It’s your information. Make sure it’s safe.