Monday, July 28, 2014

DISTRACTIONS of Majoring in Minors

I recently visited the Vasa Museum in Stockholm, Sweden. The three hundred year old warship sits majestically in the middle of this beautiful museum. You can look at it from every angle. The wooden ship is a master craftsman’s envy. The figurines on the transom are alive and tell the fascinating tale of the logic within illogic, of demand and uncertainty, of powerful words that drowned the truth seeking muted voices, of hubris, of inattention, of layered differences between the knowers of truth and the seekers of fame and ideology. In short, Vasa remains a memory to Sweden's famous warrior King Gustavus Adolphus, his ambition of military expansionism, his impulsive desire and the fearful silence of the knowers who deemed Vasa unfit for sea.

Vasa completed its 300 meter maiden voyage in 1628 and at the first hint of a strong breeze displayed its instability due to a high center of gravity and promptly sank to the bottom, lost for 300 years. It was resurrected in 1959 and after carefully organizing 95% of the remains of the warship, Vasa was brought back to its current life and rests in the Vasa Museum in Stockholm, Sweden.

The impetus of the ship-builders was to have the state of the art battle ship with two rows of cannons on either side. Unfortunately there was not enough ballast to keep it righted when the sails filled. 

The desire was craftsmanship, the regal beauty and potential  deadlyforce the vessel could unleash, however not enough measure was taken of its ability to sail. Today Vasa Museum remains the most visited museum in Europe. It is a testament to the folly of majoring in minor thoughts!

Consider the current vogue in medicine where the physician (the determiner of facts, the allocator of resources and the captain of the healthcare ship) is relegated to majoring in the minors! (you know I was going there weren't you?)

Let us consider the following issues:

1.       EMR: The object of EMRs is to create a large data-bank so that errors are minimized in the practice of medicine and additionally duplication of services is limited to reduce costs. A 2-fer! How could anyone ignore the virtue behind this logic? Well, and that is a deep one, there are many hurdles to overcome. Learning the EMR system takes time, but that is of no concern to the makers of the system (who gain from it), after all it is the responsibility of the physician. Okay, moving on, the information is to be entered close to the time of the encounter so that memory does not waiver, but then the sacred patient-physician contact is minimized by the doctor’s constant attention on the computer screen to prevent errors that can mislead the reader with incoherent information (both to the detriment of the patient and the physician). That sacred faith and the personal trust gets lodged somewhere between distrust and lack of faith. Right about there the 14% placebo effect of the comforting hand on the shoulder benefit is drowned in the sea of digital ink. Physicians spend between 40-50% of their time in “charting” while the nurses spend 50-60% of their time doing the same on the hospital units. Who takes care of the patients during that timeThe answer should not surprise you.

2.       Reimbursements for services rendered: the Medical Revenue Cycle is alive and well, thanks to the insurer models of denial of coverage and denial of payments because of lack of documentation. 11% of all medical bill submissions by physicians, hospitals get denied automatically via the software algorithms built into the large main frames of the insurers. While the Blues, the Aetna(s) and the United(s) cleanup with soaring revenues and net incomes showering their managers with huge bonuses. Meanwhile it notoriously takes the physician 6-10 weeks to collect payments from these insurers. Besides the declining present value of the money, the doctor has to keep his office afloat before he can recover the payments. (S)he at times has to take bridge loans for stability. The doctor now has to master the issue of medical reimbursement by dealing with the insurers. (S)he spends time discussing the merits of care with someone at the insurer level who may not even have a high school diploma but is using guidelines to deny care!

3.       There is also a push for physicians to enter whole-heartedly into the Social Media realm and converse with their patients. The voices are getting strong and these voices seem to take a one-better attitude against those that do not interact through the social media by calling them out. Is that the right mode for a patient-physician interaction? Is this another minor activity that the doctor will be forced to major in? Given the HIPAA laws there are optional pitfalls, sinkholes and avalanches that await the unguarded word of a physician in the digital realm. You be careful out there doc!

 Statistics: 50% of scientific medical studies are not reproducible (false, biased, improperly done or statistically manipulated)! That statement must give us pause. Physicians rely on a properly done study to determine its need in governance of their patient's care. Currently with the fudged data, biased output, conflicted interests of publish or perish, the scientific offerings are limited and it is up to the physician to major in the biostatistics to weed out the right from wrong, the good from the bad, even though both may appear the same.  This simplified .pdf book would serve everyone involved in medicine well “Know Your Chances" by Woloshin, Schwartz, Welch Complete book in pdf via @Medicalskeptic (my thanks). It would behoove us doctors to acquire this knowledge for knowledge's sake anyway.

5.       Regulations: The physician office is governed by no less than 38 different federal and State laws, rules and regulatory bodies that can with impunity shut down his/her practice of medicine. A physician is required to know these laws, rules and regulation and ignorance is never an excuse. Another major is needed to discern the legal word behind the regulatory capture of medicine. The fear alone from this is enough to drive anyone insane.
6.       Maintenance of Certification or MOC: This is a product of the private enterprise that assiduously enforces certain demands on the physicians without the clear bounds of verifiable and or validated data. They claim that the MOC process is necessary to determine the knowledge and learning of the physician. These claims are embraced by the hospitals and insurers as a means to weed out physicians from their roster should the physicians be found not in compliance to the MOC standards. There are some very relevant issues in this thinking. If those physicians involved in the MOC process compared with those not undertaking the exercise have similar patient care then how does one better the other? And to boot more than 17,000 physicians have signed a petition to eliminate the new MOC requirements. Most physicians consider MOC to be an unnecessary imposition that actually harms care by usurping physician time away from patients. All this is designed unfortunately to create mistrust in the patient towards his doctor and that leads to despondency and  and with absolutely no known benefits in patient outcomes! 

Just like the Vasa, medicine is replete with the bling of hubris, the shine of pomp and the laurels of asymmetry in thought while the underlying goal of patient care suffers. Might I suggest that the best way forward just maybe a direct patient-physician access without the intermediaries? Or pay as you go or PAYGO! Responsibility on both sides of the aisle as much as the skin in the game like the days of yore!
Healthcare Facts:
1950s = 5% of GDP
1960s = 6% of GDP
2014  = 17% of GDP
If the Trend was allowed to continue the math logic states that the cost would be:
2010s = 11% of GDP not 18% of GDP even with the population growth and demographic change! But somewhere in there by "All the way with LBJ" was inserted the 1965 Medicare Amendment to the Social Security Act and the rest is history! And that 7% of extras in GDP translates to  $17.7trillion x 0.07 = $1.24 trillion of crony pocket change.  Now that is a foreign and abhorrent concept among the elites who wish to partake in other people’s money. Here are some other facts: Direct patient care without the intermediaries will bring the cost of care down, increase the patient outcomes and get rid of this art of majoring in minor activities! It might come as a surprise to the vast enterprise of the “good-intentioned” that medical care is about caring. It is between the patient and his or her physician. Removing the barriers/layers removes the unnecessary burden and gives more stability to the enterprise of caring.

Clearly the healthcare foundational -ballast is grossly under-weighted while the top-heavy self-serving-intermediary-instability continues to increase.
Vasa Replica at the museum

A storm is brewing and history reminds us, with the shaky foundation in place, the first chill of the brisk breeze will surely sink this ship!

1 comment:

  1. Well done! I wonder how many went down with the ship, and how many will go down when our ship turns turtle?