Friday, June 26, 2015


When I was in medical school, the most important person was the patient. Your entire being was focused on the patient. What can I do to resolve this person’s ailment? In fact at one time, I rattled on about the information I had gleaned from the textbook and was babbling along when the professor interrupted, “That is all good, but what does it have to do with this patient?” That broke my train of thought and all I could do was speechlessly stare at him. Today we use terminologies like “Patient centered” and “Patient Centric,” but we fail to actually embody those words. We talk of “listening” as if listening is a new found treasure. We talk about “outcomes” as if previously we were not concerned with the well-being of our patients. We talk about “performance” as if caring for a patient is a function of a metric related athletic score. Medical care has always been about patient’s well-being. Today however the business oriented statisticians are using population medicine inspired data to treat individual patients. The wrongness of this is obvious, yet they, the experts continue to pontificate with “Hazard ratios and p-values” to the eager ears of the uninformed.

In Business parlance there has been a Merger and Acquisition between the business and the medicine mind. The merger was actuated by the "managers" in the two fields without the consent of the voting block in medicine and now that has morphed into an outright acquisition by the business mind with associated divestiture of the medical mind with layoffs and other cost control measures in progress...

When and where did we as physicians go wrong?

In the midst of this dilemma, I decided, I wanted to learn about what makes the entire healthcare system tick? Who was at the till? And what is the motive? I decided to go to a business school. I wanted to learn how business people think? The dean of the university who interviewed me told me that going through the business school would change the way I think!

It did!

I learned that business minds think differently than medical minds, in ways that are inconceivable to one another.

Let me dissect the medical mind first since I have had it for many years and my heart still beats the rhythm of medicine as surely as it conveys the next moment. The medical mind is quite simple and very complex at the same time. Simple because it has a simple ethos; to conquer the malady that afflicts another human; to salve the wound, to soothe and comfort, to help regain what is lost in human functionality, to help live, to help alleviate pain, to heal and to cure. Simple stuff there! Not a lot to think about. Complex because, what ails the individual and how many different maladies can and do create similar symptoms and signs creates mountains of stress. Further, to differentiate between cancer of the lung and to the lung is a whole textbook somewhere ready for the learning. The dilemma proceeds from medication induced damage to illness related ones, from a benign nodule in the lung to a cancer that kills in less than a year, from a cold causing fever to a more sinister disease such as kidney cancer, which sometime only presents as fever and nothing else. These and others footnotes present the conundrum, a physician faces in daily life. To embark on the correct strategy lives the need for appropriate diagnostic work, experiential intuition, much like Sir Arthur Conan Doyle’s Sherlock. “Elementary my dear Watson,” that only comes after the workup has been completed, the correct decision has been arrived at and executed. The constant vigilance of evaluating the benefits to the patient from that decision is a recurring theme in the medical mind. Medicine is true science borne of empiricism in the strictest sense not through the jargon of ratios.

On the converse side in the recent past what I have learnt from the business world is also simple and complex. Simple, that 2+2 = 4 and 4-2=2, these are, you will agree very simple arithmetic concepts. If the revenue is higher than the expense then there will be income, if the expenses are higher than the revenue there will be borrowing to maintain the business until lenders tire of the lending without evidence of higher forecast revenues. If you thought that was all, you would be wrong. There are many complex shenanigans within these simplified concepts that are employed to obfuscate. Difference between cash based and accrual based is a very interesting scenario to visit and learn from. The “Goodwill” category in income statements also poses a nice source of fodder to hide and not hint. But we will let those issues pass for the likes of HBR to contemplate.

My purpose is to look only at the human element in this short treatise. If you look at the “forward looking statements” from CEOs of large corporations you will notice that they always mouth these words, “Our employees are our best assets!” Yet when the net income declines, the first thing these managers do is choke off the employees. Pink slips fly and the “Agency Rule” comes into play so the bonuses at the year end do not suffer. Needless to say the stockholders are happy since the market rewards a rising net income which translates to the Earnings Per Share (EPS), hence the share price rises to meet their expectations. If Net income does not rise with this strategy, then by all means buyback with borrowed money is the order of the day to raise the stock artificially. This short term thinking is evident in most businesses and if you were to look back the past 5 years you might notice the headlines of thousands of workers being fired across the globe and in the U.S. In the latter part of the world there are now 93,000,000+ sitting on their hands without a job. Speaking of stock buybacks, the S and P 500 spent $914 Billion in 2014 in buybacks. Yet thinking of employees as a disposable commodity to beef up the short term quarterly interests for personal benefits has unseen but real consequences in productivity as well. Take for example the difference between Costco and Walmart. The former has loyal well-paid employees that make a decent livelihood at around $43,000 average salary. The latter has a higher turnover rate due to dissatisfaction. The former commands a $21,850 in U.S. operating profit per hour per employee vs. $11,615 at Sam’s Club, a Walmart subsidiary. And if the managers would look at the cause that should light their personal wealth fire; Costco stock price rose 139% and Walmart was up 41%, they would treat their employees as assets and not as expense.  (here:
Blue: Costco Red: Walmart

So this “employees are our assets” is nothing more than  a tired old rhetoric that fits the narrative to exploit the emotions of the employees and the shareholders. A crocodile tear at the right moment when the flash goes off is worth a few front page photos and headlines.

Unfortunately, I feel that same mentality has wormed its way into medicine.

Let us for the moment assume the following; that medicine is a large company and doctors are the main employees. The owners of the “Company,” are the Government and the Insurers, since they dole out the “reimbursements” and the patients are customers. Simple enough! The business mind attracted into the fold of medicine sees the situation in the same context as it does a widget producing manufacturer. The customers (patients) get the widget (care), employees (physicians)are told to work overtime with a lower pay or skimp on the materials (diagnostics and therapeutics) to make the widget, for the sake of the “Company” and if they refuse or if the expenses exceed the desired results are easily discarded from the payroll. Mechanisms of discard include forcing doctors out of hospital staff membership if they don’t comply with onerous requirements of hospital or other private enterprise profitability; MOC (Maintenance of Certification) a continuing annual process of re-certification (for the sake of revenues - more on it below) and Hospitals using sham peer reviews etc. Hospital and Company CEOs are flexing their collective muscles.

Reimbursements to the physicians are easily controlled; previously through the SGR formula and now through newly minted methodologies (MACRA) via ACOs and APMs which, it turns out, are more punitive than the SGR, bu their full impact will not be known till after 2018. These formulations are the work of managers of the government bureaucrats, insurance company executives, elitists that are bounded by bookends of sly and slippery words and lecture from high lecterns, all the while partaking in large grants and salaries. One only has to look at the American Board of Internal Medicine (ABIM) and the revelations by Kurt Eichenwald in the Newsweek articles of how they have fleeced the U.S. physicians (a humiliation of unparalleled proportions that certainly needs further scrutiny). The carrot and stick model used by CMS of giving a 0.5% raise now to follow the preferential business based guidelines to lower costs vs. 2-5% penalties later for not reaching to those arbitrary standards of cost control (as primary endpoint) is the dujour modus operandi. Patient care is implied as the secondary endpoint (for those of you who like reading medical literature) but is never given much credence. The Kahneman and Tversky Loss-aversion behavioral economics are fully applied with prejudice to medicine. The business side of commoditization (and here on YouTube) with “Less is More,” no doubt a business concept, is allowing unsupervised practice by NPs and PAs in some states that are facing physician shortage, akin to: (Hire the underage workers at Foxconn). There lives a beast that will turn Medusa into stone!

The idea of constantly retraining pilots and therefore the physicians is simple but here are a few loose ends; training does not equate to wisdom. One can rattle away concepts without a clear understanding that only comes with layer upon layered experience and critical thinking. I am reminded of my professor and what he said at those times. It is easy to train anyone to do a sequential task of minimal complexity, it is altogether another issue to be able to apply wisdom to the need or want for that task that comes from education and experiential reference. One can be trained in triage for routine care but when human pathos complexity hits as it does most times, repetitive training alone will not do!

Let me bring in the Airline pilot training that all the "experts" are advocating, here for comparison. If any of you remember the Sioux City Iowa crash of United flight #232, it was not the training that helped, but Captain Al Haynes' sheer intuitive brilliance that saved 185 passenger lives. In fact 55 test pilots failed to equal his success in the simulator given identical conditions and having been pre-warned of what was to happen. So a word of caution to those beating the drum of pilot training and equating it to doctor training, it is more than training! A corollary to that crash is the more recent Asiana Airline crash in San Francisco where pilots were trained in Instrument flight by the Autopilot and failed to realize that in case of Instrument Landing System failure they had to hand fly the plane and you guessed it, they couldn't! They were trained to manage the autopilot flight!

The intuition gathered from compiling years of education, knowledge and critical thinking is needed in caring for the patient. So if NPs and PAs desire to practice medicine then they should simply go to medical school, follow through with a residency in training and be ready to take on the medical world. I say welcome to that. Doctors learn daily through human - human interaction. Pathology differs in each individual as does to some extent physiology. No two humans are the same.

Meanwhile guys and gals, ease up on the physicians, if you will. Tone down the demonization! Enough is enough!

Using syllogisms to prove points are constructs of the pseudo-intellectuals. They use the informal fallacy of "post hoc ergo propter hoc" or this happened because of the preceding that! A classic example is:
The cost of medical care goes up
because of greedy doctors
Healthcare costs are rising
The doctors are greedy

This form of modus ponens methodology obfuscates, confuses and destabilizes the noble profession. In fact the very act of forced balancing a model unbalances it. To prove the point there is a daily barrage of wrongdoings highlighted in the media. Lately caring for patient's in pain with painkillers subjects the physician to criminal charge. But since the modus has been broadcast earlier the corresponding asymmetric il-logic must also be true; doctors are bad people. The result; patients are left to deal with their pain by the physicians for fear of over-prescribing allegations and indictments against the doctor.

By now you might have guessed that the business mind differs greatly from the medical mind. It does not discern the effects on the consumer as much as it covets its growth and success, although in the long run, those that survive time, pay attention to the widget creation and customer satisfaction equally. The current business mind however is a short term thinker; the next quarter and the surreptitious mechanisms to inflate the correct numbers to be rewarded for such acts has become an art form. The widget may be of sub-par value but if you say it is great on TV and the Internet through populated bots, it achieves a longer "time value." Enron is a prime example of accounting fraud that destroyed a large number of shareholder savings. LTCM, another entity which exploited small asymmetries in pricing until it took down $4.8 billion in stockholder wealth and needed $3.5 billion in bailout from the Fed.. Also remember the Gremlin and the Chevy Volt in the same context for further illumination of thought. The latter two products (widgets) expose the forced logic of failure with precision. History teaches us but as George Santanaya prophesied, "Those who cannot remember the past are condemned to repeat it."

The business mind is focused on net asset value. They consider the machines, the robots, the buildings, the pencil and paper as assets. Human workers are considered a “Fixed Cost.” Therein lies the greatest misadventures of the business mind meddling in the field of medicine.

The medical mind is focused on human healing, recovery and overall health. The business mind on the next quarterly revenue and net income!

Yes, I did learn to think differently. I see the holes in the dam where the tips of the fingers are visible. How long will it take for these cracks to rupture can only be measured in the “near term!”

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