The Problem with Altruism

Altruism is killing us. Take a second to let that sink in. Truly think about it. Resist your conditioning to refute this claim and try to apply it to your life. Still having trouble? Let me try to explain.

In order to understand the truly destructive force of altruism on medicine, one must first define altruism. This can be difficult to do in the United States as any “good” or “charitable” act will instantly be defined and praised as altruism but this is incorrect. Altruism is the complete devotion to the welfare of others at the expense and disregard of oneself. Try not to gloss over this last part, it’s important. Altruism is not providing gifts to loved ones because you care about them. It is not volunteering at a soup kitchen during your free time as a resume builder. It is not providing care to patients during working business hours or spending an extra ten minutes on the phone getting their medications approved. It is not performing a task in which you receive some benefit whether it be tangible or intangible. Altruism is the sacrifice of the self in devotion to the other. It is eliminating your vacation to see more patients. It is spending time away from family to answer pages and phone calls when you would otherwise be allowed to rest and relax. It is the uplifting of those that do not care about you to the detriment of those that still do. It is the systematic voiding of the individual that somehow ingrained itself so deeply in the field of medicine that many accept it as a core element to the practice of medicine. This is lethal.

Medicine has changed dramatically over the last thirty years. The Norman Rockwell days are gone and Big Business is here to stay. While the M.B.As have adapted rather nicely to the changing landscape, creating large networks of hospitals, clinics, and administrative overlords, the M.Ds have failed to adapt. We strive to care for our patients despite all else. We try and hold true to the teachings of those that came before us and blindly accept that altruism is essential to our craft as it was to our predecessors. The overlords understand this with complete clarity and are more than happy to walk us down the road to Hell with our good intentions. This is why your clinic roster dictates that you see twenty patients in a day, why you are hounded by “documentation specialist” on whether something is “acute or chronic”, why you are expected to complete CMEs and MOCs, why Press-Ganey demands nines or tens, why your salary goes down while your RVU requirement goes up, and why you spend most of your day interacting with a light bulb trying to figure out how it came to this point. And if there is ever an open disagreement about adhering to “the rules”, altruism is invoked by the phrase “for the patient” to stifle further unrest. Because with altruism, if it’s “for the patient” there can be no valid counter-argument that contains the phrase “for the physician”.

And what effect does all of this have? Is anyone truly perplexed that the suicide rate for physicians is over double the general population? Is anyone truly astonished that physicians are burnt out and desperately seeking the sweet release of retirement or career change? You cannot take a group of highly motivated individuals, set an unachievable goal with unrealistic expectations, and expect a large majority to not fall apart. You cannot expect those highly motivated individuals, who start seeing themselves only in the light of failure, to see much benefit in continuing their existence for decades in such a state. I am not condoning their actions but I am not ignorant to their perception of reality. And I cannot stress enough that this constructed reality has been largely fostered by the core value of altruism.

Altruism does not make you a good person. It does not make you a moral or ethical person. It does not help you take care of patients. Whatever benefit altruism may have provided in the past, it has long since passed and now serves as nothing but the anchor around our necks threatening to drown us. We have to accept that we have value, that we matter, and that we are an end unto ourselves. We have to accept that altruism is a burden and not a blessing and excise it from our core. We can still be physicians without it but we may not be physicians for long with it.

There is no Fight

The large majority of what I do, day in and day out, is tend to and treat the critically ill. I work primarily in the intensive care unit because I prefer my patients ventilated and not talking, but I also prefer to deal with real medical problems as opposed to the chronic abdominal pain epidemic found on the floors. And although I do enjoy the intensity of critical care, the procedures involved, and the problems encountered, I do find myself rather frustrated with the overall trend of critical care patients. To be more specific, I am tired of continuing with heroic efforts to save those that are well past their expected life spans.

It is a common complaint throughout the health care field. Nearly every physician that works in a critical care setting, and even those that primarily work on the floors, cringe at the idea of aggressive care for the severely debilitated octogenarian. We wring our hands every time a family elects to send grandma to the ICU, complain among ourselves how futile the situation is, reaffirm our own desires to never have any of this happen to ourselves, but ultimately still treat the patient with the family none the wiser. This torturous charade of “life-saving” care drags on, sometimes for weeks, and ends in only one of two ways: long term nursing care +/- tracheostomy/feeding tube or death. There is no happy ending. This is American healthcare dollars at work!

“Wow! That sounds hella’ depressing! Why do we do this if outcomes are so bad?!”

Excellent question, person-who-has-clearly-never-interacted-with-Americans-before! I got two big reasons for you.

Baby Boomers

The first and foremost explanation for the above scenarios has to do primarily with the fact that this country is becoming older, sicker, and increasingly unrealistic. The Greatest Generation is nearly dead and they are being followed by their exquisitely narcissistic off-spring known as the Baby Boomers.

The Baby Boomers, until recently, were the largest generation of Americans in existence. They were born around 1946-1964 and were the result of post-WWII blue balls coupled with raging prosperity. Their parents, who suffered through economic devastation prior, were hyper-focused on providing their off-spring everything they needed to succeed in this post-war boon. Good intentions abounded for this generation. They had everything. And what did they do with it? They squandered it.

The Boomers are notorious for their collective narcissistic traits and their limited insight. Unlike most generations, they seem to be focused primarily on the present, specifically their own. Despite having children and proceeding through the game known as “Life”, the Boomers have refused to give up their petulant desire for instant gratification even at the cost of the future (see: President Trump). There are several articles and books which delve into this topic. Most of these will miss the point in some way. If anyone wants a legitimate interpretation of our current cultural crisis, I would recommend listening to a drunk psychiatrist. There is a lot to process in all of that, so I will leave further elaborations to the experts. But given the above, the relevant question becomes “What happens when a narcissist nears death?”.

They fight.

Or at least, they construct a narrative in which they believe there is a fight that can be won despite the obvious truths regarding their impending mortality.

Let me explain.

There is a common narrative among many Boomers that find themselves on the unfortunate end of an unfavorable diagnosis. The narrative is that this diagnosis (usually cancer) is simply an obstacle to overcome regardless of the fact that it may be metastatic, recurrent, or has failed two rounds of treatment and is rapidly spreading. “We ended Vietnam! We accomplished Civil Rights! We brought down Russia! We can do anything!” is the mantra I envision in their minds, coupled with the Rocky theme, that echoes in the background of a pre-constructed montage set to max volume in order to drown out the harsh reality that their movie is coming to an end. There is rarely any acceptance of the inevitable because they cannot conceive of an “inevitable”. They cannot conceive of a movie without its protagonist and they cannot conceive of any existence where they are not the main lead. Rick Grimes can’t die! The end result of this is not a heroic recovery in the face of all odds with Michael Bay background explosions and epic orchestral music booming; the end result is a prolonged death in an intensive care unit often punctuated by rib-crushing rounds of CPR or withdrawal of care after extensive family discussions regarding the overall futility. And no, the patients rarely ever tell the family what they actually want in this situation outside of “do everything”. This is why the last month of life seems to be so expensive.

This extends much farther than just “end of life” care though. Given that the Boomers have been unable to be future-oriented for the entirety of their lives, the results of that present-oriented thinking are coming to light. It is no secret that more and more people are developing chronic illnesses and the truth is that most of these chronic illnesses are preventable. Or should I say, they were preventable. A lifetime of smoking, poor eating, no exercise, and recreational drug use has led to COPD, heart disease, heart failure, diabetes, high cholesterol, hypertension, and chronic hepatitis. All of these are treatable, some are curable, but it takes effort and compliance. There is a large number of patients in the Boomer population that refuse to take their medications, down-play their medical problems, or subscribe to the belief that the medical-industrial complex is in bed with the Illuminati to propagate disease in order to profit from sham treatments provided by the greedy physicians. It is this propensity towards conspiracy theories which has helped launch the anti-vax, alkaline, naturopathic, hormone craze  which seems to be spreading among the over-educated.

The end result of this childish ignorance is always the same. It ends in disaster. Their disease invariably progresses, they find themselves hospitalized with increasing frequency, their frustrations build over their inability to get better, they begin to blame physicians more for “not fixing them”, and it eventually ends where all great American stories end: the ICU. And just as above, they fixate on the idea that they are “fighting”. Their families continue to proclaim that they are “fighters”. No one seems to understand that 1) this is not a fight, it’s a beating and 2) the only thing that was being fought was reality and reality always wins.

Physicians

The medical community as a whole is horrible at delivering bad news. There is a reason that there are workshops dedicated to this, both for residents and full-fledged attendings, and why palliative medicine exists. Instead of accepting the reality of the situation, many physicians elect to walk down the road of willful ignorance hand in hand with their patient hoping for a cure via their “treatments”. This fantasy construct is best exemplified in the field of oncology.

Oncology is a field defined by the fact that nearly all of their patients are moribund faster than most other. This makes it an intrinsically difficult specialty. Unlike years past, when most people died relatively quickly from their disease due to limited treatments, this field has seen an explosion in research. There are multiple treatment lines for nearly every oncologic condition. In addition to the standard chemotherapy, there are therapies targeting specific receptors and signaling pathways which appear to have fewer side effects, potentially greater efficacy, but also higher cost. This means that those imminently terminal patients from the past are living for years instead of weeks. This also means that the relationship between the patient and physician becomes more complicated. The oncologist becomes familiar with their patient, their families, and is often involved in every complication involved with both their treatment and disease. The oncologist becomes the primary care physician. This benefits no one.

Excluding certain hematologic malignancies and immediately excisable solid tumors, cancer always progresses; cancer always wins. The oncologist knows this although many will refuse to openly accept that fact. Their ability to accept that reality is further compromised as they start treating patients more like friends. This is never more obvious than when a cancer patient is admitted to the ICU and the oncologist wants to be involved in their care. It is a recurring theme that while their patient is intubated, in septic shock, with renal failure, and developing DIC, they will continue to tell the family that further treatment options can be considered once the patient has recovered from their “critical illness”. Never mind the fact that this “critical illness” is a consequence of their multiple treatment failures, deconditioning, and metastatic spread of their underlying cancer, they will present it to the family as unrelated. They continue to provide hope for the family and the family holds fast to this hope. This will go on for days, weeks, even months. Maybe the patient leaves the ICU, maybe they leave the hospital, but the patient is never well enough to be a candidate for further treatment. There is always another unrealistic goal set which is invariably followed by several setbacks, repeat hospitalizations, treatment complications, deconditioning, and ultimately death. In other words, the patient is attached to the wagon of good-intentions and dragged down the road to Hell.

It is not easy giving bad news. There is no joy in it. And giving bad news to people that you have come to build a relationship with over a span of months to years, to people who may send you holiday cards or bring in cookies to the office, is even harder. It is the equivalent of giving bad news to your grandmother. It is easy to ignore reality, to focus on “potential”, and to give words of encouragement and hope. It is easy to buy into the pervasive myth in medicine that families are only open to receiving optimistic news. It is easy to watch the wagon be pulled down the road while you shout words of encouragement from afar. It is easy to be a coward.

Death and dying is a large part of my day in the critical care setting. I give bad news to families all the time. In some ways, it has become almost routine. It requires a degree of emotional intelligence, as some are more open to harsh realities than others, but I have found that every family is thankful for candid conversations. I have had many families comment that no one had been direct with them before, that they felt something was being excluded from past conversations, and that they wished prior physicians had been more direct regarding prognosis. I have never had a family become angry, violent, or demand transfer. I have never had “patient experience” get involved after delivering terrible news. I relay the information in rather black and white terms, limit the use of optimistically ambiguous terms (maybe, possibly, hopefully), and often times offer my opinion regarding the situation if the family is interested. Despite the medical communities push to destroy every vestige of paternalism, many families are comforted by physician recommendations against leaving their eighty-year-old father on life-support indefinitely. Sadly though, too many physicians are unwilling to have these candid conversations, due to their own discomfort, and the cycle continues until the wheels fall off.

 

These are not the only reasons for the perpetuation of futile care. There is a myriad of factors. But generational narcissism and physician cowardice are two of the dominant factors. The former can only be cured by tincture of time, but the latter can be improved upon today. Because whether or not physicians want to have the conversation, it will need to happen. We can decide to have it on our own terms or we can wait for the government to indirectly force our hand.

The fight will end somehow.

Medical Competency: An Unfortunate Truth

There is an unspoken truth throughout the medical field. It affects every specialty of medicine along with every hospital; nowhere is immune. This truth? It’s that not all doctors are competent.

“What?! But they passed boards! They went to school! They are supposed to be smart! How do you know which one? OMG should I go naturopathic?”

It is a fact that every practicing physician in the United States has completed the conditioning program known as medical school, jumped through the hoops known as their “Steps”, managed through their existential crisis known as residency, and then topped it off with their boards to finally reach the status of full-fledged pill dispenser / knife jockey. It is also true that all of these people are undoubtedly smarter than your high school friends who were unable to read a paragraph aloud in under five minutes. But none of this equates to that physician being competent.

“So why are they incompetent?”

Well, I’m glad you asked, voice-in-my-head. Let me try to explain.

Lack of Appeal

First and foremost, one of the biggest issues with maintaining a competent physician work force is to recruit people who are actually capable of being competent. It is an understatement to say that the medical profession has an “image problem”. Physician suicide remains high, the reasons for which remain vast and ever-increasing, satisfaction with career choice is poor, and the large majority of our time consists of paperwork and other bureaucratic bullshit. I remember when I was a pre-med student and shadowing a family physician in my home town. I remember, in between his morning and afternoon clinic blocks, him rushing to eat lunch in his office, checking his own blood pressure, and asking me if I really wanted to pursue a career in the slow-death known as the medical profession. I remember answering in the affirmative, willfully ignorant to the obvious, and naively hopeful that not all of medicine was like this. The joke was on me, I guess. I know for a fact that many, if not the majority of, physicians would not recommend going down this road. Many of our recommendations go unheeded, often for the same reasons we ignored prior pleas, but I get the sense that is changing.

Despite the ever-increasing number of boxes that require checking and hoops necessitating jumping for medical school admissions, I would wager that the overall quality of medical student is degrading. I do not mean that the scores are dropping or the academic focus is fading. In fact, I would argue that the requirements for medical school continue to become more stringent. But I would argue that the “well-balanced” medical student is becoming a thing of the past. At least anecdotally, I have noticed that the ability for critical thinking, deductive reasoning, intellectual flexibility, conversational fluency, perspective, and the ability to “read” people have been severely deficient in many medical students. Conditioned to be nothing more than high-scoring automatons willing to consume and regurgitate specific sets of data repeatedly over a span of years, I understand how their other faculties could suffer. But it also seems that most medical schools are purposefully selecting for those individuals who are most adept at generating high board scores usually at the cost of social intelligence. To put it into primetime TV terms, medical schools are searching for The Good Doctor .

“But The Good Doctor is super smart and saves people all the time! He’s like so amazing!”

Sure, if I ever had a TV-medical problem I may be inclined to put him on the case since House is no longer available. But this is not TV. Medicine is rarely curative and I am willing to bet you would be unable to last ten minutes conversing with someone of similar social deficiencies before clawing your eyes out. Furthermore, the intellectual rigidity most often associated with the real-life proxies of The Good Doctor make them at best questionably hygienic encyclopedias. But, if medical school admission committees get their way, you may have no other choice. Everyone else, equally intelligent but able to maintain eye contact, has already heeded the advice of their depressed and possibly medicated predecessors and veered away from the medical profession.

Lack of Thought

There appears to be a paucity of critical thinking throughout the medical profession. To be clear, research is still on-going, new treatments for diseases (primarily cancer) are being manufactured, and academia is still thriving. But all of that is largely irrelevant to the patient sitting in the waiting room; the big question is whether or not your clinician is still capable of critical thought.

There is a lot to know in medicine these days. And outside of “The Good Doctor” and “Dr. House”, it is unlikely that any physician will know it all. And even if they did, it would be irrelevant within five years. With this deluge of knowledge, the cult of Evidence-Based Medicine (EBM) was conjured forth into existence. Like all cults, EBM promised real answers to troubling questions; it promised to apply scientific knowledge (trial data) to the problems of our times in order to ascertain the best treatment option. No longer would we need to live in the dark ages of “expert opinion”; we were bound for enlightenment! But sadly, like most cults, it generated more confusion than clarity and focused on control of information but without the benefit of crazy sex parties.

Through the utilization of EBM, hundreds if not thousands of guidelines were generated spanning nearly every medical problem in existence scattered throughout hundreds of different journals and medical societies. What once was supposed to serve as a guideline for practitioners, presumably based off trial data (but more often still based off expert opinion), slowly morphed into a mandatory “standard of care”. Never mind the fact that not all trials study all patients afflicted with a specific disease. If you have Disease A then you better get treatment X or risk possible malpractice. Praise be to EBM!

I imagine it was this development, along with several others, that led to further specialist referrals. Problems that once may have been managed by a primary care doctor were now referred out because it was impossible to keep up with the ever-changing recommendations by the “Powers-That-Be” for each group of specialists.

Following this even further, the only way to effectively treat a patient now would to become a specialist. Yeah, you could still work in primary care, but no one wants to do that anymore. It’s way too much work. Instead, you should specialize and get the privilege of focusing on a specific area of the body. However, now that specific area of the body has about ten different medical advisory groups, each focused on their unique disease, and each with their own body of recommendations which can span hundreds of pages long. Shit. What do? I know! Sub-specialize! Now you can focus primarily on diseases affecting the lower third left ventricle of the heart, be an expert on relevant recommendations, and never have to concern yourself with anything involving any other part of the body! And the best part? Templated notes ensuring that you never miss any detail needed for patient questioning or billing purposes.

This is why many Americans have the luxury of seeing eight different specialist a year for a handful of different problems, each specialist prescribing their own treatments, each specialist providing their own recommendations, and each specialist wholly ignorant to the workings of their colleagues. Occasionally, the primary care provider may be able to intervene, if they have the capabilities of doing so. But for the most part, the wheels of the machine continue to turn unabated until an inevitable complication lands the patient into the hospital. This allows the patient to see all of their specialists at once for a fun Battle Royale of competing ideas. Although each specialist is likely well-versed in their specific field, they have willfully abjugated themselves from the whole of medicine. Generalized competency is lost and so is the patient. But those boxes are checked!

Lack of Control

If it has not become obvious by now, physicians appear to have far less control over their occupation than they did in the past. As mentioned already, most of their work revolves around glorified secretarial work in order to prove their worth to their respective M.B.A overlords whose job is to quantify productivity and exert bureaucratic control. This is not to say that we do not deserve this treatment. We most certainly do. We gave up our control willingly to avoid the hassle of worrying about finances and other “non-medical” issues and in turn we allowed ourselves to be pushed into a pseudo-slavery propagated solely by our collective cowardice. Ask any physician, in private, about their thoughts regarding kicking the system down, striking, or refusing to comply to the insane regulatory requirements (IE: MOCs) and they will grab their pitchfork and torches. Suggest the same in a public setting, and be met with a collective brow raise, platitudes ending with “…for the patient”, and recommendations to instead appeal to our masters for more control over our lives which is invariably denied. Eventually, another physician will kill themselves in the interim and physician burnout will be the hot topic of the day. Victim blaming often ensues during these discussions which reinforces further to the physician that the system is here to stay and that the best they can do is try and learn yoga. It is usually easier just to keep drinking until the next cycle begins though. This happens ad nauseam to the point where the medical community as a whole would be viewed as having poor insight and judgement during a psychiatric exam. Again, this is why so many physicians want out of the field and are slated to be replaced by the box-clicking, questionably autistic, automatons currently matriculating through our medical schools.

 

I’m not a genius by any stretch of the imagination. I highly doubt I will ever change the face of medical knowledge. But I can at least see that which is in front of me. This is why I have a hard time interacting with my “peers” without openly questioning their sanity. This is why “outside hospital” sends me patients that are billed as “too complex” because they have three or more chronic conditions and the transferring physician has no idea how to logically approach it. This is why I have to dictate to may different outside ED physicians how to appropriately evaluate a patient on BiPAP to determine if they need to be intubated. It is scary just how many physicians in critical care settings don’t get it. This is why cases of iatrogenic salt water drownings are so common in hospitals that are hyper-focused on guideline driven protocols, such as for sepsis. Soon they plan to roll out a protocol to initiate antibiotics and fluids on patients who MIGHT be septic in my hospital. To the three people who may read this, and have no medical background, they want to give 2-3L of fluids to people who have no business getting fluid (heart failure, kidney failure, liver failure patients). This will invariably result in respiratory failure, further complications, and likely ICU transfer. So why do it? Because CMS has changed guidelines into mandates. Because bureaucrats and spreadsheet jockies are never challenged. Because critical thinking is irrelevant. And because competency is all but dead and the patients are not far behind.

“….So how do I determine if my doctor is competent?”

Trial and Error. Good luck!

Electronic Health Records

The creation and dissemination of electronic health records (EHRs) was inevitable the moment personal computers provided every household with unlimited access to porn. While everyone was enjoying themselves in the presence of nubile cyber nymphs, the Powers-That-Be were preparing for an all-out assault on every last sector of the planet that was operating without a keyboard. Today, as long as you appreciate running water and not shitting in public, you must comply with the internet. Medicine is no exception.

I.

EHRs started to become wide-spread in the medical field sometime in the early to mid-2000s with all the snake-oil promises that one would expect which included: reducing medical errors, making information available in order to reduce test duplication, and improving accuracy and clarity of medical charts. In the same way that Congress has no idea how the internet works (some believing it to be a series of tubes), the medical community and its self-appointed leaders clearly had no idea what they were doing or how to internet. They probably should have asked a Millennial. I’m sure any one of them could have quickly showed them the error of their ways with a simple cat meme. But alas, an expert was not consulted and here we are today, wringing our hands in protest of our new overseers.

For over a decade, physicians have been struggling with accepting the use of EHR. Many have expressed dissatisfaction over the fact that more than half their time is spent “interfacing” with a shiny rectangle instead of intently listening to their patient’s complaints which are likely centered around nebulous fibromyalgia pain. Some of the older physicians are even fantasizing about leaving medicine citing the increased burden of serving as a gloried data-entry monkey instead of a physician which is what they were originally trained to do. Furthermore, the promises of reducing errors have been found to be baseless  in that the alarms and alerts scattered about the EHR do nothing more than produce alarm fatigue with only minor improvements in care processes at best. I don’t care how many pop-ups you place in front of me, the foley is staying in.  Although, to be fair, it appears that prescribing errors have decreased some but only because each order starts with a default dose followed by a range of options which allows the physician to at least have a chance at guessing the right answer; we are only trained to excel with multiple choice exams. And as far as decreasing duplication of records, that has also been found to be a bogus claim. As of 2015, 60% of PCPs were unable to electronically exchange records with other physicians outside of their practice. This is not limited to the outpatient world. Anyone who has spent any time in the inpatient setting trying to obtain records from an outlying facility is usually shit out of luck, except for in larger cities where different institutions may have the same EHR and thus are able to share some limited records. This is less that information sharing is streamlined and more a gradual monopolization of information by a superior EHR system (read: Epic). Trying to get records from an outlying transferring facility that does not have the same EHR? Good luck! I can’t tell you how many records I received either by fax or transferring medic which were still hand-written and illegible. HAND WRITTEN! And that is assuming they even send records of any remote importance. Most transferring facilities seem to believe that nursing notes and skin assessments are all that is needed.

But despite all of these problems, the fact that research has continually debunked the promises of EHRs and that many physicians would prefer to slam their dick in a sliding glass door than interact with their institution’s medical record system, they are still being touted as necessary to patient safety and improved care. Although reality is quickly becoming irrelevant (see: Presidential Election 2016), it is still fascinating and horrifying that despite very clear evidence to the contrary, the zealots of EHR refuse to acknowledge the fact that they were wrong; they were wrong about everything. None of their promises have been fulfilled but I suspect that none of their promises were ever meant to be. Hindsight is 20/20 but realization is a bitch. EHR’s were never meant to improve the lives of patients or physicians; they were meant for control.

II.

Back in the day, during a simpler time in medicine where medications were limited and payment could consist of eggs and a chicken, physician notes were meant for no one but themselves. There was little order to how they were written and legibility was only relevant to the person writing the note. SOAP notes did not exist. Best practices did not exist. Medication reconciliation and a full review of systems did not exist. Often times, a few simply lines would be all that was written as documentation for a full clinic visit. This took a few minutes. It was likely the least consequential part of being a physician. Those lucky bastards.

Fast forward 30-50 years, with the advent and dissemination of the SOAP note, and the landscape has changed. The notes are still paper, as Big Internet had not come into the picture yet, but the format was drastically changed. In some ways, the change was for the better. There was more structure provided, it required at least some relevant information for those that may be exposed to the notes and were not the author, and one could create pre-printed templates to help expedite the process. But more importantly, this change allowed the implementation and utilization of EM codes. Physician’s had to prove their worth by writing down their thoughts as well as important aspects of the patient encounter and then code accordingly based off the complexity of the encounter. This form of note writing did end up taking more time but it was not overly burdensome. Physicians could still enjoy being physicians.

Now bring it to the present, for the last twenty years or so, and the landscape has changed once again. Big Internet kicked down the door, flexed nuts, and opened a portal from Hell to fill the land with endless Best Practice Advisory pop ups, guideline reminders, data element requirements, check boxes, and ICD codes. With the implementation of EHRs throughout the land, the task of billing and note writing which was once considered an inconvenience, has become the tools of our enslavement. What once use to consist of no more than a page in short-hand has now morphed into a 4-7 page, primarily auto-populated and copied forward, irrelevant gargantuan ever evolving to demand more data without providing any useful information. Per usual, the outside influences were far more intelligent than the whole field of physicians. The insurance companies, and specifically Medicare and Medicaid, saw the opportunity that the electronic age provided for demanding more and giving less. They also seemed to understand the cowardice of the physician population and took special notice of the fact that their training made them particularly susceptible to achievement-oriented enslavement. With this knowledge, and the weaponry known as The Affordable Care Act, an all- out assault on the medical field was launched.

Notes were scrutinized with ever more arbitrary elements required to obtain a certain level of billing, the calculation of which was purposefully made difficult in an effort to then fine and demand repayment for the inevitable misbilling of encounters. Requirements regarding obtaining a “full” review of systems, despite the complete lack of evidence this provides any useful information, a family history, social history, and a complete medication list (despite the fact that NO ONE knows what they put into their mouth) were required for every note in every encounter, especially in the outpatient setting. Particular language regarding diagnosis and timing of diagnosis were established, and frequently changed, in order to deny payments for mislabeled diagnoses or for missing diagnoses of questionable importance at the time (IE: Obesity). This assault has been further augmented by the requirement of physicians to register with several different physician review organizations, often requiring renewal of registration every few months, with penalties for those who forget or have better things to do (like finish those God-damn notes). And lastly, as if to add insult to injury, the Powers That Be have felt the need to make sure one cannot successfully navigate through their EHR without suffering through no less than 5 pop ups demanding attention to several, often times inconsequential, elements of a patient’s care. (No, I am not going to order a flu vaccine. It’s May. Fuck off!)

It’s all about control. None of this is for the patient. None of this is for the physicians, in as much as it improves their lives or makes their job easier. It is all to control and bewilder those that have the real power. Keep them focused, keep their heads down, do not let them look up, do not let them get comfortable, change the rules, add more tasks, and never let up. This is their game and it works! Instead of requiring change, instead of saying “No”, instead of fighting back, we slouch down and continue with the grind. Occasionally, we like to use our “science” to make a point, but that never does any good. (Remember all the studies about how patient satisfaction is bullshit?) Science will not change the minds of those with an agenda. The assumption when studies are published is that the minds they are meant to change are ignorant to the fact presented; the fact is we are ignorant to their agenda. We are also ignorant to the fact that when we prove a system is flawed and then do nothing to change it, we are helping our oppressors. We may feel smug in our knowledge that the policies are bullshit, but the overlords already know that and we are still following them. “We got them good! Now I better get back to clicking boxes or Master gonna be upset!”.

Someday, after alcoholism and suicide has ravaged the medical profession, assuming the world has not ended in nuclear disaster or an Idiocracy-style decay, the medical field will make a change. The oppressor will be identified and de-throned. When that day will come, I have no idea. And what the profession of medicine will look like at that time is unclear. But I can assure you that if the change is not made fast enough, and while enough intelligent people still want to invest their life into it, we will be in trouble.

But in the meantime, those boxes aren’t going to click themselves.

Us-Versus-Them

There is a weird dynamic that occurs in nearly every hospital setting around the country. It’s a hostile dynamic that seems to be older than time and almost hard-wired into everyone that partakes in this seemingly fruitless endeavor known as health care. It’s an Us-versus-Them dynamic which oddly enough seems to pit physicians against nurses.

“That doesn’t make sense. Aren’t they supposed to work together?”

Indeed.

I.

The tension is immediately palpable upon your first day of third year clerkships as a medical student. If you think back hard enough, maybe you can remember the first time you walked unto the floors, asked a nurse a question, and were met with either indifference or resentment. The interaction may have surprised you. It was just a routine question, wasn’t it? Maybe the nurse was having a bad day? Regardless, you continue to solider through in your ignorance while nervously seeing patients and hoping to not make an ass of yourself in front of the attending. However, inevitably, you must approach the nurses again to ask about/for something. You proceed in your seemingly mundane and innocent task but ultimately are still left with the impression that you serve no purpose but to be a pain in their collective asses. Occasionally, you will have interactions with the nurses that are pleasant. Just as there are a handful of surgery residents who do not harbor bitter resentment and rage towards every living thing, there are also nurses who make it a point to interact with the “lessers” as if they were human beings.  These interactions are few and far between though. By the end of your fourth year, you have a clear understanding of how things work; you know which train tracks not to cross. And this is just in time for you to begin your residency where you get to see things from a whole new perspective.

Intern year is where you begin to clearly see the divide. At this point in your medical career, you effectively know a lot about nothing. And the nurses know this. At this stage, you are going to screw up, a lot. Like, a lot a lot. You are going to be too conservative in some matters and then too liberal in others. You are going to hedge when talking with family members and give too much hope when there is none to be had. You are going to contradict the nurse, even if you do not intend too, and create tension. The nurses expect this. They have been through it all before. Some nurses may even be able to do your job better than you. But still, and despite this, they are obligated to follow whatever you haphazardly put into the chart; it is a life of Groundhog’s Day just with different actors. They may call you about it, clearly annoyed, and demand you fix it. Or other, more subversive, nurses will follow the order to the T. At this point, animosity often arises and becomes rather obvious even to the dimmest of bulbs. And how do the nurses best convey their frustrations? It’s not by direct confrontation; that is a big No-No as many nurses have often been burned in the past for these types of actions. Their weapon of choice: passive-aggression.

You know it when you see it, the nurses that have taken up their passive-aggressive arms. You will receive a thousand pages for stool softeners, electrolyte replacements, diet orders, Tylenol, anti-emetics, and narcotics. You will never be called doctor; in their eyes, you are a baby doctor that barely knows how to crawl and is always covered in shit. They will interrupt you on rounds to give “updates” that contradict the information you obtained, they will question every decision you make, and they often will “go up the chain” when they disagree with you until they get an answer they like. And they will do this all in the name of “patient advocacy” because it is the ultimate trump card; it is the equivalent of invoking God’s Will as the reason for your actions. And as this goes on, as the pages piles up, and as the years tick by, things may get a little better. Eventually, you become the senior resident and no longer have to field the majority of pages, you are not presenting during rounds, and you are officially higher up on that “chain” where you can have a final say. But the memory of the past still haunts you, it still leaves a bitter taste in your mouth. Again, there were nurses along the way that were decent, amiable, and easy to interact with, but their light has been extinguished by the mounds of shit which was otherwise known as your day-to-day. And as you near the end of your indentured servitude, filled with the ugly memories of your war days, you hold on to that world-view of “Us-versus-Them” as you transition into becoming the illustrious Attending.

As an attending, you are now addressed as “Doctor”. Much of the overt rudeness you may have experienced as a resident appears to have quickly disappeared. You are at least given the impression of having more respect. And right or wrong, sometimes you may even feel like you earned it, so now you make your move. When you receive a page or call from nursing regarding a less than pressing matter, you lash out, belittle, or demand further information and a call back before hanging up. You demand to be called “Doctor”. You have little or no regard for how the timing or placement of your orders may inconvenience the nursing staff and may even erupt in a fit of indignation when something was not done perfectly the first time. And the best part? Despite occasionally acting like an impetuous child, no one will call you on it. You are the boss! Absolute power corrupts absolutely.

But despite the fact that the nurses may not outright call you a flaming dick bag to your face, they sure as hell are seething about it when you are nowhere to be found. They hate how you respond to requests for orders or information, despite the fact that it is their job to make such requests. They brace for impact when they see your name on the chart and have likely bitched to various supervisors which ultimately have no power to make changes. They will likely still use their tried and true method of passive aggression on you, which will be irritating, but you are still in control. They know that. And they hate that. And that hatred, since it can’t be paid back, is paid forward. And the cycle continues.

II.

It may appear that I have put all of this on the nurses, that I have accused them of throwing the first stone. Let me assure you, I have not. I do not know if anyone will ever know who drew first blood in this seemingly endless war as this information is likely lost in time. If I had to wager a guess though, I would bet on the physicians as cause of the initial insult. Unlike the role of physician, residents have only been a fairly recent phenomenon. Back in “the day”, many physicians just did apprenticeships with anyone that would have them, regardless of any true credentials. There were no large, urban hospitals, health insurance reviews, M&M conferences, practice standards, malpractice, or even many legitimate treatments. Hell, nursing was not even a profession until the mid-1800s and seemingly in response to most nurses at the time being rowdy drunks and assholes. Seriously.  So taking this into account, I imagine that physicians may have had to be raging ass hats towards a certain percentage of the nursing staff to distract them from their gutter whiskey long enough to perform a task that could have potentially been life-saving. Or unwittingly tortuous. Back then, it was kind of hard to tell which it was. Assuming this to be correct, or close enough, this culture has seemingly persisted throughout the ages despite the unfortunate lack of alcohol and boxing matches currently allowed in modern hospitals. But now, the physicians are not just magically appearing “fully trained” and the nurses find themselves in a position of relative power during the physician’s formative years. Let the hazing begin!

But the origin of blame is not the point. Assigning blame in this eternal conflict only distracts from the more salient issue of why this system is even in place. What good comes from the perpetuation of the “Us-versus-Them” culture? Is it good for the patients? Is it good for the hospital? Answer: It’s good for the system.

III.

It’s all about control. As I have already elaborated on, you need to distract and demoralize those you intend to control in order to make them accept your command without question. This is especially true when the servants possess the power; you need to make sure they never use it. In our current system, the nurse resents the physician for built-in subservience and the physician resents the nurse because they seemingly make their job, and by extension, life more difficult. Both camps seem to be too caught up in the conveniently constructed struggle to notice that they have a mutual adversary: the patient.

It is no secret among the health care community that the vast majority of patients that are encountered in the hospital setting are nothing more than morbidly obese, cognitively impaired, adult-themed children that are hyper-focused on the irrelevant. These patients seek nothing more than narcotics and food and invariably complaint about both the speed in which they are acquired and the pleasure that is derived. I’ve had multiple patients come in unable to breath and demand a hamburger, mashed potatoes, and soda; I’ve offered them hospice with only a minimal amount of facetiousness. Sadly, they never take me up on it. Instead, they somehow find a way to survive their hospitalization with only a minimal number of aspiration events and are eventually released back into the wild to inevitably be re-admitted again.

These “patients” serve as the impetus for the eternal conflict. They are the initial reaction that sets off a cascade of events resulting in frustration. These are the patients that the nurse is constantly calling about narcotic orders, diet orders, non-compliance with treatment, need for frequent updates, and threats of leaving AMA. These are the patients that the doctor hears about ad-nauseam that lead to a full rage meter and broken pagers. It is these patients that serve as the kindling which ignites the fire that consumes any chance of decent working relationships. They are the central cog in the system’s design however their ignorance is so great that I doubt they even understand the role in which they play; the role of the unilateral rage generator.

No matter how horrible and ridiculous they may be, patients are untouchable, especially in this era of “Health care as Business” where they will soon be referred to solely as “customers”. Save for some likely isolated incidents, the nurses are not yelling back at the patients, they are not (rightfully) telling them to go fuck all the way off, and they are not refusing ridiculous requests. Similarly, most physicians will allow these patients to run right over them in an attempt to save time by avoiding conflict in the hopes of still obtaining that coveted “9 out of 10”. Sure, some of the really crazy ones get their Haldol levels replenished, but this is not the norm.

So, what happens with this rage? Well, as alluded to above, it bounces back and forth between the physician and nurses until all they can see is their respective disdain for each other. And this does not just happen once a day, this happens several times a day. The battle royale known as “physician vs nurse” is continually powered all to the delight of the system; we are nothing but dancing puppets.

But the system is not happy with just physicians and nurses pitted against each other. The system has set up redundant circuits of in-fighting. Have you ever seen the ICU and PCU nurses get along? Have you ever seen the PCU and general floor nurses get along? How about different physician subspecialties? One could answer “yes” to any of the above, but they could not truthfully claim that it is the norm.

IV.

Think about what could happen if physicians and nurses suddenly woke up one day and began to work together. What if we started to direct our energies away from tearing each other apart and instead focused those energies on demanding patient reform? What if those energies were directed towards the bureaucrats and administrators that set the arbitrary rules which seem to govern our lives? What if those frustrations and anger were directed towards the national health care debate in an attempt to bring to light the true issues which make health care expensive? What if instead of focusing on our own bickering when faced with irrational regulations, we simply provided a collective reply of “I prefer not to”?

But unfortunately, there are dilaudid orders to place and nurses to chew out. So I guess we’ll never know.

What about patient reform?

I.

Health care reform continues to remain a rather hot topic for those least-informed on the issue (read: Americans). This singular issue has effectively defined the Obama presidency and led to the development of his brain-child known as ObamaCare. While there are a fair number of good things that came from this (expanding coverage regardless of how shitty said coverage may be), there has also been a number of terrible things to come from this (VBP, bundle payments, Burwell, etc). The goal of this reform has explicitly been to decrease the cost of healthcare; everyone seems to ignore the asterisk at the end denoting the phrase “at healthcare’s expense”. I have already briefly touched on the reforms meant to penalize hospitals for failing to meet arbitrary quality improvement standards or patient satisfaction quotas. I have also touched on the change in payment plans, specifically bundle payments. All of these programs have one goal which is to gradually push more of the tab for treatment onto the hospitals, similar to pushing the cost back on a widget manufacturer for delivering a boat load of broken widgets. Nobody wants to pay for broken widgets, so why should the government? The problem with this though is that A) hospitals are not factories B) all the widgets were made somewhere else and C) a significant portion of those widgets are apathetically trying to break themselves. To bring it back to the widget factory, this is the equivalent of fining a factory for not fixing broken widgets they received involuntarily from some Indonesian sweat shop which were already programmed to self-destruct. This is our current health care system.

Patient compliance is one element of healthcare that seems to have been purposefully avoided. I say purposefully because throughout the medical community it is the biggest complaint among all physicians but somehow has rarely made it into the national conversation. For anyone that is not familiar with this term, patient compliance has to do with the patient actually listening and doing what we ask of them in order to better their own lives through treatment of their medical conditions. One may expect that if there is a person seeking out a professional opinion that could prolong their life that the said person would make it a point to… you know… follow that advice. You may expect that everyone, save for those overtly suicidal, would make it a point to actively preserve their own lives. You would be wrong. Depressingly wrong.

Let me provide you with some examples.

Exhibit A: Jon D

Jon is a young gentleman in his 20s with type 1 diabetes that decided at an early age he was going to have approximately zero shits to give. Ever. He is well-known throughout the hospital because he is admitted every 1-2 weeks, for the last 5 years, for diabetic ketoacidosis (DKA) as he refuses to use insulin. Frequently, he is admitted to the ICU due to the severity of his DKA. Thousands of dollars are spent each hospitalization to provide him with IV insulin, fluids, electrolyte replacement, endocrine consultation, and nursing care. We get his glucose under control and provide him a stable insulin regimen. But after a few days, he comes right back to the hospital to repeat the entire episode again. He is what we in the biz call a “non-compliant patient”.

Exhibit B: Jamie Q

Jamie is a good, wholesome, middle-aged, Trump-voting, salt of the earth with type 2 diabetes. She has had diabetes for quite some time now, going on 30 years. She goes to the doctor but seems to not pay any attention. She gets her pills filled and remembers to take them less than half the time. Eventually, she requires insulin which she also avoids taking because needles suck and counting is complicated. After years of devout ignorance, she gradually loses a significant portion of her sight, has two heart attacks, a mild stroke, and one and a half feet removed from gangrene resulting from multiple diabetic foot ulcers after not wearing shoes. She is a frequent flyer in the hospital for various reasons and has been a patron of multiple different nursing facilities. She is a “non-compliant patient”. But hundreds of thousands of dollars later, Jamie does end up becoming compliant after being enrolled into a long-term care facility and having all of her medications administered to her after she becomes completely disabled from an additional stroke involving half her brain.

Exhibit C: Don K

Don is well-known to the ED staff. Don comes in multiple times a month for a variety of substance-related complications. Don loves his alcohol, he loves his cocaine, and he is starting to love his heroin. Don would be homeless if it was not for section 8 housing and a whole slew of other safety-net programs, Medicaid included. Don is not always admitted, sometimes he sobers up enough to leave belligerently from the ED, but he does find himself spending a few nights at the hospital several times a month with at least one of his problems being alcohol withdrawal. During his admissions, Don tries to refuse most care, complains endlessly about the quality of his meals, and makes it a point to leave the floor to go smoke several times a day. He is always discharged in “stable” condition. He is a “non-compliant patient”.

I could repeat the alphabet several times over with various examples of the “non-complaint” patient but I think the point is received: thousands, if not millions, of people want nothing to do with their own well-being.

“But why do you care? Isn’t that on them?”

I don’t care. At least, I don’t care that they make dumb decisions. Everyone makes dumb decisions. The human race is defined by dumb decisions. The problem is not the dumb decisions and lack of foresight; the problem is that I get penalized for their dumb decisions and lack of foresight. Their dumb decisions have greater consequences than just screwing themselves over. That’s why I care.

II.

Let us look back at value-based purchasing. I have already spent a fair amount of time discussing the insanity which is this terrible program. But in order to drive the point home further, we need to look at this push for “quality” through the filter of patient compliance. Let us start with re-admission rates.

One of the objectives that have been used as a means to determine “quality” has been to try and lower re-admission rates to the hospital. This objective has been established through a whole series of poor and inaccurate assumptions. These assumptions include but are not limited to: assuming that every patient makes every effort to improve their own health, assuming that physicians and hospitals have the power to stamp out effects of chronic and progressive diseases, assuming patients (baby boomers) are not consistently getting older and acquiring more chronic and incurable disease, assuming that patients are listening intently to everything we say and simply are not informed enough, assuming that physicians make it a point to not spend any time with patients purely out of a desire to get back to swimming in their money pools, and assuming that physicians are Jedi Masters able to wave their hands and fundamentally change patients for the better. Through these, and likely other, assumptions, CMS/HHS/Burwell have made it a point to punish hospitals if certain patients were to be re-admitted to any hospital within 30, and sometimes up to 90, days. These punishments are often financial and include limiting any further payments to the hospital for those encounters as they clearly should have been preventable with the fault laying squarely on the shoulders of the health care professionals. Hospitals and physician groups have invested a lot of money to try and bring this number down. But has it been effective?

Well, if you take Burwell for her word and refuse to look at her sources cited, the answer is yes. The number has objectively gone down. But what happens when you look at her sources? Well, the results seem less impressive. Prior to Obamacare, the re-admission rate was hovering around 19%. For the years after the Reckoning, the percent has hovered around 17-18%. WE DID IT! YES, WE CAN! This number seems to have been fairly stagnant since. But despite this miraculous change in re-admission rates (the view in which I assume Burwell takes), every hospital that I have any interaction with seems to be at near max capacity save for the rural hospitals that make it a point to transfer all their patients to larger hospitals.

Again, hospitals have invested millions of dollars in attempts to decrease readmission rates. We go through great lengths to provide patients with free medications, education for appropriate medication use, quick follow up appointments, nursing home placements (if needed), durable medical equipment at home, home health care, and even assist with applications for Medicaid. But despite all of this, many of these patients keep coming back. What are we supposed to do?

III.

Well, the answer seems rather simple, assuming you are not a physician. According to a number of paper monkeys (Ph.D’s), the solution to the problem involves simply talking to the patient. I can safely assume they have never spoken to a patient.

Kaplan and Co (NEJM 11/2016) dedicate an entire article to poor assumptions and made up calculations. They use two different chronic diseases, CKD and diabetes, to demonstrate how “talking” can add value. In the setting of worsening CKD (chronic kidney disease) and impending need for dialysis, our Ivory Tower colleagues cite the use of temporary tunneled dialysis catheters for the initiation of dialysis as a failure of nephrologists to adequately discuss fistula placement with patients due to their high patient volume (more on this later). They claim that $200 in patient discussion (a completely made up number) can save $20,000 over six months in catheter insertion and potential complications. In regard to diabetes management, it is suggested that the only reason why patients are non-compliant with their insulin therapy is that the physicians and other staff did not spend enough time explaining the importance of the medication or appropriately address the patient’s concerns. Never mind the fact that most of these patients were non-compliant with pills for several years before insulin was ever on the table.  In addition, it should be noted that a large number of uncontrolled diabetics often progress to end-stage renal disease. So, that same patient population that was non-compliant with pills, that you are supposed to convince to use their insulin, will end up establishing with a nephrologist and somehow be expected to be convinced to drop their impenetrable ignorance barrier and replace it with proactive insight.

A girl can dream.

In this same article, Kaplan and Friends continues down the road of unsubstantiated claims without even an attempt at citing relevant sources. “Several studies” apparently show that the more time you spend with patients the more compliant they are. It is interesting that despite there being “several”, they cannot be bothered to simply cite one. He eventually does go on to cite an article showing increased conversations with family, patients, and treatment teams of “high risk geriatric” patients had positive effects such as decreased cost and higher quality of life. However, if you take the ten seconds to look at his sources, the article he cites is from a study involving metastatic lung cancer patients. Although technically they can be “high risk geriatric” patients, this is extremely misleading to the point of blatant deception. Kaplan suggests increasing uses of phone calls, electronic communications, and greater office staff involvement of reminding and encouraging with the estimate costs of these changes in the “tens to hundreds” of dollars. Again, there is still no word on exactly how these magical calculations were made, but you should just accept it as fact. Lastly, we are presented with “real life” examples of how certain health care organizations are getting it right. Kaplan makes it a point to show how the time and money spent by Kaiser Permanente for “high need” Medicare beneficiaries was able to decrease their hospital costs and how weekly meetings of physicians in the M.D Anderson Cancer Center to discuss new patients has supposedly led to better patient care. What he fails to mention, but is obvious to most exposed to this article, is that these two organizations are behemoths with deep pockets. Not to mention, Kaiser is an organization with a huge network for which they can easily adjust costs and M.D Anderson is a cancer hospital that only has to meet and discuss things relevant to cancer. Good luck getting a group of specialists to sit down for a lengthy, non-reimbursable discussion about every diabetic with hypertension, morbid obesity, and renal dysfunction.

IV.

Let us ignore reality for a moment. Let us hold hands with our Ph.D friends above and jump into the world of make-believe. Let us assume that all a patient needs are more “Go Get’Em’s”, back pats, and words of encouragement before they see the light and dutifully take their medications and listen. Where is all this time going to come from?

There seems to be some weird misconception that by doing away with fee-for-service that you are somehow lightening the physician load and allowing them to spend more “quality time” with patients. As I have already tried to make clear, the new system of bundled payments does nothing of the sort. In this new age, where you will be paid a set amount with adjustments (read: deductions) made for “quality”, you are incentivized (read: required) to see a larger number of patients in a day; the nephrologist from before is not being rewarded for spending more quality time. As some may point out, there are ways in which to bill for time spent conversing with patients, however these codes are infrequently used and do not sufficiently reimburse for the time spent. Furthermore, exiting the exam room does not end the time spent with the patient. In our modern era of instant gratification, a barrage of electronic messages or phone calls come in daily from multiple patients a day. Some of these are simple medication refills or FYIs, but a large number of them tend to be things we need to spend at least a little time on. And again, sometimes these communications are billable (by some insurance companies) but the catch is that you often do not have time to bill for them as you are too busy dealing with everything else in a day. Or worse, you are too intimidated to bill for these encounters as you may bill incorrectly and be fined for over-billing. It’s interesting how no one really cares too much if you under-bill though, except the office manager, so you are screwed either way.

“So, are you just in it for the money?”

No, but I would like to be reimbursed for my time. Wouldn’t you? Or is the act of working overtime a reward unto itself?

V.

“Ok, so, how do we fix it? You spent a lot of time complaining but do you have any solutions?”

I do. But you won’t like them.

As physicians, the first thing we need to do is stop being cowards. I know this is hard, given our propensity for cowardice, but we need to speak truth to stupidity. Those patient examples given above, the reality of the situation, needs to come to the forefront of the conversation. We need to quit sweeping it under the rug and start to hold people accountable for their actions. We cannot control the actions of others, no matter how persuasive we are expected to be, and we cannot be expected to serve as parents for an entire country of overgrown children. They should learn to wipe their own ass or get used to smelling like shit.

Second, we need to shun and banish those that attempt to guilt or shame us in order to distract us from the truth. Let us go back to Kaplan. The following quote is a perfect example of what I mean.

“Clinicians who are reimbursed under new value-based payment plans should seize the initiative to determine how much of their valuable time should be spent in the various types of productive conversations, especially as they become more accountable for their results”

Pay close attention to the wording and its insidious meaning. At first glance, this could be seen as inspirational; it’s a call to arms for improving health care. But upon further inspection, you can see that this statement is based on several faulty and dangerous assumptions. For starters, the assumption that the new value-based payment system creates a nurturing environment for these time initiatives is clearly wrong; the very use of the word “initiative” implies a degree of freedom and self-direction which is entirely absent. These “initiatives” are mandates which serve as nothing more than unobtainable objectives that are made unobtainable by rules being created by those enforcing the mandates. It is impossible to spend more time with patients when you are forced to see an increasing number of patients in a day for dwindling returns. But more importantly, even if you find a way to take that extra time, there is no guarantee that it will pay off. This game is set up to maximize failure; the house always wins. They win at our expense.

But why do we allow this to go on? I am sure I am not the only one that has noticed what is going on. I can’t be. That would be insane.

We allow it to happen because we have internalized a deep sense of guilt evident by the last part of the quote which is utilized to invoke that particular sentiment:

“as [physicians] become more accountable for their results”

We are accountable. We are accountable for every action a patient takes, or doesn’t take, and we are accountable for the result. We are accountable for not explaining things appropriately, regardless of how much time we take. We are accountable for their bad outcomes. If only we could find a way to get through to them, if only we could take more time out of our day to communicate more effectively, if only…. This is the line of thought that we are being fed and expected to internalize. It is not their problem, it is ours. This is the chain around your neck, attached to an anchor, threatening to drown you. Your options are to break the chains or hold your breath. Which do you choose?

V.

“So, we need to grow a pair and stop feeling guilty? That’s it?”

It’s a start. But remember, the system does not like change, especially change which could be bad for the system. Even more importantly, the system is not being run by physicians but by patients. Think about it. How much gray hair resides in your state congress? In the federal congress? Everyone with gray hair is, or has been, a patient at some point. Do you really believe that patients are going to make changes to health care that could negatively impact them by holding them accountable for their actions? Do you think career politicians are going to risk upsetting a sizable chunk of their constituents by advocating for policies that may make them work harder or incur some financial penalty? The answer is obvious: sacrifice the minority to appease the masses. The problem with this simple calculation though is that it ignores the amount of power that the minority possesses. Thankfully, the system has done an excellent job in ensuring that same minority remains ignorant of its own power.

And this is why we will not have to worry about patient reform.

You Get What You Pay For

Healthcare is expensive. This is a fact. To get into the details for why it is expensive is a topic for another time. But the big push over the last few years has been to decrease the cost of healthcare. More to the point, the push to decrease cost of healthcare has been to simply pay less for healthcare by the government through Medicare and Medicaid. Ever since President Obama passed his magical ObamaCare act, the healthcare system has been in a constant state of flux. CMS/HHS (center for Medicare) has been churning out new rules and initiatives at break-neck speeds all in an attempt to leave most hospitals and healthcare systems in a state of fear and bewilderment; they are the Neagan to our Rick. By this point, most of the larger hospitals and healthcare systems have fallen in line and “volunteered” to start choking down at least one of the alternative plans for reimbursement. But what effect will this have? What do we have to look forward to?

I’m glad you asked.

I.

A quick perusal through the CMS website will grant you information on the BPCI, which is the bundled payment plans for hospitals and post-acute care facilities. There are 4 different models with models 2-4 being the primary options. For reasons that become rather obvious, model 2 is the overwhelming favorite in the same way that getting smacked in the face is preferable to getting kicked in the balls. Briefly, model 2 (BPCI-2) retrospectively pays a bundle payment based off an episode of care to hospitals that participate in the program while still paying the fee for service rates to the physicians. In other words, if you have Medicare and come in with a pneumonia then Medicare will continue to “pay” like fee for service while you are in the hospital but will then compare that cost to their pre-determined bundle payment after you are discharged and come to a reconciled final amount to pay the hospital after the fact. This also includes post-acute care costs 30, 60, or 90 days out. Thankfully, this does not include physician costs. This beats model 4 (BPCI-4) where Medicare prospectively (as soon as you enter the door) pays a bundled amount without negotiation which is also to include your post-acute care costs as well. This includes physician costs. At this time, only 10 programs are dumb enough to continue down the model 4 road.

Now, for all these hospitals included in the above plans, they get to pick from a list of 48 distinctive diagnoses to be used as benchmarks for comparison to other hospitals as well as for reimbursement purposes. Not surprisingly, most picked major joint replacements with far less picking such exciting things like heart failure and COPD. Being able to pick the metric that is to be used as a tool for grading and scrutinizing oneself must be a nice perk. I hope the hospitals enjoy it while it lasts. I also hope they also enjoy believing that this is all “voluntary”.

But I digress. Someone must want to know how hospitals are doing when it comes to decreasing cost and improving quality through metrics of their own choosing, right? CMS sure as hell does! They hired a company to put together a report published in August 2016 based off information through 2014 to look at how things were going. Here are some highlights:

  • Orthopaedic surgery costs on average went down $864, they sent people to less SNFs [skilled nursing facilities] (64% to 57%), and those that went to SNFs spent 1.3 days less. The down side? Medicare paid, on average, $2137 less per episode from baseline through the intervention period. Ouch. Keep in mind, 75% of hospitals participated in this metric.
  • Cardiovascular surgery saw relatively stable reimbursement through the intervention period (Great!) as long as they did not go to a SNF (SHIT!). If the patient had to go to a SNF, or any other institution post-discharge, hospitals were on average shorted $4149. Now, their rates for SNFs decreased (55% to 44%), but that is still a large number. Furthermore, their ED visit rate increased as well. Can you imagine what this looks like yet?
  • Lastly, spinal surgery seems to be the only success story (or failure, depending on your prospective). Their reimbursement INCREASED $3477 with overall no major changes. Guess what specialty is next on the chopping block?

In short: it appears cost is going down but reimbursement may be going down at a faster rate.

“But aren’t there incentives like value-based purchasing which are supposed to reward high-performing hospitals?”

Excellent question! Let us look at this value-based purchasing program initiated by CMS. This is a program with the goal of rewarding “quality” of care over “quantity” of care. Sounds like a great idea until you realize that both those words effectively mean nothing and are little more than trite, banal aspirations set forth by the demon princess, Sylvia Burwell, herself.

The Value-Based Purchasing program is a program that came into effect in 2013 and seems to gradually change every year in some shape or form. It allows CMS to base payments off “Set measures and dimensions grouped into specific quality domains”. At this time, two percent of Medicare reimbursements are being tied to this program and the score which determines whether or not you see any of that money again is based on some revolving and arbitrary criteria. Below is an overview of how each is weighted:

VBP Image

  • Outcomes = Safety and patient experience = patient and care-giver experience.

Take a second to really read that chart.  I want you to try and imagine what this program is really trying to reward. From 2016 there is a 40% weighing towards outcome/safety which drops off to 25% by 2018. By 2018, your safety/outcomes are as important as your “experience” in the hospital. To put it another way, it is equally important that you enjoy your hospital dinner as it is that you not get a surgical site infection or C diff. And if you do not know what C diff is, please consult Dr. Google.

“But two percent is pretty small, right?”

Sure, the number two is small. But let me better demonstrate the current impact by a simple math problem: What is 2% of $500 million? Answer: $10 million. Do you find that number to be insignificant? If so, let me know, I have a bank account I would totally love for you to donate an insignificant amount of money towards. Hospitals, however, do not find this number insignificant; they find it terrifying. They have invested large sums of money to play the “value game” and shove it down the throats of every single employee all because they are being scored on the above arbitrary measures and being given a final number that dictates where they fall in the spectrum of “providing value”. For those that are in the health care field, this is where the HCAHPS scores come into play with “patient experience”. This is why you are hearing administrators drone on and on about going from an 8 to a 9 in patient satisfaction because if you drop too low you lose. This is why even if you do your job perfectly you are a failure due to circumstance you cannot control because they are irrelevant to your goals. This is why you are a glorified, narcotic-dispensing, note monkey.

It should be noted that the scores for value-based purchasing are completely relative to the scores of other hospitals. If everyone is scoring 97% on a metric, then the only way to see any benefit may be to score 98.5% which is challenging even by Tiger Mom standards. CMS may periodically change the metrics around to keep it interesting but, contrary to popular belief, most hospitals are already doing a pretty good job at that whole “keeping people alive” thing. Eventually, there will be a ceiling in which there can be no realistically obtainable improvements. At that point, stagnation occurs and innovation through desperation will lead to some rather interesting creations. Ultimately, the best that hospitals will be able to look forward to is to simply not lose more money from the VBPires.

But it doesn’t end there; It is just the beginning. If this program was only going to max out at two percent, it may not be so bad. There are always ways to reallocate resources to stem the bleeding. Burwell and her HHS minions have much greater plans and have made it a point to be rather transparent to her victims through the New England Journal of Medicine.

II.

In 2015, Burwell wrote an article laying out her plan. Titled: HHS efforts to improve U.S health care, Burwell discussed plans for tying a larger and larger percentage of Medicare payments, whether it be fee for service or bundled payments, to the concept of “quality”. How much? Well, Burwell wants 85% of fee for service payments linked to “quality” by 2016 and 90% of those payments linked by 2018. At the time this article was written, only 20% was tied to “quality”. Regarding the alternative payments (read: bundled payments), Burwell has decided to tie 30% of those payments to “quality” by 2016 and 50% by 2018. Can you take a wild guess at what the purpose of those rather disparate percentages could be? Can you feel the walls closing in around you? No? Well, the hospitals probably can. You will too, in time.

Burwell proceeds to further lay out her sinister plan of throttling the health-care system through various different means. Most of her plan is laid out in double-speak, so it does take some effort at translation, but I will try and do the best I can. First up, Burwell states she intends to “create an environment in which hospitals, physicians, and other providers are rewarded for delivering high-quality health care AND have the resources and flexibility to do this.” Sounds great, right? Sounds aspirational. This phrase probably gives some people the warm-fuzzies and fills their heads with ambiguous thoughts of “fixing health care”. If this is you, you are an idiot. Or at the very least, really, really gullible. You must keep in mind that Burwell and the HHS are not out to “fix” health care; they are out to make it cost less. That is the bottom line; that is the goal of this reform. This is evident by the next paragraph which goes onto talk about creating further alternative payment models for cancer treatment and other specialty care. (For those not in the know: cancer hospitals/centers are currently DRG-exempt and can be rather lucrative and off-set costs of other less sexy conditions like COPD, pneumonia, liver disease, etc) Again, this sounds rather aspirational and reasonable until you find yourself faced with the indisputable fact that treating cancer is expensive as hell! There is a lot of money that goes into treating cancer, from the bench research and clinical trials to the manufacturing of next-generation gene-specific cancer therapies, the cost associated is astronomical. However, save for a few therapies and specific cancer diagnoses, most treatments for cancer provide little more than a few extra months of life with questionable quality. Hundreds of thousands of dollars spent to have an extra few weeks to few months, the majority of which may be spent in a hospital setting, is the very definition of current cancer treatments.

Can you see it yet? Burwell is not out to improve the “quality” of cancer care. The current “quality” of cancer care is already exceptional and to some degree decadent. This decadence is what needs to be extinguished. But the Powers-That-Be at HHS are smart enough to know they cannot outright ban costly treatments; that is not the American Way. The backlash from a move like that would bring the whole charade crashing down. Instead, Burwell and Co, are quickly creating an environment where the hospitals, and to some extent the physicians, will be forced to make the decision on how best to triage care relative to financial solvency. The government may never explicitly state “Don’t use this treatment, it’s expensive as hell and a poor use of resources!” but they sure as hell will refuse to cover the cost of those expensive treatments under the guise of “bundled payments” which will ultimately leave the physician weighing the pros and cons of appropriate resource utilization against the life of their patient. How does one explain to a patient, and their grieving family, that nothing further can be done because no one will pay for it? How do physicians continue to be physicians once “accountant” becomes a part of their job title? The answer: “It doesn’t matter. It costs less.” –  Burwell while drinking fresh virgin blood.

“Well, it has to happen, doesn’t it? Haven’t we gone a little overboard on all these cancer treatments anyways? You even said it yourself, they only get a few months at best.”

Agreed, but it’s not just cancer treatments. The above scenario applies to ALL chronic diseases, or at least will in time. How will the treatment of advanced heart failure or COPD change in the near future? Will we continue to offer LVADs, frequent hospitalizations for diuresis, lung transplants, or heart transplants? Will we set a limit on the number of admissions one is allowed over three months for their chronic conditions? Will research come to a halt due to lack of funds and profits for new therapies? (Europe may be able to answer that question for us) And again, none of these answers will come from CMS/HHS/Burwell and company; they will be reluctantly answered by the hospitals and physicians under the whip of the insurance companies and government. This, in turn, will change the very culture of those involved in providing health care. Altruism, despite its several flaws, is a primary motivator for many in the health care field. How will that change once you fully transform medicine into an “industry” with the focus becoming the bottom line? Will you still attract the intelligent and independent thinkers that have so often gone into the field? Or will you attract customer-service oriented, guideline-directed, intellectually-throttled, bureaucrats that see the patient’s cost as their fifth vital sign? The change will be gradual but there will be a change. Prepare yourself.

III.

For many in the health care field, the future of health care is considered “uncertain”; this is a self-imposed deception to shield themselves from the truth. The future of health care, at least at this time, is very certain and viewed with variable degrees of optimism relative to one’s station in the health care industry. For those in Burwell’s boat, flying the Jolly Roger and riddled with scurvy, the future looks rather bright. Costs will go down, health care will become more “accessible”, and hospital and health care systems will make great efforts to demonstrate their “value”. For those in the trenches, the future is far less bright and will likely consist of a never-ending stream of best-practice advisories in the form of unavoidable pop ups through the EHRs (electronic health records), increased focus on “customer service” and satisfaction scores in the form of yearly modules and quarterly reviews, as well as increasing scrutiny over documentation and hospital-encounter costs per physician. For patients, your care will likely dramatically change and your “satisfaction” will likely be further pursued to your detriment. In some ways, it is already happening. I cannot tell you the number of patients I see, transferred from other hospitals that were bound and determined to kill them, and hear nothing but praise about that transferring facility due to their expansive and highly palatable meal options. It did nothing for their disseminated histoplasmosis, but I’m sure it still received excellent reviews. But while your Salisbury steak gets more palatable, your options for treatment will gradually be restricted, and you will ultimately be provided with less avenues in which to delay your death. Intensive care services will gradually be rationed and we will likely see a system not too dissimilar to Brazil where litigation is often used to acquire an ICU bed due to limited resources. Palliative care will continue to become more important. Hell, it already is becoming more utilized for various reasons, one of which is spelled out by the advisory board as “saves hospitals thousands of dollars per inpatient case and reduces ICU length of stay, contributing to cost savings and freeing up of capacity”. And don’t get me wrong, palliative care is extremely important, especially in our current health care system, but do not keep expecting that it will forever remain a choice to “keep fighting” as the baby-boomer time bomb continues to tick down. The best one can hope for is that they are wealthy in the future because “executive medicine” isn’t going anywhere anytime soon.

“Isn’t this all a little extreme? Besides being a total buzz-kill, you seem to be taking this pretty far.”

It is extreme. And I am a buzz-kill. But this is the plan taken to its logical conclusion with each step being revealed at the very moment the path behind you has fallen away. Many hospitals and health care systems were lured in with the prospect of financial gain through actions which many were already pursuing; I assume the thought was that this would be easy money. In contrast to this opportunistic stance taken by many health care systems, physicians seemed to take a more fatalistic approach. They began accepting those changes as inevitable and, because physicians are cowards, never made any real attempt to resist. The AMA, which is supposed to be a lobbying group FOR physicians, showed where their true allegiances lay by strongly supporting Obamacare for reasons which had nothing to do with improving the lives of physicians. What did it have to do with? Money. So, here we are, about five years or so into this Brave New World, and the future is starting to come into view over the horizon. Despite President Meme Trump threatening to dismantle Obamacare (he won’t, at least not significantly), the wheels are already in motion, the gears are turning, and this Kill-Dozer of health care reform is about to turn the corner on a busy street and start making metal pancakes.

And you will get what you pay for.