Skip to comments.How Government Killed the Medical Profession
Posted on 08/25/2015 10:34:18 AM PDT by MarvinStinson
I am a general surgeon with more than three decades in private clinical practice. And I am fed up. Since the late 1970s, I have witnessed remarkable technological revolutions in medicine, from CT scans to robot-assisted surgery. But I have also watched as medicine slowly evolved into the domain of technicians, bookkeepers, and clerks.
Government interventions over the past four decades have yielded a cascade of perverse incentives, bureaucratic diktats, and economic pressures that together are forcing doctors to sacrifice their independent professional medical judgment, and their integrity. The consequence is clear: Many doctors from my generation are exiting the field. Others are seeing their private practices threatened with bankruptcy, or are giving up their autonomy for the life of a shift-working hospital employee. Governments and hospital administrators hold all the power, while doctorsand worse still, patientshold none.
The Coding Revolution
At first, the decay was subtle. In the 1980s, Medicare imposed price controls upon physicians who treated anyone over 65. Any provider wishing to get compensated was required to use International Statistical Classification of Diseases (ICD) and Current Procedural Terminology (CPT) codes to describe the service when submitting a bill. The designers of these systems believed that standardized classifications would lead to more accurate adjudication of Medicare claims.
What it actually did was force doctors to wedge their patients and their services into predetermined, ill-fitting categories. This approach resembled the command-and-control models used in the Soviet bloc and the Peoples Republic of China, models that were already failing spectacularly by the end of the 1980s.
Before long, these codes were attached to a fee schedule based upon the amount of time a medical professional had to devote to each patient, a concept perilously close to another Marxist relic: the labor theory of value. Named the Resource-Based Relative Value System (RBRVS), each procedure code was assigned a specific value, by a panel of experts, based supposedly upon the amount of time and labor it required. It didnt matter if an operation was being performed by a renowned surgical expertperhaps the inventor of the procedureor by a doctor just out of residency doing the operation for the first time. They both got paid the same.
Hospitals reimbursements for their Medicare-patient treatments were based on another coding system: the Diagnosis Related Group (DRG). Each diagnostic code is assigned a specific monetary value, and the hospital is paid based on one or a combination of diagnostic codes used to describe the reason for a patients hospitalization. If, say, the diagnosis is pneumonia, then the hospital is given a flat amount for that diagnosis, regardless of the amount of equipment, staffing, and days used to treat a particular patient.
As a result, the hospital is incentivized to attach as many adjunct diagnostic codes as possible to try to increase the Medicare payday. It is common for hospital coders to contact the attending physicians and try to coax them into adding a few more diagnoses into the hospital record.
Medicare has used these two price-setting systems (RBRVS for doctors, DRG for hospitals) to maintain its price control system for more than 20 years. Doctors and their advocacy associations cooperated, trading their professional latitude for the lure of maintaining monopoly control of the ICD and CPT codes that determine their payday. The goal of setting their own prices has proved elusive, thoughevery year the industrys biggest trade group, the American Medical Association, squabbles with various medical specialty associations and the Centers for Medicare and Medicaid Services (CMS) over fees.
As goes Medicare, so goes the private insurance industry. Insurers, starting in the late 1980s, began the practice of using the Medicare fee schedule to serve as the basis for negotiation of compensation with the doctors and hospitals on their preferred provider lists. An insurance company might offer a hospital 130 percent of Medicares reimbursement for a specific procedure code, for instance.
The coding system was supposed to improve the accuracy of adjudicating claims submitted by doctors and hospitals to Medicare, and later to non-Medicare insurance companies. Instead, it gave doctors and hospitals an incentive to find ways of describing procedures and services with the cluster of codes that would yield the biggest payment. Sometimes this required the assistance of consulting firms. A cottage industry of fee-maximizing advisors and seminars bloomed.
I recall more than one occasion when I discovered at such a seminar that I was undercoding for procedures I routinely perform; a small tweak meant a bigger check for me. That fact encouraged me to keep one eye on the codes at all times, leaving less attention for my patients. Today, most doctors in private practice employ coding specialists, a relatively new occupation, to oversee their billing departments.
Another goal of the coding system was to provide Medicare, regulatory agencies, research organizations, and insurance companies with a standardized method of collecting epidemiological datathe information medical professionals use to track ailments across different regions and populations. However, the developers of the coding system did not anticipate the unintended consequence of linking the laudable goal of epidemiologic data mining with a system of financial reward.
This coding system leads inevitably to distortions in epidemiological data. Because doctors are required to come up with a diagnostic code on each bill submitted in order to get paid, they pick the code that comes closest to describing the patients problem while yielding maximum remuneration. The same process plays out when it comes to submitting procedure codes on bills. As a result, the accuracy of the data collected since the advent of compensation coding is suspect.
Command and Control
Coding was one of the earliest manifestations of the cancer consuming the medical profession, but the disease is much more broad-based and systemic. The root of the problem is that patients are not payers. Through myriad tax and regulatory policies adopted on the federal and state level, the system rarely sees a direct interaction between a consumer and a provider of a health care good or service. Instead, a third partyeither a private insurance company or a government payer, such as Medicare or Medicaidcovers almost all the costs. According to the National Center for Policy Analysis, on average, the consumer pays only 12 percent of the total health care bill directly out of pocket. There is no incentive, through a market system with transparent prices, for either the provider or the consumer to be cost-effective.
As the third party payment system led health care costs to escalate, the people footing the bill have attempted to rein in costs with yet more command-and-control solutions. In the 1990s, private insurance carriers did this through a form of health plan called a health maintenance organization, or HMO. Strict oversight, rationing, and practice protocols were imposed on both physicians and patients. Both groups protested loudly. Eventually, most of these top-down regulations were set aside, and many HMOs were watered down into little more than expensive prepaid health plans.
Then, as the 1990s gave way to the 21st century, demographic reality caught up with Medicare and Medicaid, the two principal drivers of federal health care spending.
Twenty years after the fall of the Iron Curtain, protocols and regimentation were imposed on Americas physicians through a centralized bureaucracy. Using so-called evidence-based medicine, algorithms and protocols were based on statistically generalized, rather than individualized, outcomes in large population groups.
While all physicians appreciate the development of general approaches to the work-up and treatment of various illnesses and disorders, we also realize that everyone is an individualthat every protocol or algorithm is based on the average, typical case. We want to be able to use our knowledge, years of experience, and sometimes even our intuition to deal with each patient as a unique person while bearing in mind what the data and research reveal.
Being pressured into following a pre-determined set of protocols inhibits clinical judgment, especially when it comes to atypical problems. Some medical educators are concerned that excessive reliance on these protocols could make students less likely to recognize and deal with complicated clinical presentations that dont follow standard patterns. It is easy to standardize treatment protocols. But it is difficult to standardize patients.
What began as guidelines eventually grew into requirements. In order for hospitals to maintain their Medicare certification, the Centers for Medicare and Medicaid Services began to require their medical staff to follow these protocols or face financial retribution.
Once again, the medical profession cooperated. The American College of Surgeons helped develop Surgical Care Improvement Project (SCIP) protocols, directing surgeons as to what antibiotics they may use and the day-to-day post-operative decisions they must make. If a surgeon deviates from the guidelines, he is usually required to document in the medical record an acceptable justification for that decision.
These requirements have consequences. On more than one occasion I have seen patients develop dramatic postoperative bruising and bleeding because of protocol-mandated therapies aimed at preventing the development of blood clots in the legs after surgery. Had these therapies been left up to the clinical judgment of the surgeon, many of these patients might not have had the complication.
Operating room and endoscopy suites now must follow protocols developed by the global World Health Organizationan even more remote agency. There are protocols for cardiac catheterization, stenting, and respirator management, just to name a few.
Patients should worry about doctors trying to make symptoms fit into a standardized clinical model and ignoring the vital nuances of their complaints. Even more, they should be alarmed that the protocols being used dont provide any measurable health benefits. Most were designed and implemented before any objective evidence existed as to their effectiveness.
A large Veterans Administration study released in March 2011 showed that SCIP protocols led to no improvement in surgical-site infection rate. If past is prologue, we should not expect the SCIP protocols to be repealed, just improvedor expanded, adding to the already existing glut.
These rules are being bred into the system. Young doctors and medical students are being trained to follow protocol. To them, command and control is normal. But to older physicians who have lived through the decline of medical culture, this only contributes to our angst.
One of my colleagues, a noted pulmonologist with over 30 years experience, fears that teaching young physicians to follow guidelines and practice protocols discourages creative medical thinking and may lead to a decrease in diagnostic and therapeutic excellence. He laments that evidence-based means you are not interested in listening to anyone. Another colleague, a North Phoenix orthopedist of many years, decries the cookie-cutter approach mandated by protocols.
A noted gastroenterologist who has practiced more than 35 years has a more cynical take on things. He believes that the increased regimentation and regularization of medicine is a prelude to the replacement of physicians by nurse practitioners and physician-assistants, and that these people will be even more likely to follow the directives proclaimed by regulatory bureaus. It is true that, in many cases, routine medical problems can be handled more cheaply and efficiently by paraprofessionals. But these practitioners are also limited by depth of knowledge, understanding, and experience. Patients should be able to decide for themselves if they want to be seen by a doctor. It is increasingly rare that patients are given a choice about such things.
The partners in my practice all believe that protocols and guidelines will accomplish nothing more than giving us more work to do and more rules to comply with. But they implore me to keep my mouth shutrather than risk angering hospital administrators, insurance company executives, and the other powerful entities that control our fates.
Electronic Records and Financial Burdens
When Congress passed the stimulus, a.k.a. the American Reinvestment and Recovery Act of 2009, it included a requirement that all physicians and hospitals convert to electronic medical records (EMR) by 2014 or face Medicare reimbursement penalties. There has never been a peer-reviewed study clearly demonstrating that requiring all doctors and hospitals to switch to electronic records will decrease error and increase efficiency, but that didnt stop Washington policymakers from repeating that claim over and over again in advance of the stimulus.
Some institutions, such as Kaiser Permanente Health Systems, the Mayo Clinic, and the Veterans Administration Hospitals, have seen big benefits after going digital voluntarily. But if the same benefits could reasonably be expected to play out universally, government coercion would not be needed.
Instead, Congress made that business decision on behalf of thousands of doctors and hospitals, who must now spend huge sums on the purchase of EMR systems and take staff off other important jobs to task them with entering thousands of old-style paper medical records into the new database. For a period of weeks or months after the new system is in place, doctors must see fewer patients as they adapt to the demands of the technology.
The persistence of price controls has coincided with a steady ratcheting down of fees for doctors. As a result, private insurance payments, which are typically pegged to Medicare payment schedules, have been ratcheting down as well. Meanwhile, Medicares regulatory burdens on physician practices continue to increase, adding on compliance costs. Medicare continues to demand that specific coded services be redefined and subdivided into ever-increasing levels of complexity. Harsh penalties are imposed on providers who accidentally use the wrong level code to bill for a service. Sometimesas in the case of John Natale of Arlington, Illinois, who began a 10-month sentence in November because he miscoded bills on five patients upon whom he repaired complicated abdominal aortic aneurysmsthe penalty can even include prison.
For many physicians in private practice, the EMR requirement is the final straw. Doctors are increasingly selling their practices to hospitals, thus becoming hospital employees. This allows them to offload the high costs of regulatory compliance and converting to EMR.
As doctors become shift workers, they work less intensely and watch the clock much more than they did when they were in private practice. Additionally, the doctor-patient relationship is adversely affected as doctors come to increasingly view their customers as the hospitals patients rather than their own.
In 2011, The New England Journal of Medicine reported that fully 50 percent of the nations doctors had become employeeseither of hospitals, corporations, insurance companies, or the government. Just six years earlier, in 2005, more than two-thirds of doctors were in private practice. As economic pressures on the sustainability of private clinical practice continue to mount, we can expect this trend to continue.
Accountable Care Organizations
For the next 19 years, an average of 10,000 Americans will turn 65 every day, increasing the fiscal strain on Medicare. Bureaucrats are trying to deal with this partly by reinstating an old concept under a new name: Accountable Care Organization, or ACO, which harkens back to the infamous HMO system of the early 1990s.
In a nutshell, hospitals, clinics, and health care providers have been given incentives to organize into teams that will get assigned groups of 5,000 or more Medicare patients. They will be expected to follow practice guidelines and protocols approved by Medicare. If they achieve certain benchmarks established by Medicare with respect to cost, length of hospital stay, re-admissions, and other measures, they will get to share a portion of Medicares savings. If the reverse happens, there will be economic penalties.
Naturally, private insurance companies are following suit with non-Medicare versions of the ACO, intended primarily for new markets created by ObamaCare. In this model, an ACO is given a lump sum, or bundled payment, by the insurance company. That chunk of money is intended to cover the cost of all the care for a large group of insurance beneficiaries. The private ACOs are expected to follow the same Medicare-approved practice protocols, but all of the financial risks are assumed by the ACOs. If the ACOs keep costs down, the team of providers and hospitals reap the financial reward: surplus from the lump sum payment. If they lose money, the providers and hospitals eat the loss.
In both the Medicare and non-Medicare varieties of the ACO, cost control and compliance with centrally planned practice guidelines are the primary goal.
ACOs are meant to replace a fee-for-service payment model that critics argue encourages providers to perform more services and procedures on patients than they otherwise would do. This assumes that all providers are unethical, motivated only by the desire for money. But the salaried and prepaid models of provider-reimbursement are also subject to unethical behavior in our current system. There is no reward for increased productivity with the salary model. With the prepaid model there is actually an incentive to maximize profit by withholding services.
Each of these models has its pros and cons. In a true market-based system, where competition rewards positive results, the consumer would be free to choose among the various competing compensation arrangements.
With increasing numbers of health care providers becoming salaried employees of hospitals, thats not likely. Instead, well see greater bureaucratization. Hospitals might be able to get ACOs to work better than their ancestor HMOs, because hospital administrators will have more control over their medical staff. If doctors dont follow the protocols and guidelines, and desired outcomes are not reached, hospitals can replace the problem doctors.
Doctors Going Galt?
Once free to be creative and innovative in their own practices, doctors are becoming more like assembly-line workers, constrained by rules and regulations aimed to systemize their craft. Its no surprise that retirement is starting to look more attractive. The advent of the Affordable Care Act of 2010, which put the medical professions already bad trajectory on steroids, has for many doctors become the straw that broke the camels back.
A June 2012 survey of 36,000 doctors in active clinical practice by the Doctors and Patients Medical Association found 90 percent of doctors believe the medical system is on the wrong track and 83 percent are thinking about quitting. Another 85 percent said the medical profession is in a tailspin. 65 percent say that government involvement is most to blame for current problems. In addition, 2 out of 3 physicians surveyed in private clinical practice stated they were just squeaking by or in the red financially.
A separate survey of 2,218 physicians, conducted online by the national health care recruiter Jackson Healthcare, found that 34 percent of physicians plan to leave the field over the next decade. Whats more, 16 percent said they would retire or move to part-time in 2012. Of those physicians who said they plan to retire or leave medicine this year, the study noted, 56% cited economic factors and 51% cited health reform as among the major factors. Of those physicians who said they are strongly considering leaving medicine in 2012, 55% or 97 physicians, were under age 55.
Interestingly, these surveys were completed two years after a pre-ObamaCare survey reported in The New England Journal of Medicine found 46.3 percent of primary care physicians stated passage of the new health law would either force them out of medicine or make them want to leave medicine.
It has certainly affected my plans. Starting in 2012, I cut back on my general surgery practice. As co-founder of my private group surgical practice in 1986, I reached an arrangement with my partners freeing me from taking night calls, weekend calls, or emergency daytime calls. I now work 40 hours per week, down from 60 or 70. While I had originally planned to practice at least another 12 to 14 years, I am now heading for an exitand a career changein the next four years. I didnt sign up for the kind of medical profession that awaits me a few years from now.
Many of my generational peers in medicine have made similar arrangements, taken early retirement, or quit practice and gone to work for hospitals or as consultants to insurance companies. Some of my colleagues who practice primary care are starting cash-only concierge medical practices, in which they accept no Medicare, Medicaid, or any private insurance.
As old-school independent-thinking doctors leave, they are replaced by protocol-followers. Medicine in just one generation is transforming from a craft to just another rote occupation.
Medicine in the Future
In the not-too-distant future, a small but healthy market will arise for cash-only, personalized, private care. For those who can afford it, there will always be competitive, market-driven clinics, hospitals, surgicenters, and other arrangementsincluding medical tourism, whereby health care packages are offered at competitive rates in overseas medical centers. Similar healthy markets already exist in areas such as Lasik eye surgery and cosmetic procedures. The medical profession will survive and even thrive in these small private niches.
In other words, were about to experience the two-tiered system that already exists in most parts of the world that provide universal coverage. Those who have the financial means will still be able to get prompt, courteous, personalized, state-of-the-art health care from providers who consider themselves professionals. But the majority can expect long lines, mediocre and impersonal care from shift-working providers, subtle but definite rationing, and slowly deteriorating outcomes.
We already see this in Canada, where cash-only clinics are beginning to spring up, and the United Kingdom, where a small but healthy private system exists side-by-side with the National Health Service, providing high-end, fee-for-service, private health care, with little or no waiting.
Ayn Rands philosophical novel Atlas Shrugged describes a dystopian near-future America. One of its characters is Dr. Thomas Hendricks, a prominent and innovative neurosurgeon who one day just disappears. He could no longer be a part of a medical system that denied him autonomy and dignity. Dr. Hendricks warning deserves repeating:
Let them discover the kind of doctors that their system will now produce. Let them discover, in their operating rooms and hospital wards, that it is not safe to place their lives in the hands of a man whose life they have throttled. It is not safe, if he is the sort of man who resents itand still less safe, if he is the sort who doesnt.
The portion of the medical profession that has moved offshore is well and getting stronger. That is where our best doctors are going, those who don’t retire or those bright youngsters who don’t decline to enter medicine in the first place.
The average American will be allowed to have doctors who studied anatomy on a dog in a hut in Bangladesh. The “elites” will have doctors from Harvard. Socialism creates two tiers, “Us” and the top tiered politicians.
While most of what he says is true, evidence based medicine is not totally a bad thing. A lot of things we were doing, when actually tested, turned out not to be what we thought.
Most everything else is right on. I have picked my retirement date for the near future, and so has DH. The sooner I can get out the happier I will be.
I wonder what life will be like for my daughter who just started medical school. And yes, we tried hard to talk her out of it.
Doctors at a Northern California hospital, concerned that a 40-year-old woman with sky-high blood pressure and confusion might have a blood clot, order a CT scan of her lungs. To their surprise, the scan reveals not a clot but large cancers in both breasts that have spread throughout her body.
Had they done a simple physical exam of the woman’s chest, they would have been able to feel the tumors. So would the doctors who saw her during several hospitalizations over the previous two years, when the cancer might have been more easily treated.
A middle-aged man admitted to a Seattle emergency room for the third time in six weeks displays the classic signs of liver cirrhosis for which he has been repeatedly treated, including swollen legs and a distended abdomen.
But a veteran doctor spots a telltale indicator of a different disease: rapid inward pulsations just beneath the man’s right ear. The patient’s problem is not his liver but his heart: he has constrictive pericarditis, a serious condition that requires surgery.
Both cases reflect a phenomenon that some prominent medical educators say has become increasingly commonplace as medicine becomes more technology-driven: the waning ability of doctors to use a physical exam to make an accurate diagnosis. Information gleaned from inspecting blood vessels at the back of the eye, observing a patient’s walk, feeling the liver or checking fingernails can provide valuable clues to underlying diseases or incipient problems, they say.
But over the past few decades the physical diagnosis skills that were once the cornerstone of doctoring have withered, supplanted by a dizzying array of sophisticated, expensive tests.
“A lot of people downplay the physical exam and [wrongly] say it’s fluff,” said Salvatore Mangione, associate director of the internal medicine residency at Philadelphia’s Jefferson Medical College and director of its physical diagnosis curriculum.
In a 2012 article in the Cleveland Clinic Journal of Medicine, Mangione wrote that he has seen “many cases in which technology, unguided by bedside skills, took physicians down a path where tests begot tests and where, at the end, there was usually a surgeon, and often a lawyer. Sometimes even an undertaker.”
To address the problem, programs to revive and teach physical diagnosis - also known as bedside medicine - are underway at some medical schools, including Stanford, Jefferson and Johns Hopkins. The programs are predicated on a belief that these skills are an essential adjunct to technology and can boost diagnostic accuracy, curb unnecessary and expensive testing and foster a greater connection between patients and doctors, many of whom spend increasing amounts of their day staring at their computers rather than looking at the patients they are treating.
At Hopkins, a Web-based program called Murmurlab.org seeks to improve young doctors’ ability to use a stethoscope — a tricky skill that studies have shown is lacking - to distinguish serious cardiac problems from far more common benign heart murmurs.
The goal is to reduce unnecessary and costly echocardiograms.
“There are two reasons it remains crucial to do this [physical diagnosis] at least as well as doctors did 100 years ago,” said internist and best-selling author Abraham Verghese, senior associate chairman of Stanford’s program on the theory and practice of medicine. Verghese was instrumental in creating the six-year-old Stanford Medicine 25 program: 25 physical exam skills that students are required to learn, demonstrate and teach. These include assessing enlarged lymph nodes, measuring ankle reflexes and performing a knee exam.
“We can pick off the low-hanging fruit - the obvious diagnosis that one can miss at great cost to the patient,” such as the woman whose metastatic breast cancer was repeatedly missed, Verghese said. In his view, the physical exam also represents an “important transactional moment” between doctor and patient - a laying-on of hands that helps foster trust. An increasingly common complaint from patients, he said, is that “the doctor never touched me.”
Overreliance on technology, he said, has produced perverse results. “If you come to our hospital missing a finger,” he quipped, “no one will believe you until we get a CT scan, an MRI and an orthopedic consult.”
Differentiating Heart Murmurs
But some experts are skeptical that reviving the physical exam is the best approach in the 21st century. Robert Wachter, former chairman of the American Board of Internal Medicine, said he shares Verghese’s concerns about declining clinical skills. But Wachter said he isn’t sure that “restoring the physical exam of yore” is a solution.
“Taking time and energy to train doctors in the physical exam may be less valuable than teaching them how to communicate or to analyze . . . data,” said Wachter, associate chairman of medicine at the University of California at San Francisco. “You’ve got to make some choices.”
There is general agreement that the technological explosion that began in the 1980s led to the decline of bedside skills.
Insurance that pays for tests but gives short shrift to a careful and time-consuming history and physical exam accelerated the trend, as has the growing paperwork burden doctors face. The generation of influential mentors who taught physical diagnosis has largely retired. Even bedside rounds - where such knowledge was often imparted to impressionable neophyte physicians — are mostly a thing of the past, migrating from a patient’s hospital bed to a conference room down the hall where test results and the chart — not the actual patient — are examined.
Too often, physical exam skills are dismissed as inferior relics of the past when compared with “the glitter and perceived objectiveness of modern technology,” said Steven McGee, a professor of medicine at the University of Washington and the author of a recent textbook on evidence-based physical diagnosis.
McGee said that studies have found that physical exam findings can be as accurate as their technological counterparts. Case in point: A pair of studies involving 185 acutely dizzy patients found that the presence of certain abnormal eye movements were more accurate than an initial MRI scan in distinguishing a serious stroke from a benign inner ear problem.
The enormous amount of technology that doctors now must master has crowded out physical diagnosis, he said. But, he noted, “there is a giant chunk of diagnosis that still depends on what we see and detect” through observation and a physical exam.
For a surprising number of diseases, McGee added, diagnosis is based on observation and examination, not a test. Among them are Parkinson’s disease, shingles, drug rashes and constrictive pericarditis.
These days, medical students often train on actors who are only pretending to have medical problems, notes Poonam Hosamani, a newly minted hospital-based internist who joined the Stanford team last year.
Hosamani said that she recently enlisted her husband, who has a bad knee, as a featured patient. Many students told her they had never seen a patient with a knee problem. “When we bring in patients with real pathologies, the students are very excited about that,” she said. “We have to show them that this is worth their time and demonstrate how much information you can gain” through a good exam, which is not intended to replace technology but to guide its use.
Internist John Kugler, an assistant professor of medicine at Stanford, said that typically medical students learn diagnosis skills before they have seen patients. “They are taught where to put their hands, but these techniques are taught in isolation and there is little to no reinforcement,” he said.
W. Reid Thompson, a pediatric cardiologist at Hopkins, launched Murmurlab, a website containing the normal and abnormal heart sounds of more than 1,300 people, in part to curb unnecessary referrals for echocardiograms, which cost up to $900 apiece.
Heart murmurs in children, Thompson said, are common — between 60 and 70 percent of children have them — but only about 1 percent are problematic. Distinguishing “innocent” murmurs from serious ones, he said, is an essential skill for physicians, not just cardiologists. But studies have repeatedly found that many doctors do a poor job with auscultation, or listening to the heart and lungs with a stethoscope.
Despite doctors’ reliance on a plethora of sophisticated tests, auscultation remains “a fundamental clinical skill,” Thompson says. “Every day . . . I walk up to a patient and the first thing I do is listen” to the heart. “People walk around with a stethoscope not just because it looks good or is expected, but because there is information to be learned.”
But Thompson said it is not yet clear whether Murmurlab has improved doctors’ skills. Stanford officials say they are attempting to devise ways to measure the impact of their program as well.
Lots of Data, Little Interaction
In a recent essay, Arnold Relman, a former editor of the New England Journal of Medicine, described the months he spent last summer at Massachusetts General Hospital after he broke his neck in a near-fatal fall. “Doctors now spend more time with their computers than at the bedside,” wrote Relman, an emeritus professor of medicine at Harvard. Reviewing records of his hospital stay, Relman “found only brief descriptions of how I felt and looked” but “copious reports of the data from tests and monitoring devices.” Conversations with his doctors were “infrequent, brief and hardly ever reported.”
McGee said that he once saw a nurse tell a resident that a patient had spiked a fever and watched as the young doctor frantically scrolled through the electronic medical record searching for a cause, instead of walking down the hall to the patient’s room to discover the reason: an inflamed IV site.
“In most hospitals today, the average amount of time a busy intern spends with a patient is four minutes,” said Brendan Reilly, who until recently was the executive vice chairman of medicine at New York-Presbyterian Hospital. No longer are tests ordered based on the results of a careful physical exam and history, Reilly said, but the “technological tests become the primary source of information on the patient. It’s backward now,” and the process is driving up health-care costs and subjecting patients to the risks posed by sometimes unnecessary, risky procedures.
“Doctors trained outside the U.S. are much better clinically than young American doctors,” said Reilly, the author of “One Doctor,” an unsparing 2013 account of his medical career. They are trained — or forced by circumstance — to rely less on technology and more on physical diagnosis skills.
The Stanford Medicine 25 program reflects Verghese’s medical training in Ethiopia in the 1980s. Doctors were required to hone their clinical skills because technology was largely nonexistent.
“In some ways,” Reilly said, “what Verghese is doing is opening people’s eyes and showing that medicine can be a lot of fun.”
Reilly said he hopes the accountable care organizations that are part of the new health law - groups of doctors that band together with hospitals to improve the quality of care for patients and share in cost savings - might boost the effort to revive bedside medicine. “The current system is so ridiculous and inefficient and expensive that we’re going to have to go back to doing some of the old stuff.”
A Skill Set for Doctors
Some components of a physical exam are familiar, such as listening to the lungs and heart, and assessing blood pressure and pulse. But parts of the Stanford Medicine 25 — a list of skills that the school considers important for doctors to know how to perform — may be less familiar. Below are some of those beside tests:
Feel lymph nodes and differentiate benign enlargement from possible maligancy.
Evaluate patient’s walk for signs of neurological or musculoskeletal impairment.
Inspect the tongue for the presence of infection or underlying illness.
Feel the thyroid gland and palpate the spleen to check for enlargement.
Assess the liver, checking for tenderness and enlargement, and recognize signs of liver disease elsewhere in the body.
Evaluate tremors and involuntary movements.
Examine fingernails for signs of kidney, heart or lung disease or nicotine use.
Check shoulders for range of motion.
Evaluate knees for pain and movement.
The complete list is available on the Stanford School of Medicine website
“The elites will have doctors from Harvard.”
Unfortunately for them, this might kill them off.
This is actually the one I wanted to post.
But true, seen it with my own eyes.
When All Else Fails, Examine the Patient?
|August 09, 2013
It’s a favorite tongue-in-cheek line I used when I was a resident on morning rounds with anxious interns and students at my side. After spending the entire night on our feet, we heard exhaustive histories, presented lab results as long as a ticker tape, and proudly displayed X rays and CTs while fighting sleep in the soft glow of the radiology board. Occasionally, I’d ask a salient question, “But what did their physical show?” Sometimes it was obvious the examination was the more cursory portion of the presentation.
I’d like to share a few scenarios that occurred in the short space of just a few days in my private practice to make the point that the physical exam is on the endangered list. These scenarios say a lot about what’s happening with modern American medicine, cardiology included. Please don’t kill the messenger.
“I’m here for a second opinion with my mother because the last three times we’ve seen our cardiologist, he never once touched her,” lamented the concerned daughter with a smiling geriatric mother at her side. “How does he know what’s really going on without listening?”
“I saw my doctor the other day. He used to give me a thorough exam. He even found my prostate cancer a few years back, but this doctor that I saw the other dayhe’s not the same Dr X,” said the patient. “He even mentioned that I should have blood work now and then come back in four months and said we’d ‘do more blood work,’ but he didn’t even use his stethoscope and I’ve not seen him in months. I don’t think I’m going back.”
A beautiful, blonde, statuesque patient came to my office for near syncope. Her orthostatic BP was normal. Her labs were normal. The Holter from another facility was benign. Cardiac exam was completely normal, but when I stretched her out on the exam table, her abdomen was rock hard. For all the world, in that position, I thought she was nine months pregnant.
“Are you pregnant, by any chance?” I asked.
“That would be impossible,” she replied. “I’ve had a tubal.”
I actually placed my arms around this gigantic tumor as an OB would do to query for fetal position. “I think you have a very large tumor in your abdomen,” I said, and sure enough, on CT, there was a 16-cm mass accompanied by multiple tumors crowding her entire abdomen.
But, Wait . . . It Gets Worse
She developed chest discomfort a couple of weeks after a completely normal stress cine was performed for preop assessment. She was out of town, and I directed her to go to a local ER. I received a phone call from a healthcare extender, who at the time of our communication (which I postulate should have occurred after a physical exam) was couched in such a way that they seemed to have no knowledge of the issue at hand. I patiently explained the case and said, “Here, take my cell number and ask anyone who would like a discussion to call me. Her stress exam looked great, but I’d check her troponin and if she has ongoing pain, you may even have to take a look at her coronaries because she’s a preop patient. My bet is that she is having pain from a very crowded abdomen.”
But, Wait . . . It Gets Even Worse
The following morning I received a phone call from an intern who said, “Your patient has this odd abdominal pain,” then hesitated as if clueless, to which I impatiently replied, “Yes, and if anyone, anyone, would put their hand on her abdomen, she has a tumor the size of a large watermelon that spans from her symphysis pubis to nearly her diaphragm. It is likely compressing her vena cava in a seated position, causing presyncope. It’s crushing her bladder such that she has to urinate every hour on the hour all night long and she can no longer have intercourse with her husband without severe pain. You might want to examine her abdomen. I think you’ll be impressed!” and then hung up.
I am not a perfect examiner or a perfect physician. None of us are. I even find things on a second exam that I have missed, like a soft carotid, an abdominal bruit, or a murmur that I’m certain didn’t just occur yesterday, but the point is this: If I don’t listen or touch or feel, I’ll never find it. I’m alarmed because these scenarios are cropping up more often, and harm is coming to the patient population more commonly because of it. Doctors are busy. Constraints on time are greater due to the changing healthcare climate that invites greater revenue if less time is spent in the room with the patient to allow more time to see others. We are relying on healthcare extenders more often, who haven’t spent as many years training in physical-examination technique (hold up! I’m not insulting anyone, just stating the obvious and at the same time, I acknowledge that some patients are examined more thoroughly by healthcare extenders than some doctors and sometimes it’s the only exam they get).
We Are Cardiologists, but We Are Also Internists
It’s okay to examine the patient, find a melanoma, diagnose walking pneumonia, refer a hammer toe for surgery, get a gall bladder removed, discover an uretovesciular tumor that is causing referred chest pain due to a complete ureteral obstructionthese are actual scenarios that occurred in our cardiology office over the past few months.
Some provider somewhere in this disjointed loosely woven patchwork quilt of American medical care must own the process. Someone must declare “the buck stops here” when a patient who has exhausted several avenues presents to us in desperate need. I think the best attitude is this: “If I can’t find it, I will find someone who will,” and then of course, when all else fails, examine the patient.
Cite this article: When All Else Fails, Examine the Patient? Medscape. Aug 09, 2013.
For better or worse Harvard is a “Symbol” of what was ONCE great in America. I experienced a foreign doctor who almost killed me. I now travel 110 miles three days a week to be treated by an American graduate of a top medical school. He has stabilized me and got me a few more years.
I gave the entirety of my youth to this profession, and am rewarded by knowing that I helped a fair amount of people. Beyond that, I am deeply saddened about what has happened to a profession that was my dream come true.
I just spent the last 2 years overseas as an expat. Made a ton of money, the company paid my taxes for me, super vacation and benefits, and I got to give a big finger to Obamacare.....
” I experienced a foreign doctor who almost killed me.”
The best medicine, bar none, comes from those places that treat the sickest patients and that value clinical care above all else. Many of those places are private hospitals that you might never have associated with transcendent quality of care. Regarding ‘foreign’ doctors, I agree that there is much more variability amongst them. There are some that are amazingly good and caring, and some that should not be allowed to practice at all. There’s more consistency among American grads, IMHO.
My Grandson was on track to become a physician, with a 4.0 GPA through college..., when he sought counsel from several family members in the medical field, he turned down an excellent medical scholarship in favor of a career in medical technology development and was earning $100K/year 18 months after graduating. After 3 years he is now earning $150K/year! It is sad, but, physicians and nursing professionals are becoming slaves to bureaucrats in the USA. My family physician has two RNs and EIGHT clerks working at his office! This is what our medical system has become!!!
A few years back, I was in an auto accident and went to the emergency room for evaluation and X-Rays. At intake, I was offered the choice of cash payment of 30% or insurance processing at 100%. In that instance, due to deductible amounts I opted for CASH PAYMENT and was ahead of the game. It is easy to see why medical tourism is such a booming business today !!!
What a depressing article—because I believe every word of it. My dad was an OB-GYN who retired early in the 1980s because he found THAT level of government interference to be intolerable. He’s passed on now, but he’d be stunned to see what’s happened to his profession.
Most doctors will not listen to patients and do complete physical exams unless they have a financial incentive to do so.
In large hospital systems, doctors have productivity incentives set by administrators. In small groups, doctors must see a large volume of patients per day to break even. Specialists will only stick to their specialty and not make the extra effort to investigated related conditions for fear of practicing outside their specialty for a variety of reason.
And then there is one other factor that has made the physical exam less useful than it was in the 1960s- the obesity epidemic. Americans are so obese now that auscultation is difficult and palpation is nearly useless. Even radiological imaging is of little use in the extremely morbidly obese.
Bookkeepers, clerks, and lawyers.
It’s killing everything these days.
Your M.D. father and my mom, an RN since 1945, have now both passed on after staring this train-wreck in the face since it was first enacted in the 1960s. My mom brought home stories of the doctors’ reactions during discussions between surgeries. They saw it and hated every bit of what they read. Some were quite stalwart John Birchers, according to mom, and they predicted it would lead us exactly where we are today. People pooh-pooh any conversation about the “slippery slope” but there’s just too much evidence to overlook.
I would not disagree with what you said. The “consistency” about which you speak was at one time quite high in intelligence and training for American medical students. In today’s PC world “diversity” is coming to govern the selection of medical students rather than excellence. The average American will get “diversity” the “elites” will get excellence.
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