JESSIE GRUMAN, PHD

The other day I came across this photo of a couple clasping each other in a dramatic tango on the cover of an old medical journal—a special issue from 1999 that was focused entirely on doctor-patient partnerships.  The tone and subjects of the articles, letters and editorials were identical to those written today on the topic: “it’s time for the paternalism of the relationship between doctors and patients to be transformed into a partnership;” “there are benefits to this change and dangers to maintaining the status quo;” “some doctors and patients resist the change and some embrace it: why?”

Two questions struck me as I impatiently scanned the articles from 12 years ago: First, why are these articles about doctor-patient partnerships still so relevant?  And second, why did the editor choose this cover image?

I’ve been mulling over these questions for a couple days and I think answer to the second question sheds light on the first.   Here are some thoughts about the relationship between patients and doctors (and nurse practitioners and other clinicians) evoked by that image of the two elegant people dancing together:

It takes two to tango.  Ever seen one guy doing the tango?  Nope.  Whatever he’s doing out there on the dance floor, that’s not tango.  Without both dancers, there is no tango. The reason my doctor and I come together is our shared purpose of curing my illness or easing my pain. We bring different skills, perspectives and needs to this interaction.  When in a partnership, I describe my symptoms and recount my history. I talk about my values and priorities. I say what I am able and willing to do for myself and what I am not.  My doctor has knowledge about my disease and experience treating it in people like me; she explains risks and trade-offs of different approaches and tailors her use of drugs, devices and procedures to meet my needs and my preferences. Both of us recognize that without the active commitment of the other we can’t reach our shared goal: to help me live as well as I can for as long as I can.

Each dancer adjusts to his or her partner.  In tango, each partner has different moves; the lead shifts subtly and constantly between them throughout the dance. In a partnership, when I am really ill, I delegate more decisions to my physicians; when I am well we freely go back and forth, discussing treatment options and making plans.

Both dancers have to want to dance.  One dancer is not familiar with the music and holds back, reluctant to look foolish; another woodenly goes through the motions, dancing with her father-in-law out of obligation. If my doctor doesn’t indicate that she is interested in listening to me—doesn’t invite my contribution to a discussion, answer my questions or address my concerns, chances are we won’t be having much of a partnership.  If I believe my doctor can diagnose me based on a few tests, cure me by prescribing a few pills and that she will tell me everything I should to know—I need only do what she’s told me to—the chances of us building a strong working relationship are low.

Everybody has to learn to dance. No one is born knowing how to tango—you have to learn the steps and practice them over time. We witnessed the deference our parents accorded our physicians and most of us have had few opportunities to behave differently, either because we are pretty healthy and have little contact with health professionals or because we are pretty sick and we have other things on our mind at the time.  Similarly, most doctors practicing today trained with physicians who expected considerable deference from their patients.  The saying “Just because you have furniture doesn’t mean you are an interior designer” applies: Just because you can talk doesn’t mean you know how to build a partnership where it is possible to openly discuss intimate bodily functions, symptoms, drugs, hope, depression, fear, life, death—and what might be done to ease the suffering—with this relative stranger. Building and maintaining a partnership between a doctor and patient constitutes a dramatic change in power, responsibility and ways of interacting.  Making those changes requires that both partners learn to listen, talk and act in ways that are unfamiliar and often uncomfortable.

There’s no revenue model for dancing. Unless they win “Dancing With the Stars” or work tirelessly to become professional ballroom dancers, most people who tango receive no financial reward for their efforts. They dance because it is satisfying; because they love the music or the feeling it gives them or the joy of mastery or the fancy outfit.  No one will pay me or my doctor to forge a partnership with each other, although it is possible that one barrier to my doctor doing so—lack of time—will be removed by being better compensated in the future.  But no policy, incentive program or performance measure is likely to induce either of us to interact differently.  We will only change the way we communicate because we see value in doing it and because we see risk of harm in not doing it.  We will change because we respect what each other knows and needs in order to do his or her best.  And we will change because we realize that only by communicating as partners can we reach the goal we share—my improved health.

Viewing the relationship between doctors and patients through the lens of these dancers, I am reminded of the flexibility and sensitivity required of both doctors and patients, working as partners, to accommodate the ebb and flow of illness.  These new communication skills can only be learned through practice in the company of a partner who is similarly committed to using them. Partnerships between patients and their providers are driven not by financial incentives or punishments but because we both realize that it is no longer safe or feasible to deliver or receive the full benefit of health care without them.

And so while I’m disappointed, I’m not discouraged by the relevance of the dated articles in the journal with the dancers on the cover.  Moving from paternalism to partnership between doctors and patients constitutes a huge shift in attitude and practice for all of us.  That shift is difficult for many and as a result, its pace has been, to quote CMS director Don Berwick, “majestic.”  The public and professional media cover health care reform, public health program cutbacks, daily advances in medicine drugs and technology, demands of evidence-based medicine, and the reorganization of care, reflecting the priorities of those within health care.  So I am grateful for every journal article, training program or conference announcement and media campaign that sends up the flag to remind us and our doctors that it is only through our partnerships with one another that we will receive—and they will deliver—the best care.

I may not be discouraged but I am still impatient.  Come on! The music is playing…it’s time for all of us to start dancing.

Jessie Gruman, PhD, is the founder and director of the Washington, DC- based Center For Advancing Health. She is the author of “Aftershock. What to Do When You or Someone you Love is Diagnosed with a Devastating Diagnosis.”

Physicians who have adopted smartphones and tablet devices access online resources for health more than less mobile physicians. Furthermore, these “Super Mobile” doctors are using mobile platforms at the point of care.

Physicians adoption and use of mobile platforms in health will continue to grow, according to a survey from Quantia Communications, an online physician community. This poll was taken among 3,798 physician members of QuantiaMD’s community in May 2011. Thus, the sample is taken from the community’s 125,000 physicians who are already digitally-savvy doctors. QuantiaMD calls physicians with both mobile and tablet devices “Super Mobile” physicians.

The most common mobile devices among the Super Mobile doctors in QuantiaMD are iPhones, used by 59%; iPads, used by 29%; and, Android smartphones, used by 20% of the physicians surveyed. Blackberry devices are used by 14% of the doctors in the poll.

Just under one-half of these doctors plan to purchase a mobile device in 2011, notably an iPhone, an iPad, or an Android.

Among all physicians, 19% already use a tablet device in practice, and 35% say they’re “extremely likely” to do so. Another 29% say they’re “somewhat likely” to use a tablet in clinical practice.

The chart shows various professional activities that Super Mobile physicians do using mobile devices. Among the activities Super Mobile physicians use mobile devices for are looking up drug and treatment reference materials and learning about new treatments and research. Nearly 1 in two doctors who use both smartphones and tablets use the devices to help with diagnoses and choosing treatment paths for patients.

Physicians told QuantiaMD that accessing EHR data via mobile devices is a top priority.

It’s important to know that there doesn’t seem to be a mobile-divide among Super Mobile physicians based on age or practice setting. Currently, 20% of doctors practicing 10 years or less use a tablet in practice; 19% of doctors practicing 31 years or longer use a tablet.41% of doctors practicing 31 or more years say they’re likely to use a tablet in practice versus 58% of doctors practicing 10 or fewer years.

Jane’s Hot Points: The phenomenon of the Super Mobile doctor who, armed with mobile platforms, engages more in online health apps via mobile is similar to a trend Susannah Fox of the Pew Internet & American Life Project spotted in her survey on consumers’ use of online health resources: that when a person has access to broadband, their health searches are more engaging in terms of time spent seeking health information.

In the case of the Super Mobile physician, adoption and use of mobile platforms deepens their relationship with the online health world. They’re using smartphones and tablets in their workflow in two ways:

• When face-to-face with patients for education and to access patient data via EHRs and other databases; and,
• Research into diagnoses, therapeutic options, and clinical research.

This first aspect of patient-facing use of mobile technologies is an exciting development: physicians using mobile devices can bolster patient health engagement, which when coupled with accessing EHR data can move the doctor toward meaningful use of HIT. Engaging in patient education at the point-of-diagnosis and -care can further the patient’s health literacy and self-efficacy in care once she leaves the exam room.

Lest we get carried away in interpreting the results, let’s remember that this poll was conducted among Super Mobile doctors who represent the vanguard of the new-new digital clinician. There are barriers that will impede other physicians from pursuing patient activities using a mobile device which were, smartly, explored in the survey. Top of the list of barriers are concerns about patient privacy, noted by 54% of the doctors in the survey, followed by concerns about liability (46%), concerns that patients don’t have the technology (37%), and ability to be paid for the use of mobile activities in practice (36%).

Jane Sarasohn-Kahn is a health economist and management consultant that serves clients at the intersection of health and technology. Jane’s lens on health is best-defined by the World Health Organization: health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity. She blogs at HEALTHPopuli.

Yesterday’s Wall Street Journal (When Your Doctor Sells Credit Cards) documented the growth in credit cards issued to finance elective procedures such as LASIK, plastic surgery and dental implants. The article covered the usual points but missed one important but little-known aspect of the industry.

Briefly, physicians offer the cards for procedures not covered by insurance. The cards have a zero percent interest rate and no fees, usually for the first 12 months. After that the interest rates spike and to make matters worse customers are also charged retroactive interest on their first year’s balance. Ouch! The article details the pitfalls you’d expect from cards like these, and of course there have been some abuses.

A card company spokesman quoted in the article says, “the vast majority of account holders pay off their balances before the promotion ends.” That statement doesn’t surprise me, because most people who have these elective procedures are relatively well off.

I used to think that the card issuers lost money on patients who paid off their balance during the first 12 months but more than made it up on those who took longer to pay. In fact, I once told an executive at a credit card company that they must have lost money on me, because I once had a card like this. I had been prepared to pay cash for a procedure, but decided to take the no interest offer and keep the money to invest. However, the credit card executive smiled and told me that I had still been a money maker, because the credit card issuer charged fees to the doctor for issuing the card.

A major reason doctors were willing to pay the credit care company was because it gave them a way to offer a discount without having to negotiate with the patient explicitly. That insight also helps explain why the cards charge zero interest rather than just a low interest rate. For most cardholders the credit card company really isn’t trying to make money from the financing. Rather the objective is to serve the physician by facilitating price realization and volume.

David E. Williams is co-founder of MedPharma Partners LLC, strategy consultant in technology enabled health care services, pharma,  biotech, and medical devices. Formerly with BCG and LEK. He writes regularly at Health Business Blog, where this post first appeared.

The Disease Management Care Blog, believing that the ultimate end game will be an historic insurer-physician alignment, checked out an “Issue Brief” on the Rising Employment of Physicians, courtesy of the Center for Studying Health Center Change (hat-tip to the folks at KHN).  The authors interviewed hospital, health plan and other provider executives from 12 representative locations around the country and came away with some telling impressions on what’s happening in the hospital market place.

The authors didn’t find much in the way of insurer-physician alliances, but they sure found evidence of increasing employment of physicians by hospitals.  Why?  For the docs, it’s a perfect storm of declining reimbursement, growing overhead, increasing insurer hassles, the cost of implementing an EHR and the high premium for liability (malpractice) insurance.  In addition, younger physicians are attracted to the prospect of a better work-life balance that comes with steady employment.  For the hospitals, it’s the opportunity consolidate market-power, maintain a referral base and do away with the revenue-stealing physicians’ in-office and surgi-center procedures.

Yet, while economics are driving docs into the arms of the hospitals, the authors cautioned that all is not well when it comes to 1) coordination of care/quality, 2) costs and 3) access to care.

To wit:

1.  Employing doctors is not the same as “integrating” care services.  There is little evidence that that alone leads to coordination of care – outside of some limited service-line issues, like reducing readmissions among patients with chronic heart failure.

2.  The continued reliance on fee-for-service as the predominant mode of payment is leading hospitals to increase revenue by encouraging their newly employed physicians to increase the volume of services.  In addition, hospitals can charge insurers a “facility fee” for many of the services that were previously independently performed by physicians.  Wanting to control the market for some services also leads to “bidding wars” for certain types of physicians, and if the bidding is successful, hospitals can command higher prices from payers. These four factors spells increased costs.

3. There isn’t anything about hospital-physician employment that automatically does anything to increase access to care.

“Precisely!” says the DMCB.

The threat of losing leverage with ascendant hospitals in their networks is one reason why large insurers have every reason to start courting the physicians in their networks.  They also understand that it’s the physicians that can increase quality, reduce costs and increase access.  All they have to do is develop the information systems, joint programs and incentives to make it happen.  As the bloom comes off the rose of hospital-physician mergers, the DMCB predicts that tide will turn in the other direction.

Jaan Sidorov, MD, is a primary care internist and former Medical Director at Geisinger Health Plan with over 20 years experience in primary care, disease management and population-based care coordination. He shares his knowledge and insights at Disease Management Care Blog, where this post first appeared.

I started writing a post a few days ago about the challenge of quickly finding what you’re looking for in a medical record. As I came back to my draft this morning, it struck me how much this felt like some of the games my children played when they were young. This got me thinking…

Where’s Waldo: Finding what’s important in the medical record

I did a peer review once of an office note about an elderly man with a low grade fever. The past medical history was all there, several prior laboratory and imaging tests were imported and there was a long narrative section that blended active medical problems and ongoing specialist relationships. There was also a lengthy Review of Systems under its own heading.

In what would probably have printed out over ten pages long, the final diagnosis was “Urinary tract infection” and the man was prescribed antibiotics.

This final diagnosis seemed to come out of left field. I didn’t recall reading anything about urinary symptoms, urinalysis, an abdominal exam or pain on percussion over the back.

I had to read the note again twice. Finally I found mention of increased urinary dribbling in the sentence that stated that the patient was seeing a urologist for his enlarged prostate. There was a same day urinalysis mixed in with almost a dozen other, previously done lab tests for things that in no way had any bearing on body temperature. And the physical exam was exhaustive, including items that in no way could relate to why an elderly man might have a fever.

My task as a reviewer included answering the question whether the Chief Complaint, Review of Systems, Physical Exam, tests ordered, Assessment and Plan were all consistent. I gave the note a passing grade with a scathing comment about how hard it was to follow my colleague’s line of thinking in diagnosing the patient’s problem because of all he irrelevant data that was included.

After reviewing this one office note, my brain was exhausted. I had not expected chart review to be so much more like “Where’s Waldo” than “Who Dunnit”.

Spot the Difference: How to monitor trends and find the abnormal among the normal

I’ve said it before, much of what we do in medicine is triaging. We run down symptom checklists and we run our fingers over lymph nodes; we scan lab reports and run our eyes over dozens of moles on people’s backs; we look at growth charts for consistency and medication lists for inconsistencies. Our job is to find the abnormal among everything that is normal. Sometimes an apparent abnormality is a persistent and normal “baseline” for one particular patient. To do the best job possible with this, we shouldn’t have to rely on memory alone. We need our EMRs to display information in a way that makes our job easier and reduces the risk of errors. The ability to quickly generate graphs or flowsheets for lab results is crucial because of the volume of tests we have to review, or triage, actually.

We still use warfarin, even though the $400/month never anticoagulants don’t require blood test monitoring and dose adjustments because of interfering medications or foods. Not all EMRs display historical INR values and dose changes well; I have some colleagues who will look at only one INR value and change their patient’s warfarin dose. Sometimes their typical increase or decrease will create the same overcorrected result again and again because the EMR doesn’t provide the same overview as the old paper flowsheets.

Whack-a-Mole: Just when you think you’ve solved one problem, another pops up

This is the most clinical and most deeply frustrating child’s game we have to play in medicine. One leg ulcer heals, and another one develops. One COPD or heart failure exacerbation successfully treated and the patient gets sick again. One cancer seems beaten and another tumor develops.

The other games we find ourselves playing are annoying obstacles created by health care workers or systems. But Whack-a-Mole is the modus operandi of the many human diseases we battle. And unlike the other two “games”, this is one we must accept and not take personally when we don’t win. And because this is a game with sometimes devastating consequences, I take absolutely no pleasure in the child’s play version, although I did enjoy playing both Where’s Waldo and What’s the Difference when my children were young.

Hans Duvefelt is a Swedish-born rural Family Physician in Maine. This post originally appeared on his blog, A Country Doctor Writes, here.

U.S. Sen. Charles Grassley (R-Iowa) sent a letter today to the Health Resources and Services Administration, criticizing its decision to remove a public version of the National Practitioner Data Bank, which has helped reporters and researchers to expose serious gaps in the oversight of physicians.

“Shutting down public access to the data bank undermines the critical mission of identifying inefficiencies within our health care system – particularly at the expense of Medicare and Medicaid beneficiaries,” Grassley wrote to HRSA Administrator Mary Wakefield. “More transparency serves the public interest.”

Grassley, ranking Republican on the Senate Judiciary Committee, continued: “Generally speaking, except in cases of national security, the public’s business ought to be public. Providers receive billions of dollars in state and federal tax dollars to serve Medicare and Medicaid beneficiaries. Accountability requires tracking how the money is spent.”

The National Practitioner Data Bank is a confidential system that compiles malpractice payouts, hospital discipline and regulatory sanctions against doctors and other health professionals. For years, HRSA has posted aggregate information from the data bank in a Public Use File that did not identify individual providers.

HRSA officials removed the public file from the data bank website last month because a spokesman said they believe it was used to identify physicians inappropriately. The Association of Health Care Journalists has protested the action, along with Investigative Reporters and Editors, Society of Professional Journalists, National Association of Science Writers, Reporters Committee for Freedom of the Press, and National Freedom of Information Coalition.

Grassley’s letter comes days after the official who created the Public Use File in the mid-1990s and managed it until 2008 said that HRSA was “erroneously interpreting the law” governing the data bank by removing the public version.

In a letter to AHCJ, Robert Oshel said HRSA officials have confused the requirements of the law.

“HRSA’s current management seems to confuse the law’s requirement that a public data file not permit use of its records to identify individual practitioners with a very different requirement, and one not in the law: that the file not allow the records of previously identified practitioners to be identified in the file,” Oshel wrote.

Oshel further wrote that HRSA’s view will “seriously hinder use of the file for important public policy research.”

“It seems disturbing and bizarre that HRSA would attempt to chill a reporter’s First Amendment activity with threats of fines for merely ‘republishing’ public information from one source and connecting it with public information from another. A journalist’s shoe-leather reporting is no justification for such threats or for HRSA to shut down public access to information that Congress intended to be public,” Grassley wrote.

Grassley asked Wakefield a series of questions and asked for responses by Oct. 21.

AHCJ President Charles Ornstein called on the Obama administration once again to restore access to the Public Use File. “Using this file, reporters across the country have preparedstories that have exposed holes in the oversight of doctors – and those stories have led to greater transparency and improved patient protections,” he said. “This information needs to be restored now.”

Pia Christensen is managing editor/online services at the Association of Health Care Journalists (AHCJ). She assists with the editing and production of AHCJ’s publications, including books, conference programs and the quarterly newsletter.

This post first appeared at Covering Health, the blog of AHCJ.

The American College of Physicians has published their updated manual on ethics for physicians and the following passage is causing quite a stir:

Physicians have a responsibility to practice effective and efficient health care and to use health care resources responsibly. Parsimonious care that utilizes the most efficient means to effectively diagnose a condition and treat a patient respects the need to use resources wisely and to help ensure that resources are equitably available.

On the right, American Enterprise Institute scholar Scott Gottlieb writes “Parsimonious, to me, implies an element of stinginess, and stinginess implies an element of subterfuge.” (Quote of the Day in American Health Line.)

On the left, Aaron Carroll writes:

I would fight tooth and nail to get anything — and I mean anything — to save [his own child]. I’d do it even if it cost a fortune and might not work. That’s why I don’t think you should leave these kinds of decisions up to the individual. Every single person feels the way I do about every single person they love, and no one will ever be able to say no. That’s human.

Similarly, I don’t think that it’s necessarily fair to make it a physician’s responsibility. I also want my child’s doctor to fight tooth and nail to get anything that might save my child. Many times, physicians have long-standing relationships with patients. Asking them to divorce themselves from the very human feelings that compel them to do anything that might help their patients is not something that I think will necessarily improve the practice of medicine. They also should be human.

So whose job is it? Well, mine for instance. That’s what I do as a health services researcher. That’s what policy makers should also do….

That’s a roundabout way of saying that only the government can ration care the right way. Here is Don Taylor’s (Incidental Economist) take on the subject.

My view: people in health care have become so completely immersed in the idea of third-party payment that they have completely lost sight of the whole idea of agency.

[youtube]http://www.youtube.com/watch?v=BQMI7TksYo0&feature=player_embedded[/youtube]

This game of life I play
Living and dying with the choices I made

Can you imagine a lawyer discussing the prospects of launching a lawsuit without bringing up the matter of cost? What about an architect submitting plans for a building but completely ignoring what it would cost to build it?  Outside of medicine, can you imagine any professional anywhere discussing any project with a client and pretending that money doesn’t matter? Of course not.

Then what is so special about medicine? Answer: the field has been completely corrupted by the idea that (a) patients should never be in a position to choose between health benefits and monetary cost, (b) doctors shouldn’t have to think about such tradeoffs either, (c) in order to insulate the patient from having to choose between health care and other uses of money, third-party payers should pay all the medical bills and (d) since no one else is going to think about what anything costs, the third-party payer is the only entity left to decide which services are worthwhile and which ones aren’t.

To appreciate how doctors could do the same thing other professionals do in advising patients on how to spend their own money, take a look at the graphic below. These numbers are several years old and there may be more recent studies, but the graphic will serve our heuristic purpose. Armed with this information, what would a responsible doctor tell her patient about Pap smears and how often the patient should get them?

Source: Tammy O. Tengs et al., “Five Hundred Lifesaving Interventions and Their Cost-Effectiveness,” Risk Analysis, June 1995.

Note that getting a Pap smear every four years (versus never getting one) costs $12,000 per year of life saved, when averaged over the whole population. What the responsible doctor should say is, “In the risk avoidance business, this is a really good buy. Based on choices people like you make in other walks of life, this is a good decision. This type of risk reduction is well worth what it costs.”

What about getting the test every three years (versus every four) or every two years (versus every three)? Here the doctor should say, “Now we are moving toward the upper boundary of what most other people are willing to spend to avoid various kinds of risks. So at this point, serious thought needs to be given to whether the test is really worth what it cost.”

How about getting the test done every year (versus every two years)? Here the responsible doctor will say, “This is definitely a bad buy (unless there is some specific indication). The cost of an annual Pap smear in relation to the amount of risk reduction achieved is way outside the range of choices most people make with respect to other risks.”

Notice what is going on here. The responsible doctor, functioning as an agent of a patient who is not familiar with the medical literature and who is not skilled at evaluating risks or trading off risk reduction for other uses of money, advises her patient in these matters. She helps her patient manage both her health and her money — because both are important.

When Dr. Carroll says “I’d do it even if it cost a fortune and might not work,” I am sure he is being sincere. But I am equally sure that is not how he normally makes decisions. It is in fact easy to spend a fortune to avoid small-probability events. The EPA makes the private sector do it every day. But if an ordinary family tried that, they would end up spending their entire income avoiding trivial risks. And that is not what normal people do.

Here is another example of a money-is-no-object-no-matter-how-improbable-the-prospects-if-life-and-death-are-at-sake choice. This is Zeke Emanuel, writing in The New York Times the other day:

Proton beam therapy is a kind of radiation used to treat cancers. The particles are made of atomic nuclei rather than the usual X-rays, and theoretically can be focused more precisely on cancerous tissue, minimizing the danger to healthy tissue surrounding it. But the machines are tremendously expensive, requiring a particle accelerator encased in a football-field-size building with concrete walls. As a result, Medicare will pay around $50,000 for proton beam therapy for a patient with prostate cancer, roughly twice as much as it would if the patient received another type of radiation.

Emanuel claims there is no evidence the treatment works for prostate cancer — so the therapy is a waste of $25,000. Is he right? I don’t know. If you’re paying the extra $25,000 out of your own pocket, listen to what the doctors at Mayo have to say (in favor of its use) and then listen to what Emanuel has to say and make up your own mind.

Bottom line: helping patients manage their health dollars as well as their health care should be what doctoring is all about.

John C. Goodman, PhD, is president and CEO of the National Center for Policy Analysis. He is also the Kellye Wright Fellow in health care. His Health Policy Blog is considered among the top conservative health care blogs where health care problems are discussed by top health policy experts from all sides of the political spectrum.