A Country Doctor Writes:

Healthcare is on a different trajectory from most other businesses today. It’s a little hard to understand why.

In business, mass market products and services have always competed on price or perceived quality. Think Walmart or Mercedes-Benz, even the Model T Ford. But the real money and the real excitement in business is moving away from price and measurable cookie cutter quality to the intangibles of authority, influence and trust. This, in a way, is a move back in time to preindustrial values.

In primary care, unbeknownst to many pundits and administrators and unthinkable for most of the health tech industry, price and quality are not really even realistic considerations. In fact, they are largely unknown and unknowable.

The real price in primary care isn’t just the cost of each doctor visit. It is the cost of the total number of visits needed to solve a problem, and also the cost of the various tests, procedures and treatments each primary care doctor orders when solving that problem or managing a particular condition. This can vary enormously.

In Accountable Care Organizations, actual costs are compared to presumed or projected costs, which are based on Hierarchical Code Categories (see my post), which aren’t well known or commonly used by primary care doctors. To a degree, you can game this baseline cost calculation by mastering HCCs (Medicare Advantage plans’ financial well being hinges on making the most of this; this is why they offer doctors $150 to sign off on a list of each patient’s known or suspected expensive diagnoses).

Quality in healthcare is largely in the eye of the beholder. I’ve said it before and I’ll say it again here: A patient population’s immunization rates or aspirin use or non-use (depending on shifts in knowledge) are not comprehensive measures of quality. Accuracy of diagnosis, if anything, is. But who is measuring that? You might say “those who can’t practice medicine measure it”. That’s why most quality measures these days are of things you don’t need a medical degree or license to accomplish.

Primary care, in the eyes of our patients, is instead about relationship, authority, trust and (gasp) convenience. This is what people in most other businesses talk about all the time. It is what even tech and medicine pundits, EMR companies and many other middlemen want for themselves. They don’t want to be evaluated on the basis of price or quality standards set by others. Yet they want mass market medicine for the masses, not relationship based care.

Driving 200 miles between my two clinics, I often listen to audiobooks. Once I finished my Board Review, I turned to business books. “Influence”, “Authority”, “Brand”, “Story” and “Content” have replaced “Quality”, “Six Sigma” and “Excellence”. In business now, it is all about standing out and setting your own standards. It is about building relationships with and listening to consumers.

In healthcare, I see the paradox that insurers are now reaching out to patients to check up on them while at the same time making doctors work so hard and so fast producing “encounters” that there is less and less time for us to talk with our patients when we are with them, and never mind on the phone in between visits. Do they really think patients wouldn’t rather see their own doctors having enough breathing room to talk to them than have some strangers from out of state they never met calling to check in?

We have data that the doctor-patient relationship influences outcomes. From hospitalization rates to prescription adherence to effectiveness of treatments for mental health diagnoses, it is well known that the doctor is a large part of the treatment.

Doctors have increasingly become part of multicenter systems that, in spite of efforts like Patient Centered Medical Home recognition, simply have become too large and impersonal to foster the kind of customer relationships the business world is now realizing are necessary.

Between the bottom-line objectives of such healthcare organizations and the bureaucracies of health insurers, doctors and patients are clearly not in complete charge of their own relationships anymore.

So what happens with those relationship dependent outcomes when so many doctors feel like lineworkers, rather than professionals? What happens to their ability to nurture those relationships, gain that authority and earn that trust?

What happens if they lose it altogether?

There are modern, big companies who listen to their customers, even research and anticipate their customers’ needs. There are companies that empower their employees to solve customer problems, give refunds and do extras. There are companies who treat employees like owners or even offer them actual ownership.

Healthcare could do some more of that.

But there is more, lest we forget: Doctors aren’t just employees.

Who has the license to practice medicine? Who places the needle or scalpel? Who selects the medication? Who says “I’m sorry, we did everything we could” or “Congratulations, it’s a beautiful baby girl”?

Salespeople, YouTube stars and business leaders give a lot of thought to their customer relationships, their personal authority and the essentials of building and maintaining trust.

Are we doctors doing enough of that? Those things are ours to claim, and to strive for. Even if a big corporation issues our paycheck.

Doctors need to be true to themselves but at the same time they must be chameleons.

A doctor fills certain roles in the lives and stories of patients. It is a two-way relationship that looks different to each person we serve throughout every workday and even in the most casual interactions we have.

Some patients need us to take charge for a while because they’re exhausted, others need us to listen quietly while they vent or process something out loud.

Some patients need reassurance and empathy, others thirst for detailed information. Some patients thrive on viewing us as equals and friends, yet others need some distance because what they need to share with us is something they couldn’t even tell their best friend – only a priest, rabbi or doctor without the familiarity of a friend.

I may be naturally analytical, intuitive, reserved or outgoing, but I must get a sense of my patient and the situation he or she is in and understand how I can fit into that situation.

This is not acting or being dishonest. I don’t dress the same way for a day in the office as I do for a day in the barnyard or a night at Chateau Frontenac. Neither do I conduct myself the same way in every situation in my life. It would be selfish and inconsiderate of me to act exactly the same way with every patient – “take it or leave it”.

I work at being chatty and cheerful, but that is no more dishonest than practicing another language. I may know the perfect word for something in Swedish but that doesn’t do my English speaking patient any good.

The roles we play in people’s lives are necessary for them in those moments, in their personal journey. Many people need someone in an archetypal role to carry them to the next level or the next chapter in their lives by saying or doing something they cannot do themselves.

Doctors are performers, not only when we perform procedures, but also when we deliver a diagnosis or some guidance. This is the premise of an audiobook I listened to a while ago during my commute between my two clinics: Dr. Bob Baker, retired physician and an accomplished magician, draws parallels between the two professions in “The Performance of Medicine”.

I have done a lot more thinking lately about these two P-words: The Practice of Medicine and The Performance of Medicine. Both words, both concepts, point out that what we do in this job is much bigger than we ourselves are, something that transcends time and place. We have to continually work at it and it takes place in the energy field of two people in a therapeutic encounter.

Quoting Dr. Baker: “The magic of medicine begins with the doctor/patient connection.”

That connection requires us to be what we Swedes call “lyhörd”. There is no single word I know of in the English language that conveys the same notion. Literally, it means “of keen hearing”. Google Translate suggests three words: responsive, keen and sharp.

Osler said “Listen to your patient, he is telling you the diagnosis”. Duvefelt says “Listen to your patient, he is telling you what kind of doctor he needs you to be”.

Non-clinicians skip over some of the most necessary underpinnings of Doctoring and speak too much about housekeeping issues: Blood Pressure targets, aspirin use, mass screenings, immunization rates and so on.

People without medical degrees could do those things. But there are steps that must be taken before we worry about the measurables. These are the essence of being a physician, what people ask for when they come to see us. Most people don’t come in and say “I need you to regulate my blood pressure” or “Help me lower my cholesterol”. They come in saying “I don’t feel good” or “Help me stay healthy”.

DIAGNOSIS

More than anything, people come to us to find out what’s wrong with them. They come with rashes, aches, fevers, coughs, “bunches” (the Maine word for lumps and bumps on their bodies) and concerns like fatigue, which could be a symptom of almost anything.

In that scenario, not to be melodramatic, making a correct diagnosis could be a matter of life or death, or at least wasteful spending of thousands of dollars and valuable time.

We don’t get enough credit by outside observers, like health care administrators, insurers and “consumers” for the value of our diagnostic acumen. It is the first fundamental of health care. Different diseases have different treatments and the success of medical care hinges on treating the right diagnosis.

A trivial example is a patient I heard of just recently with sudden agitation and high blood pressure presenting to the emergency room. Many hours and many tests after arrival – blood tests, EKG, CT scans and so on, he turned out to have urinary obstruction. A Foley catheter relieved the obstruction and cured his high blood pressure as well as his agitation.

A young woman came to see me a few days before graduation for a mild rash on her legs. Not only was she about to graduate; she was also planning a long trip afterward. The bloodwork I ordered STAT on our first encounter showed that she had acute leukemia. She was allowed a temporary leave from the cancer clinic to attend the ceremonies and then went back to continue her treatment. Today, she is the proud mother of a soon-to-graduate teenager. What if I, as she later said, had glanced casually at her skin and sent her off on a faraway trip with a prescription for a cream?

GUIDANCE

“Treatment”, the second part of the traditional duad, is too simplistic a notion, only useful for lancing boils and prescribing penicillin for strep throat. Most diseases are multifaceted and most patients have several health and disease considerations. Most diseases are also chronic, even ones we thought of as rapidly terminal earlier in our own lifetime, like HIV and an increasing number of cancers.

The physician’s role is not a knee jerk intervention, it is informing and educating the patient and helping each patient choose a plan of action that is right for them.

Primary Care does what Google can’t, it applies knowledge of the patient and of the relative importance of medical facts and factoids and offers guidance in the sense of ranking options.

Even when the treatment requires specialized care we have a role as guides. We help patients choose specialists depending on each patient’s particular medical problems and personal preferences – referral to a particular subspecialty and to a take-charge doctor or a collaborative one, for example.

As guides, we follow patients along on their journey, sometimes actively by showing what to do, sometimes only watching from a distance, ready to intervene if they stumble. We don’t just prescribe, we anticipate – we warn patients and their families of things that may come up at the next turn. It takes experience and expertise do that well, not just handing out mass produced information to meet “meaningful use” mandates.

Sometimes our Guide role requires us to talk about a different journey – not one back to health and function, but one of decline and death. We must be comfortable with that role as well as the cheerleader’s.

The almost pastoral duty we have is to instill and preserve hope. Although this is often for a cure involving certain obstacles or challenges, sometimes the hope we can offer is only the hope of feeling better and sometimes it is just of relief from suffering.

We live in an era of tweets, sound bites and intellectual shortcuts. Medicine doesn’t fit into that kind of mindset very often. Contrary to what some outsiders think, ours is a deeply cognitive profession of careful consideration and deeply personal counsel.

“Treatment” is simply a misnomer for what we do. Even when there is no cure, there is care.

My clinic belongs to an Accountable Care Organization. My job is to keep my patients medical costs down, in my clinic as well as in the hospital and specialist offices, without sacrificing quality. Of course, I have about zero control over costs generated outside my office.

So, since I can’t do very much about what Cityside Hospital and all the specialists they employ charge for their work, my only chance of getting any “shared savings” is to make my patients look real bad.

That is what some of the Medicare Advantage plans (Federally subsidized for profit contractors who manage Medicare subpopulations that get extra benefits, like glasses and gym memberships, in exchange for Prior Authorizations and other forms of rationing). I used to puzzle over why they paid us $150 just to update/verify my patients problem lists until I got caught up in the same situation through no fault of my own. Now I also know why these lists sometimes contained outrageously erroneous diagnoses such as paraplegia.

The baseline cost, from which any savings (shared savings for my clinic) or the dreaded opposite is calculated, is predicated on complex actuarial formulas, summarized in what Medicare calls Hierarchical Condition Categories.

This is how that works:

Even through Medicare paid for patient X’s medical care in previous years, and received bills with all of his terrible diagnoses listed, they calculate my base “cost” only counting the diagnoses submitted recently. If they don’t see anything that looks expensive, they budget about $8,000 for the coming year for that patient. Never mind that he is a quadriplegic amputee (which I might not include as a reason for any particular visit, although I might treat and code for his bedsores). Of course, since he may need a new power wheelchair anytime, I wouldn’t want that cost to drag down my “performance”, so I’d better put “quadriplegia” and “below-the-knee amputation” on at least one superbill every year.

It seems obvious they hope I’ll forget to “take credit” for how sick Mr. X really is, so that his multiple hospitalizations and new power chair will hurt my clinic’s bottom line.

In other cases, it is more a matter of word choice: If somebody has fairly stable heart disease and takes nitroglycerin two or three times per year, “coronary artery disease” gets me no points, whereas “angina pectoris” jacks up my baseline a little.

Obesity is an interesting problem. If a patient is morbidly obese, that gives me more of this HCC “play money” to work with. Once they lose the weight, I will of course lose those dollars. But there are quality bonuses to be gained from treating obesity. However, Medicare will REJECT any and all claims for office visits conducted solely for the purpose of treating obesity.

There is obviously more money to be made, at least for the next several years, from aggressive coding than from looking over the shoulders of hospitalists and specialists. I can’t even tell from the hospital reports exactly what they did and why they did it. So how and why could I gain more from that than from becoming a Hierarchical Condition Category Coding expert?

This is what I not so fondly call Metamedicine.

(See also https://acountrydoctorwrites.wordpress.com/2014/07/24/medicine-is-easy-but-metamedicine-is-hard/. The diagnosis codes in that post are the old ICD-9 ones, but the principles still apply.)

Clinical guidelines are a mixed blessing. Wise clinicians know that they offer a general pattern of doing things that usually results in favorable outcomes. They also know there are lots of situations when guidelines can’t be applied because of unique patient characteristics.

Guidelines can be dangerous if we apply them indiscriminately. Education and experience teaches us when and when not to follow them.

The problem with guidelines is that people without our knowledge or experience have placed themselves in positions where they judge physicians by whether we follow a particular guideline or not. Never mind that there are competing guidelines, and that the web repository of them shut down a month ago.

That reminds me of a colorful Swedish analogy my grandmother often used, “som fan läser Bibeln”, translated “like Satan reads the Bible”.

One of many American Christian authors writes about it this way:

“What makes Satan happy is when he can get Christians to believe that Proverbs 15:6 justifies the accumulation of wealth in a world of hunger; that 2 Thessalonians 3:10 abolishes charity; that Romans 9:16 makes evangelism superfluous; that 1 Timothy 2:4 means God is not sovereign in conversion; that John 10:28 means a “Christian” can do whatever he wants and still be saved; that Hebrews 6:4–6 means there is no security and assurance for God’s elect.”

If Satan can pick and choose Bible phrases to confuse, tempt or mislead earnest and well meaning Christians, imagine what someone with ill will or authority without wisdom can make out of clinical guidelines.

That is the reality of today’s Quality Quagmire in health care.

We sometimes get judged if we don’t have diabetics on ACE inhibitors, even if they don’t have microalbuminuria. According to UpToDate, there is insufficient evidence for this practice.

Regarding statins, the American College of Cardiology writes: “Five major North American and European guidelines on statin use in primary prevention have been published since 2013. Guidance on use in the growing elderly population (age >65 years) differs markedly…The main goal of primary prevention with statins is to achieve net-benefit from treatment. Potential harm(s) is a crucial part of appropriate decision making. As frailty, comorbidity, and polypharmacy may increase the risk for adverse statin-associated symptoms, the “risk-benefit” balance in the elderly could theoretically tip in favor of withholding statin therapy if such conditions are present.” So much for following guidelines there.

Another striking example of how crazy this system is:

A doctor sees a patient with bronchitis. Guidelines discourage antibiotics. That is a Quality indicator. On the way out of the office, empty handed, so to speak, with no antibiotic but a lengthy diatribe about the uselessness of antibiotics and the looming threat of multi resistant superbugs, the patient is asked to rate his physician. Such ratings are an increasingly large part of provider evaluations and even compensation formulas. Will that patient give the doctor a favorable rating?

This what I do: Some patients, like those with chronic lung disease, get antibiotics right away. Others get a thorough explanation of why I’m not prescribing them. And a few get a “backup prescription”: “If this, this or this happens, fill it”.

Guidelines and doctor ratings shouldn’t tie our hands. We are the professionals here. We must apply our knowledge to every clinical situation we encounter. In some cases, the people who dangle guidelines or popularity ratings over our heads are simply being ignorant bullies.