Sunday, April 20, 2014

Can We Survive an Epidemic of Corporate Wellness?

I’m a physician and I’m against wellness.  Let me explain.

Wellness is the new health mantra that has much more to do with marketing than with evidence-based medicine.  Wellness institutions and practitioners are omnipresent promising benefits that are often untested or rejected scientifically.   Hospitals that years ago would have shunned new age healing arts, now offer yoga, meditation, Reiki and massotherapy.  Do they do so because they have had a Damascus Road experience and now believe that these techniques are effective?  Guess again.

Ahead of His Wellness Time?
100 Years Ago Metchnikoff Suggests Probiotics 

Wellness is no longer restricted to medical campuses, costly weekend retreats for emotional and physical catharses and ubiquitous yoga storefronts.  Wellness is now championed by corporate America.   Business leaders argue that keeping employees well is not only a demonstration of good corporate citizenship, but is also good business.   Healthy employees, they claim, will reduce health care costs.  I agree, but not for the reasons they offer.

Their premise that wellness program participants will use fewer medical resources sounds rational, but it may not be true, despite claims from human resource professionals who want to justify these programs.  Here’s the argument.  “If we lower employees’ blood pressure, bring their weight down and control their diabetes better, than these folks will avoid heart attacks, strokes and surgeries which will save mega bucks and improve productivity.”  

Sure it sounds right, but is it really true?  Shouldn’t corporations that know the cost of every paper clip be able to prove that this strategy is sound?   Just earlier this year, a major study on obesity published in the prestigious Journal of the American Medical Association concluded that overweight individuals live longer.  My point?  Just because something sounds like it should be true, doesn’t make it so. 

Many companies are now coercing employees with financial rewards and penalties depending upon their success and enthusiasm in participating in company wellness programs.  If you don’t make their health grade, then the employee will lose serious cash, which may be far in excess of actual medical costs incurred.  In other words, an unstated motivating factor here may be simply to get employees pay more health care costs.

Indeed, two studies published earlier this year in Health Affairs, a peer-reviewed journal, strongly suggested that corporate wellness programs save company money simply by cost-shifting to employees.  Is this what is meant by corporate ‘wellness’?

The Cleveland Plain Dealer (PD) reported on April 20th that CVS Caremark is requiring employees to participate in its wellness program by May 1st or they will have to fork over $600 more for health care next year.  Do we really know that non-participants would drain the company’s coffers?   Realize that many employees change jobs every few years, and that adverse health effects of being obese or having elevated blood pressure may take decades to develop.   A CVS worker with a pair of love handles or modest hypertension, isn’t likely to consume more medical resources in the short term.  Yet, he would be docked on day 1 next year.  Does this policy pass the fair and reasonable test?

The PD article quotes CVS as claiming that their policy is “the most effective way to encourage our colleagues to take control of their own health…”  This statement breaks the needle on the hypocrisy meter.  The gall that CVS wants to serve as a health guardian, or should I say health police, while it sells cigarettes, alcohol, junk food and the sugary beverages that New York City Mayor Michael Bloomberg has outlawed for health reasons.  This is chutzpah of the first order.
If CVS wants to adopt a sincere health mission, then let them get rid of their Camels, Marlboros and Lucky Strikes.  Otherwise, their flimsy argument goes right up in smoke. 

If a company truly believes that wellness is right for workers and business, then create a corporate culture that encourages this and provide leadership.   If it’s really as good an idea as they say, then folks over time will be persuaded to do join in.   Leave the financial rewards and penalties off the field. 

I’m not a wellness antagonist.   I support any activity that is safe and makes people feel better.  But making folks pay-to-play in the wellness game, doesn’t make me feel good.  Perhaps, I need to meditate more on this.  

First published in Crain's Cleveland Business, May 13, 2013

Sunday, April 13, 2014

Sued for Medical Malpractice - Again

Folks who have wandered through the Legal Quality category of this blog understand my views on our perverted and unfair medical malpractice system.  I've been in the arena many times, and always walked away unharmed.   If this system were presented in front of a fair minded and impartial jury, it would be dismantled.  Sure, there are positive elements present, but they are dwarfed and suffocated by the drawbacks. The self-serving arguments supporting the current system are far outweighed by the financial and emotional costs that innocent physicians unfairly bear.  Tort reform should not be controversial. 

You may wish to peruse a few of my medical malpractice posts before spewing forth vitriol in the comments section.

Beyond the medical arena, who wants to defend the crushing volume of litigation in the United States?   Let me be bold.  I think we have too much litigation and fear of litigation in this country.  Put that item up for a vote anywhere in the country except at an American Bar Association convention, and you don’t need to be a soothsayer to predict the outcome.  You just need to be breathing.

About two years ago, I was sued months after the death of a patient for whom I provided appropriate care.  Being sued is not a lonely process.  I was among many defendants, including several doctors, a hospital and other corporate entities. 

I reviewed the medical record and reached two conclusions:

    (1)    My care was appropriate and proper
    (2)    The record documented the above.

In the medical malpractice arena, it is much more important what has been documented than what has been done.  Meditate on this statement for a few moments.

The complaint against me didn’t offer a single specific allegation of a breach of my care.   Instead, there was a general statement, which used against every defendant, that we were negligent.  My attorney also could not divine from the complaint an actual allegation against me.   Isn’t there an obligation to state to the accused what the alleged negligence is?

In Ohio, a physician not involved with the case must sign an affidavit of merit swearing that there is a reasonable basis that malpractice occurred before a case can go forward.  While this sounds like a filter, it functions as a sieve.  Shockingly, this single physician swore that every physician deserved to be sued.  I suspect that if a hamster were sued, that this doctor would have put the little varmint in the dock also.
Many of these physician ‘experts’ earn a substantial portion of their incomes by serving trial attorneys.  Anyone spot a conflict of interest here?

The case was dropped against everyone, presumably as the plaintiff’s attorney couldn’t find real experts to support the claims of negligence. 

I thought I was in the clear until the case was refiled a few months ago.   My attorney petitioned the court to dismiss me as the physician who signed the affidavit of merit was not in my specialty.  The court agreed.  For all I know, this doctor may have been a psychiatrist.

What a system.  Consider that I’m only one defendant who was drawn into the legal labyrinth.  My malpractice carrier informed me it cost $11,750.22 to defend me, and my case never even reached the discovery phase.  How's that for money well spent?

I wonder what the financial costs are from all of the unnecessary litigation that our country endures in a year.  Probably, enough to truly reform the health care system.  Hey, this gives me an idea…

Sunday, April 6, 2014

Hospital Medicine Threatens Quality of Care with Communication Lapses

To those brave souls who have returned after digesting last week’s cheerleading on hospitalists, here is the Achilles’s heel of the system.  While the advantages are clear and substantial, there are serious vulnerabilities which have not yet been adequately remedied. 

Achilles Held by the Heel Being Dipped into the River Styx
  • Hospitalists cannot appreciate the medical nuances, personality, family dynamics, life events and prior experiences that may be well known by the out-patient physician.   
  • There are serious communication lapses, all of which cannot be bridged.  The out-patient doc may know that the patient’s chest pain is his typical anxiety and that it is not necessary to repeat the cardiac evaluation that was done 2 years ago.  The hospitalist may take a different tack here. 
  • Despite their best efforts, hospitalists know that they will not be seeing the patients after discharge.  As they are not permanently vested,  they may not address certain patient concerns, punting these  to the outpatient arena.  While this may be medically acceptable, it may be frustrating for some patients.
  • The hand off back to the out-patient doc after hospital discharge can be a minefield.   Patients may be on new medications.   They may have had a variety of laboratory and radiology tests.  Some of these results might be ‘pending’ at the time of discharge.   How does the out-patient physician reliably receive these results and understand their context?   Did medical specialists on the case leave recommendations that the primary physician now has to track and implement?   When the primary care doctor resumes care of a patient who had a complex hospitalization, is he now responsible to search out and address every loose end contained within the voluminous hospital record?   Could a single laboratory abnormality buried in the record that was totally unrelated to the medical illness become a medico-legal issue years later?  Do we really think that the hospitalists discharge summary to the primary care physician is airtight? 
A primary care physician recently complained to me that the local hospitalists never call him when his patient is admitted when he might provide useful information about his patient that only he know.   This is a legitimate gripe.

No system is perfect
So, over the past 2 weeks you have been offered a fair and balanced presentation on hospital medicine.   Which side of the issue has the better argument?

Sunday, March 30, 2014

Hospitalists Improve Quality of Care

Hospitalists are now firmly planted in the medical landscape.  These doctors have no office practices and earn their living exclusively by managing hospitalized patients.  These guys and gals are either hospital employees or are private groups who are under contract by hospitals.  The market and the profession were hungry for this new specialty, which has exploded across the country.   The advantages to patients and to practicing physicians are enormous.  Are there drawbacks?  Of course, but you’ll have to wait a week to read about them.

Hospitalists Pro or Con?  Which side has more weight?

When these hospital physicians first appeared on the hospital scene, there was buzz that patients would push back against these stranger-docs wanting their own office doctors to attend to them instead.   This never materialized.    Patients no longer had the expectation that their own doc would be available to them 7 days a week.  Indeed, medical physician groups and institutions had on-call rosters such that it was likely that the doctor available was not the patient’s actual physician.  So, the heavy lifting had already been done.
Once patients and their families recognized the high quality of care that hospitalists provide, whatever doubts that may have existed evaporated.

Here’s the upside.
  • Hospitalists provide superior hospital care because of their training and experience.   It is probably true that a physician who treats 75 heart attack patients each year is more skilled at doing so than is a family doctor who does this quarterly.  In general, higher volume translates to higher quality.
  • Hospitalists are there around the clock.  They are available to check on patients throughout the day and night.  Can anyone argue that this is not superior to the prior system of the attending physician seeing the patient once daily?  Go ahead.   Make your case.
  • Hospitalists allow primary care physicians to stay clear of the hospital so they can focus on their out-patient practices, where their skills are better matched.   Additionally, it is very inefficient for a primary care physician to come each day to the hospital to see a patient or two.  For these reasons, the vast majority of primary care physicians refer their hospitalized patients to hospitalists for care and treatment.
  • Internists enjoy a higher quality of life as they no longer have to stagger in at 3 a.m. to admit one of their patients.
Next week, I’ll offer my view of the downside of hospital medicine.  Yes, I know the suspense is killing you.  I can only hope that if I write it, that you will come.

Sunday, March 23, 2014

Alternative and Complementary Medicine, Placebo Effect or Panacea?

Readers know that I am skeptical over the efficacy of complementary and alternative medicine.  This is not merely a demonstration of my inborn skepticism, but doubt based on the fact the so much of their claims are untested, unproven or refuted.

I don’t regard the above comment as controversial.  It is factual.   I’ll let readers decide if it is but another example of the arrogance of conventional physicians who worship on the altar of evidence based medicine. 
Recently, I read a column in The New York Times by a university professor who was treated for a cold in China by drinking fresh turtle blood laced with grain alcohol.  In a day or two, he felt better.  Cause and effect?

 It’s not easy to talk someone out of a view that a pseudoscientific remedy healed them.  Why should we do so?   If a patient tells me that his fatigue has finally lifted after giving up guacamole, do I serve him or the profession by pointing out the absence of any scientific basis for his renewed energy level?   Or, is the better response for me to celebrate his progress and urge him to continue his ‘treatment’ which clearly poses no health risk?

Guac anyone?

Certainly, if I felt a patient was pursuing an alternative medical treatment, or any remedy, that threatened his health, I would plainly state this so the patient was making an informed choice.  If a patient was suffering from a bleeding ulcer, and wanted only herbal medicines, I would make sure that the risks of this choice were well understood.

I need to make a confession here.   Physicians face a huge knowledge vacuum with regard to the human body which is the product of millions of years of natural selection.  We are no match for comprehending its nuances and complexity.  Taking care of patients is a hugely humbling experience.  Consider how microscopic germs, organisms that are not sentient and have no brains, can wipe out millions of humans.   We should acknowledge that we’re not that smart.

There’s another possibility to be considered when a patient relates the success of remedy that we don’t support or understand.  It might actually be working.

Have you been tired lately?  Fatigued?   How much guac have you had lately?  

Sunday, March 16, 2014

Quiz on CAT Scan Ownership, EMR, Defensive Medicine and Obamacare

From time to time, the Whistleblower will offer readers a quiz.  Physicians, similar to other professionals, have taken scores of standardized tests over the years.  Most physicians are skilled at these exercises which, in my view, are a poor measurements of skills necessary for becoming a capable and caring physician.  Yet, as we have learned from pay-for-performance and other ‘quality’ initiatives, we measure what can be easily measured even if it doesn’t really count. 

The Kirsch progeny have been exposed to well over 100 quizzes during their formative years, when they competed for valuable prizes at the dinner table.  As we know at carnivals and county fairs, everyone wants to win that Teddy bear, no matter how much it costs to win it.   It’s the victory, not the prize.

1902 Washington Post Cartoon with Teddy Bear and TR

True or False?

A physician who owns a CAT scan machine is more likely to order scans than would another physician who does not own a scanner on an equivalent population of patients.

True or False?

Electronic Medical Records helps to cultivate the doctor-patient relationship by facilitating eye contact and reading body language.

True or False?

Defensive medicine improves medical quality as these additional diagnostic tests give an extra margin of safety that a serious condition will not be missed.

True or False?

The Patient Protection and Affordable Care Act, aka Obamacare, should be zealously supported as it will provide every American with high quality and affordable health care.

Ok, so these questions were ‘gimmee’s.   Future quizzes will be tougher and are likely to include multiple choice questions.   Prize donations welcome.

Sunday, March 9, 2014

Can Private Practice Survive?

Just read another article forecasting the demise of private practice, which is the model I practice in.  We certainly feel the squeeze here in Cleveland, where our small gastroenterology (GI) practice is suffering from some breathlessness as surrounding health care institutions suck up oxygen in the community.

Now, being deprived of oxygen isn’t necessarily fatal.  Many patients suffer from diseases that result in low oxygen levels in their blood.  Folks who live at high altitudes don’t have the same concentration of oxygen available as do those who reside at sea level.  Yet, they live active lives.

How do these folks survive?  Do they have lessons for my GI practice?

Take a Deep Breath...

Here are some options that help individuals with low oxygen levels breathe easier.
  • Receive supplemental oxygen using an oxygen tank.  No analogous solution for my medical practice here.  For us, the ‘oxygen level’ can’t be artificially increased.
  • Reduce activity level to minimize oxygen requirement.  This is why folks with respiratory conditions tend to remain sedentary so they can function at a lower oxygen level.  Not sure if there’s a lesson here for our practice.  Do we move more slowly in the office?  Do we see fewer patients?  If we doctors used oxygen tanks, would this inject more vitality into the practice?
  • Attack the root cause of the oxygen assault.  If the cause of a patient’s low oxygen is pneumonia, then prescribe the right antibiotic to reverse the injury.  If the doctors in our practice attacked the proximate cause of our oxygen deprivation, we could go to jail. 
  • Train at a high altitude locale for athletic competition in the lowlands.  Marathoners seek out high altitude training courses to build endurance in preparation for the big race down below.  Perhaps, we should move our practice to high altitude Colorado for a year.  After doing colonoscopies there for a year, imagine the increase in our performance when we returned to Cleveland?  I will place this on the agenda of our upcoming practice meeting. 

Great choices for us.  Breathe less, do less or move.

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