Random Thoughts from a Restless Mind

Dr. Darrell White's Personal Blog

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Posts Tagged ‘medicine’

Better Understanding Conflict of Interest By Studying Bias

So much strum und drang in the air. So many panties in a bunch. The offensitive are on the warpath about, well, everything. We seem to have a surfeit of ethicists among us, proclaiming in nearly real time where anything and everything fits on some mythical ethics grid. To them I offer my own filter, the question I ask before I expend an iota of energy of any kind on the type of “news” that has them all so agitated:

Is what I am viewing unethical, or simply unseemly?

Ethics is a synonym for morals. As such it should be universal and timeless. Ethics should bear nothing in common with fashion.

Speaking of which, it is fashionable in pretty much any field in which expertise can be obtained and the label “expert” attained to lay waste to those so acclaimed by accusing them of having a “conflict of interest”. Traditionally this meant that one might enjoy some sort of tangible gain by trafficking in one’s area of expertise, thereby rendering the expert’s stated opinions somehow tainted. Of late it means that being employed by someone with whom your critic has a beef means your standing to hold an opinion at all is nullified.

Nonsense.

We would be a wiser society if we instead made an effort to sort through the biases held by experts in any field. To demand that one not express any opinion that would support your employ should disqualify the individual who holds such a position, not the expert. To look at the bias that may be present in any expert opinion allows the audience to better evaluate both the veracity of the opinion, as well as its relevance to their own situation. For example, in my day job I have a strong bias to treat any condition that produces meaningful symptoms in my patients.

In truth, in many of the general categories that I cover my remuneration is identical whether or not I treat. Those who bleat on about conflict of interest would seek to nullify all of my thoughts simply because I make my living in the arena on which I opine. Again, this is silly. It is far more useful to read my professional writing through the prism of my pro-treatment bias. In so doing it is far easier to compare and contrast my public opinions with others in my space who may differ. Do they differ on substance, or do they differ because or a countervailing bias?

This is not to say that conflicts of interest do not exist, or that if they do exist that they are never a problem. If you have invented a medical device and choose to use your own device rather than a competitor’s you have a COI. Disclosure of your COI should be mandatory (I disclose all consulting contracts around prescription drugs, for example). If they are of equal quality (equal safety, equivalent outcomes), the COI is mooted. If your device is much more expensive (thereby generating much more income to you), your conflict of interest is unseemly but not necessarily unethical. It should be obvious on its face that using your invention if it is less effective (or Heaven forbid, unsafe) is unethical.

Expertise exists everywhere. Here, on CrossFit.com in the fitness world. Would you disqualify Greg Glassman because CrossFit has been a successful business? How about Jeff and Mikki Martin who have launched a business in the same space? Is their competition a conflict that nullifies their contributions to youth fitness? Among the bureaucrats at the EPA in the care of the environment. Do they not have a contribution to make despite their tax-supported position? Is their (presumed) anti-business bias a reason to dismiss all federal policy? Among the various and sundry talking heads on all of the financial offerings on cable news channels. Don’t you really want them to be rich and successful, especially if you are going to follow their advice?

If we seek to understand the biases that exist underneath the opinions of experts we can better evaluate the conflicts of interest that they inevitably carry along with those opinions. From there is is an easier task to evaluate the character of those conflicts, and better decide whether or not we accept their guidance.

Getting paid to be an expert and to share your expertise is only a meaningful conflict of interest if it is unseemly or unethical, not just unfashionable.

 

Why Private Practice Survives

“I’m surprised these kind of places are still open.” –Physician employed by World Class Medical Center

“And yet, here you are, bringing your mother in for a visit.” Technician checking in mother.

In my day job I am an ophthalmologist, an eye doctor who takes care of medical and surgical diseases of the eye. Our practice, SkyVision Centers, is an independent practice, what is often referred to as a “private practice”. As such we are neither connected nor beholden to either of the large organizations here in Cleveland, both of which have large ophthalmology practices with offices near us. The mother in question was originally seen on a Sunday in my office through an ER call for a relatively minor (but admittedly irritating) problem that had been ongoing for at least a week.

That is not a typo; an ophthalmologist saw a non-acute problem on a Sunday.

Now Dr. Daughter swears that she tried to get her Mom in to see a doctor all the previous week. “She” even called our office (more in a moment) and was told all of the doctors were booked. Strictly speaking, the staff member who answered the phone was absolutely correct in noting that our schedules were full (actually they were quite over-booked in the pre-Holiday rush), and that we would not be able to see a patient who had never been to our office. Dr. Daughter works for a massive health system that advertises all over town–on billboards, in print, on the radio and online–that anyone can get a same-day appointment with any kind of doctor in the system, including an eye doctor. In fact, we saw several dozen existing patients that week for same-day requested ER or urgent visits with the urgency determined by the patient, not our triage staff.

What’s my point? Dr. Daughter never made a single phone call. She had one of her staff members call on behalf of her mother; neither I nor my staff is responsive to proxy calls from staff. I know Dr. Daughter and much of her extended family. Over 25 years practicing in the same geographic area and populating the same physician panels she has sent me barely a handful of patients, even though I care for a substantial majority of that extended family. Despite that my staff would have moved Heaven and earth to find a spot for Mrs. Mom if Dr. Daughter had called either my office or me personally.

I know what you’re thinking: Mrs. Mom would get in because her daughter is a doctor. Nope. Not the case. I may have taken Dr. Daughter’s phone call for that reason, sure, but Mrs. Mom gets an on-demand ER visit despite it being our busiest time of the year because she is the family member of other existing patients. We treat family members as if they are already SkyVision patients; we just haven’t officially met them yet.

Now you’re thinking “what does this have to do with private practice?” Without meaning to be either too snarky or self-congratulatory, this is precisely why private practice continues to not only survive, but in many cases thrive. We have the privilege of putting our patients first. Really doing it. Same day urgent visits? No need to put it up on a billboard; we just answer the phone and say ‘yes’. Lest you think we are simply filling empty slots, or that we have open ER slots we leave in the schedule just in case, let me assure you that this couldn’t be further from the truth. We. Are. Booked.

Well, it must be that we are so small that the personal touch is easy. Surely if we were huge we couldn’t get away with this. Sorry, wrong again. A bunch of my buddies are orthopedic surgeons in a massive private group on our side of town. Like 15 docs massive, with all of the staff you’d expect to go along with that many doctors. Got an orthopedic emergency? You’re in. You may not get the exact doctor you’ve seen before on that first visit, but you won’t be shunted to either an ER or an office an hour away, either. The staff members making appointments for a particular office are right there, sitting up front. The same goes for the enormous Retina practice that spans 4 counties here in Northeast Ohio. Ditto for the tiny little 3-man primary care practice up the street from me, lest you think only specialists do this.

The private practice of medicine survives because the doctors go to work for their patients, and they don’t leave until the work is done. Private practice docs bend their own rules on behalf of those patients. Every day and every night. You know what happens when private practices are acquired by massive medical groups like the two 800 lb. gorillas in Cleveland? All of those rules get made by people who don’t really take care of patients at all, and they never bend a single rule ever. Those former private practice doctors become shift workers beholden to an institution, no longer working for their patients at all.

That family doctor or specialist who was routinely asked on a daily basis if someone could be squeezed in is not only no longer asked, she doesn’t even know the question was there in the first place. Everything is handled by the institution’s call center, somewhere off in a lower rent district, with no sense of what is happening at that moment in the clinic. Your doctor might have a cancellation and a spot open to see your emergency. Indeed, if she’s been your doctor for a long time she would probably rather see you herself because that would make for better care.  But there are now someone else’s rules to follow, efficiencies to achieve so that they can be touted, and institutional numbers to hit.

“I’m surprised these kind of places are still open.”

“And yet, here you are, bringing your mother in for a visit.”

On her way out, after impatiently waiting while her mother thanked me profusely for seeing her when she was uncomfortable, Dr. Daughter extolled the virtues of her employer. Fixed hours. Minimal to no evening or weekend call duty. A magnificent pension plan that vests rather quickly. I should join up, she said. She was sure that World Class Medical Center would love to have me.

I smiled and wished her, her Mom, and the extended family a Happy Holiday Season. As I turned, shaking my head a bit, my technician put her hand on my arm.

“If you did that, who would take care of her Mom?”

Equal Pay for Equal Work: Medicine is the Perfect Laboratory

The endless debates about the “Pay Gap” between men and women in the United States drones on. Today is “Equal Pay Day”, kinda like “Tax Day”, the day when you stop paying the government and instead start paying yourself, only it’s the day when the “average” woman supposedly has to wait for before she starts to make what a man makes. It all makes for great spectacle and epic barstool arguments for the same reason that people argue about who’s greater, Michael or Elgin, Kareem or Russell, The Babe or Barry: there is no proper, standard way to measure the issue at hand. On a barstool arguing “greatest ever” you never agree on either the definition of “greatest”, nor can you account for the vast differences in historical eras.

So it is with the pay gap. No one agrees on what constitutes work, let alone equal work.

This creates the maddening situation in which we find ourselves now whenever this comes up for discussion. Absent a meaningful definition of either “work” or “equal” we are left with folks on all possible sides of the issue simply choosing whatever statistic will support their deeply held beliefs about the issue. It’s crazy, actually. I read a dozen citations today and each one was so deeply flawed that it couldn’t stand the scrutiny of the middle if you velcroed it to the  50 yard line. Work is invariably conflated with “hours worked” with no discernible effort made to investigate something like intensity, or the measurable work performed per unit of time. “Equal” work is just a quagmire of competing opinions with, again, no effort whatsoever at objective measurement. How can you have a discussion that is meant to conclude with some sort of actionable agreement when all you do is pull numbers out of the ether and throw them at each other?

While engaging in a sorta, kinda conversation about this on Twitter it struck me that I actually live and work in the perfect laboratory to investigate the issue of the Pay Gap between men and women. You see, we have reams of objective data that can be evaluated. We all, men and women, do exactly the same things if we have the same jobs. Not only that but we have a unit of measurement for that work, the RVU. If Dr. Darrell does a cataract surgery and Dr. Dora does a cataract surgery, we have both done the same job. We can even determine the “intensity” of our work, our output if you will. A simple survey of hours worked per day can generate the metric: RVU/hour. Better yet, don’t take my word for it in a survey, just look at that heretofore meaningless and useless EMR and look at the measured time Darrell and Dora took to do their work. The OR record is a precise measurement of how much work we did per unit of time.

This is powerful stuff. Work is defined. An appendectomy is an appendectomy. A Level 4 New Patient Office Encounter is a Level 4…you get the idea. You get to compare apples to apples, heck, you get to compare Honeycrisp apples to Honeycrisp apples. It doesn’t matter if you are a man or woman or transgender. White, Black, Brown, Yellow, Red (did I miss anyone?), Millennial, Boomer and everything in between, work is work and an RVU is an RVU. Heck, you could gather all of the information about the work without anyone knowing who did it until after it’s all together. We could have a big unveiling when we lift the blinders and see who did what and how much they did. Seriously, how cool is this? It would almost be like science.

Let’s do be a bit serious for a moment. Imagine what kind of information we could acquire and what kinds of questions we could ask and answer. For sure there will be very reasonable concerns about how much we will be able to extrapolate from medicine to other areas of employment (advertising, investment banking, etc.), but it’s a great place to start. The question of the Gender Gap is primary, but how about looking at work across the generations. There is a “feeling” in medicine, certainly among crusty old folks in my generation, that younger physicians of both genders work fewer hours and do less work per hour when they do work. Is that true? It sure looks like it would be easy to answer that one, too.

There are actually a number of other issues in medicine that would be clarified if we had this kind of data, at least insofar as the work done is concerned. For example, how do private practitioners stack up against salaried physicians in large groups? Is there a correlation between how those salaries are determined and the intensity of work done? We can also look at value, work done per dollar paid (again, assuming equal outcomes). Where are we getting the best bang for our buck? For that matter, with the EMR’s that never sleep we can actually look at the responsiveness of doctors to their patients in urgent or emergent circumstances. Is there one group (men vs. women, private practice vs. employed) who are more responsive?

Having a discussion that is based on hard definitions of terms and data-driven rather than belief-driven opens up a whole world of meaningful inquiry.

Once upon a time I was among the highest paid physicians in the U.S. I worked insane hours, and the intensity of my hourly output was off the charts. In a word, I earned every penny I made, and the fact that I made more than another ophthalmologist had nothing to do with the fact that I was a man. Funny thing though–I now make a fraction of what I once made because I don’t work as much as I once did. The intensity of my work is similar; I still do as much work per unit of time, and my ability to perform at this high level of intensity is still greater than 95% of my peers, I just work fewer hours. What are we to say about women who do what I do, work more hours than I do, and yet do less work? Is there a gender gap in pay if I make more money than they do? What are we to say about my ambitious female colleagues who work more hours than I and work at the same intensity? I’m firmly stating that they should make more than I do. Is that the reality on the ground?

In medicine we have the ability to answer this question in a very objective, non-ideological way. I don’t know if what we find will be something we can extrapolate to other jobs, especially if we find that pay is directly related to actual work done in a domain where work can be both defined and measured. But hey, it’s a start. And it’s way better than just playing emotional whack-a-mole with how we value what we all do.

 

Measuring Health Part 4: Fitness ‘F’

Health should be defined along the lines of individual human potential. An actionable definition would go something like “the ability to live at the limits of your fullest potential without any encumbrance now or in a foreseeable future”. Fitness as defined by Greg Glassman and CrossFit–work capacity across broad time and modal domains–should therefore be seen as “applied health”. As such, since fitness at any given time is an accurate measurement of one’s functional ability, our variable ‘F’ should have the heaviest weighting in our Health Index.

Let us begin our discussion of Fitness by reviewing and dispelling several myths and misconceptions about the interrelation between health and fitness. First, is it really necessary to review all of the date which now stares us in the face as far as the importance of exercise in health? By the same token, it should be clear to any sentient being that not only is what we eat important (although we must concede that this may differ across populations) but how much?  Simple carbohydrates, manufactured substances meant to cheaply replace real food, harmful (trans-) fats–it doesn’t matter what KIND of nutrition plan you follow, these are all BAD. As I write this I am recovering from surgery and I am not able to exercise. Does anyone believe that I will NOT gain useless weight if I maintain my pre-operative food intake? This part isn’t rocket science, folks. Coach Glassman says it as well as anyone: “Eat [protein] and vegetables, nuts and seeds, some fruit, little starch, and no sugar. Keep intake to levels that will support exercise but not body fat.”

Next up is the canard that fitness is simply being able to do something for a very long time. This view, promulgated and propagated by the likes of Outside Magazine and others, is not only insufficient but has been shown to be false as well. In the last couple of years there have been a number of very important studies showing a degradation of heart function in so-called “Ultra” athletes in any area. Decreased cardiac output and an increase in cardiac arrhythmias such as atrial fibrillation have been shown to be caused by excess endurance training. Endurance as the sole defining characteristic of fitness is as incomplete as would be strength. One need only look at the life expectancy of the strongest humans on record to see that strength in and of itself is not sufficient to produce health.

The question of what constitutes fitness is one that has been answered, at least insofar as health is concerned. It is not enough to be able to run or bike or swim long distances if you cannot also lift heavy things, including your own body. In the same vein one is not truly fit if one can deadlift or squat 3X his or her own bodyweight but cannot run a mile in under 15:00. One must have some measure of BOTH. As such the inescapable conclusion is that Greg Glassman is correct when he says that fitness equals work capacity across broad time and modal domains. You must be able to lift heavy things over a short distance when necessary, but also possess the ability to carry lighter things a longer way for a longer time as well. While I am not naive enough to expect that this will be accepted without spirited debate, when it comes to any measurements of health now available, all arguments to the contrary are not supportable. Glassman has won this battle.

As an aside, this should once and for all put to rest the myth of the “healthy obese”. What good is it to be happy, ‘W’ off the charts, with a stratospheric ‘M’ because all of your bloodwork is perfect, to go with your BP of 120/70, if your joints will cave under pressure decades sooner than they need to? You simply cannot escape the reality that health requires physical fitness.

If fitness can be described as “applied health”, it stands to reason that it will have the greatest contribution to our eventual Health Index. As such it is especially important that our chosen tests meet the criteria outlined in Part 1, that the measurement be as broadly accessible in all ways as possible. In the purest sense we would be able to measure an individual’s “work capacity”, the totality of his or her expression of fitness as measured by many tests covering different loads, distances traveled, and time. In CrossFit we talk of this as the “area under the curve” of a graph that records Power (lbs-ft. per second) on the X axis and Time (in minutes) on the Y. In a perfect world this would be part of every individuals ongoing pursuit of health, but alas, even in the CrossFit world where a very committed everyone records everything, this has proven to be problematic. In designing a series of tests to be applied to the broadest possible swath of humanity this ideal must yield to a more pragmatic approach.

What, then, should we measure, and how? Let us first propose a couple of general characteristics of the tasks in our test and then see what fits the bill. We should test an individual’s ability to move from one place to another under their own power–running is a fundamental human trait and should be part of our evaluation. Likewise, the ability to pick something up off the ground is a pretty basic, everyday movement and would qualify as our test of strength. Lastly, in the U.S. we have a storied heritage from the 1960′s, The Presidential Council Fitness Challenge (PCFC), in which candidates are tested on their ability to perform calisthenic exercises for both speed and endurance. It would be fitting to include something that evokes this historical element.

Once again I anticipate a vigorous debate about the particular elements we include. I’ll go first. We can reward both speed and endurance by starting with a timed run in which the result is distance traveled. The most common example of this comes from athletic programs and the military: a 12:00 timed run for distance. We live in the U.S.; the unit is yards. Pick up something heavy? Sure sounds like a deadlift to me. Any deadlift you wish, standard or sumo, will do. My bias is that a lifting belt is just fine, but except in very special circumstances (e.g. one-armed subject) I would say that straps to help you grip the bar are not a good idea, especially for the very inexperienced subject.

After giving considerable thought to the exercises and format in the original PCFC I think we should simplify the test while at the same time bringing it into the modern fitness world. In the PCFC one sought a maximum number of reps in 2:00 of pull-ups, 2:00 of sit-ups, and 2:00 of push-ups. What exactly are we testing with sit-ups that reflects true fitness? I would favor swapping out sit-ups for air squats. With a nod to CrossFit and Greg Glassman’s outsized contributions to this discussion, let’s use the format made famous by the CrossFit WOD “Cindy” with a small adjustment. To test our subject’s ability to perform bodyweight movements and move quickly, repeats of the triplet of 5 pull-ups, 10 push-ups, and 15 air squats in 6:00, counting as our result the total number of repitions achieved.

There you have it. A definition of “Health” and “Healthy”. The introduction of the three variables that go into the measurement of “Health”: traditional medical values ‘M’, emotional well-being ‘W’, and Fitness ‘F’. Next I will address how we will value each of these measures, and then ultimately how they will be combined to give us a meaningful, actionable health measurement ‘H’.

 

Measuring Health Part 2:The Traditional Metric ‘M’

Any measurement of health must provide some sort of predictive value with regard to the likelihood that one will remain healthy. While the entire idea of screening tests is fraught with controversy–both false positives and false negatives bring with them real risks–there are still a number of health measurements in the realm of traditional medical care that have a proven value when trying to predict downstream adverse health events. The trick, of course, is to decide which ones matter, filter that group to come up with tests that are as close to universally available as possible, and then decide how much weight each particular test in the group of survivors should receive in the single cumulative metric that is then created. This measurement, call it “M”, will be one of the variables in our calculated health measurement.

Let’s start with the simplest of all medical inquiries, a medical history. More specifically, let’s include a brief family history in our calculation of M. While it is becoming increasingly easy to obtain a very accurate genetic profile that identifies very specific health risks, these genetic tests are both controversial and expensive. Until the very real societal issues of knowing your exact genome and the risks it includes have been worked out by both ethicists and elected government, we should take a simpler and more narrow approach and ask two very simple questions: Has anyone in your family died from heart disease? Has anyone in your family died from cancer? Equally simple follow-up questions (How young were they? What kind of cancer) would allow us to add risk (reduce M) or ignore the historical note since the disease is not hereditary.

From here we move to an equally spartan individual medical history. Again, just two questions in this part: Do you smoke? Do you drink alcohol? The negative effect of smoking on an individual’s health, both in the present and future tense, must be accounted for in any measurement of health. It weighs so heavily on what we know about future risks that we will see it as a negative integer in M. Too many studies to count exist pointing out the deleterious effect of excess alcohol consumption to count. One compelling study, The Eight Americas Study in PloS One, found alcoholism to be the single most powerful lifestyle variant after smoking when predicting the life expectancy of groups studied. A recently published study of Harvard men found that alcoholism was the greatest second greatest influence on the happiness of the men studied, just behind the presence of loving friendships. Unlike smoking, however, there is a volume component to alcohol consumption. Indeed, a modest intake actually INCREASES longevity, while no intake DECREASES longevity. So M will see a small bump from moderated alcohol intake, an equally small decrease for teetotalers, and a dramatic negative effect from heavy alcohol intake.

So far we’ve managed to obtain some variables underlying M through the use of simple inquiry, costing only the time it takes a subject to fill out a questionnaire. At least two other variables are as accessible and inexpensive: blood pressure (BP) and a measurement of body habits. Once upon a time you had to visit a doctor or hospital to get your blood pressure checked. Now? Heck, for $20 you can buy a reasonable accurate BP monitor and take your BP at home! Minute Clinics in pharmacies, health clinics in the workplace, and coin-operated machines in the local Mall now make it easy to get a BP without visiting a doctor. While there is ongoing controversy in the medical world about what constitutes Hypertension it is safe to say that health risks are higher with a systolic pressure >140 and a diastolic >90. Above or below these levels is our toggle for M, positive or more healthy for lower and the opposite for higher BP.

Using body habitus is controversial, mostly because the measurement that is routinely utilized is so inadequate. The Body Mass Index, or BMI, is wildly inaccurate when it is applied to the fit. 4-time winner of the CrossFit Games Rich Froning, arguably the fittest man on the planet, would be deemed obese at 5′ 10″ and roughly 195 pounds with a % body weight fat of around 4%. Ridiculous, huh? The temptation, of course, is to use % BW fat as the preferred method of measuring body composition risk, but measurements that are accurate enough to be useful tend to be very expensive and difficult to access. On the other hand, all you need to determine the waist/hip ratio is an 89 cent paper tape measure and a calculator. A waist/hip ratio of >1.0 is associated with an increased risk to health from myriad metabolic illnesses including diabetes and heart disease, especially in men. Greater health in M for measurements under 1.0, and progressively less as that number increases.

It is impossible to utilize all that modern medicine has to offer when it comes to measuring health without spending a little bit of money. Several simple blood tests can be obtained with or without the input of a physician. The presence or control of diabetes can be ascertained with a HbA1c and a fasting glucose level. In the presence of a normal HbA1c an elevated fasting glucose may indicate a problem with insulin sensitivity, so it is important to include both. While it is far from settled whether or not it is cholesterol itself which is responsible for heart disease there is simply too much evidence that serum lipids can help predict cardiac events to leave them out of any health measurement. Our basic health index should therefore include the basic measurement of total cholesterol, HDL, LDL, and triglycerides, and M should reflect the negative effect of elevated Total Cholesterol, LDL and triglycerides and the positive effect of a high HDL.

How should we put all of these together to come up with our traditional health variable, M? This one is fairly simple; there are a number of “risk factor” measurements online that are good models. I envision a rather simple form on which one would add up weighted values for the measurements above, arriving at a straight forward mathematical sum. The final formula is being developed with the assistance of cardiologists at my medical school alma mater, the University of Vermont.

 

How You Treat the People Who Serve You

In my day job I work in the ultimate customer service business, medicine. Ever listen to how people address folks on the providing side of the customer service continuum? Do you ever stop to listen to yourself, or think about how you will sound before you speak? Fascinating. In North America we are moving ever more swiftly to an economy that is majority a service economy; we don’t really make stuff so much anymore, we help people use stuff someone else made, or provide assistance based on a knowledge base or skill set. Listening to people on the receive side of the customer service equation is fascinating.

I’m prompted to this line of thought by three interactions at my day job, SkyVision. Three individuals not so much requesting a service but demanding it, doing so with a tone that implies not only a deep sense of entitlement but also a deeper lack of regard for the individual who will provide that service. Both in tone and content, the to-be-served make it clear to the service provider that he or she is there to serve only them. In fact, the server’s only reason to exist is to serve, as if the to-be-served were some kind of different, superior version of the species. It’s quite loathsome, actually.

I spend every waking moment of each working day on the “serve” side of the equation, whether I am at SkyVision plying my profession or CrossFit Bingo coaching. Having achieved some measure of expertise in both it’s very rare that I am on the receiving end of this type of behavior, but it does happen. More often is the case that it is someone lower on the org chart who gets this. The receptionist, phone operator, or check-out person who gets this “lower life-form” treatment, not the doctor or business owner.

Life can be hard for these front line people in a service business. There’s not only a “customer is always right” mentality on the other side of the interaction but also a sense that being a customer who will get what they want is as much a human right as Life or Liberty. That’s what it sounds like, anyway, if you are off to the side listening. No matter how frustrated one might become from a service situation gone wrong it’s important to remember that there is no continuum in the relationship when it comes to the inalienable rights, nor is there any evolutionary hierarchy across that desk or over that phone line. Being served if you are the customer is not a right at all, not even one up there with the pursuit of happiness. Server and served both have the right to life, liberty, etc.

In a funny little side note, the more effort I (and my partners and staff) make to be better at the whole customer service thing, the less tolerant I am when I am on the receiving end of poor customer service. Actually, I should be a bit more specific on this point: I am much less tolerant if I am being served by an organization that openly preens about its excellent customer care but won’t deliver. Heaven forbid if I detect a cynical lack of effort, either institutional or on a more personal level, when the expectations that I’ve been led to have are mis-met because of this. The harder we try and the better we get at providing an excellent customer experience at SkyVision the less likely I am to choke down indifferent service or a lack of effort when I’ve been lead to believe (and paid for) something extraordinary. The difference, though, is that I initially engage with the expectation that all I have to do is be polite and kind to those folks charged with taking care of me; my first shot across the bow is not to treat them like serfs.

Danny Meyer, the great NYC restauranteur, is probably closest to correct when he says “the customer is not right all of the time, but mostly right most of the time. A customer [only] has the right to be heard.” How you express yourself when you are on the “receive” side of the customer service experience is not only an important measurement of how you value the person across from you providing the service, but frankly is probably also a predictor for how likely you are to be successful in being heard. It’s instructive that none of the three SkyVision clients who made difficult (bordering on unreasonable) requests in an unpleasant manner were accommodated because doing so would have required an extraordinary effort which may not have been successful in any event. After being treated a some sort of sub-human primate, who would make such an effort?

Sorry, no pithy statement to wrap this up. In the end we all want what we want, and we all need to be heard. It helps to look at the person on the other end of the service divide as if you were looking in a mirror. Would you say that, like that, to the person in front of you then?

 

Conflict of Interest Mania

Sometimes someone says something so profound and says it so profoundly well it’s best to simply share what they said and get out of the way. This is one of those times. This gem appeared in the WSJ letters to the editor 7/10/15:

 

“The philosophic underpinning of the conflict-of-interest mania in medicine is the assumption that every physician is a spineless, deceitful, money-grubbing felon-to-be. The conflict-of-interest mafia stifles innovation and restricts creative thinking.

The New England Journal of Medicine would never have published the Hippocratic Oath if it ever found out that Mel, the local herb salesman on the Island of Kos, once bought Hippocrates a flagon of wine on a hot summer day.” –Leo A. Gordon M.D. Los Angeles

 

That, friends and colleagues, is brilliant.

 

 

 

Evidence Based Medicine? Preferred Practice Patterns? You Are Behind the Times

If you practice Evidence-Based Medicine (EBM), or religiously follow a Preferred Practice Pattern (PPF) such as one published in a white paper by a specialty society or organization, you and your patients can be assured of one very important fact: you are providing care that is neither up to date nor care that can be described as “Best Practices”.

You might be increasing the likelihood that your patient’s medical insurance will pay for their care, in part because insurance companies have already figured out how to make money on older treatments and protocols. I guess you can feel good about that, or at least feel good that your staff won’t be forced to fill out all of those appeals forms when state of the art care is denied. So you’ve got that going for you. What used to be considered good enough care might feel better to you if your patient isn’t avoiding the older treatment because of payment issues like they do with the newer. Adherence to some care is better than non-adherence to “Best Practices”, right?

There are certainly some of you out there in doctor land who think that citing EBM or fidelity to a PPP will inoculate you from medical malpractice tort. Sadly, nothing is further from the truth. Not only will your adversary nullify a PPP by citing a “Standard of Care” that is up to the minute when it comes to how to treat literally anything (though as we know “Standard of Care” is neither Best Practices nor EBM), but there are so many instances of EBM not allowed as evidence at trial that it’s nearly useless to try. Even the strongest body of research can be nullified at trial by introducing a single non-peer reviewed study with opposite findings to a naive jury of lay people.

EBM and PPP are the result of years of studies that were launched based on prevailing thoughts at that time. They are subject not only to what is fashionable among the medical intelligentsia, but also what is fundable. The potential ROI from the industry side of the medical pie has a direct impact on not only what is studied but what treatments are available at all. A company with a blockbuster drug that has years of patent protection remaining will be unlikely to support the study and use of its own competitor or successor until under the gun of generic competition. Governmental funding of maladies without either a popular champion or sympathetic victim is slow in coming, if it arrives at all. Both EBM and PPP enter the public arena only after months or years of time spent “in committee” with old data.

At the end of the clinic day both EBM and various PPP’s suffer from being out of date on the day they are published. Because of this they create at least as many problems as they attempt to solve. In addition to providing ammunition to insurers all too happy to avoid paying for newer, more effective care that might be more expensive, the wide dissemination of various articles on EBM or PPP’s can sow confusion and doubt in the minds of those patients most in need of Best Practices, particularly those with severe or complex problems.

Any specialty in medicine could provide examples, but since I’m an eye doc let me offer one that illustrates most of the nuances involved. We’ve long known that elevated tear osmolarity (salt content) is a component of dry eye (DES). Prior to 2009 testing the osmolarity of human tears required a complex, time-consuming process that also suffered from the twin-blade cut of being both expensive and not covered by any insurance plans. Consequently the use of tear osmolarity as a core diagnostic test in the care of DES was pretty much a non-starter.

In 2009 TearLab introduced a much simpler, much less expensive test that could be done in the course of a regular office visit, and in 2010 the company received a waiver from the FDA which allowed doctors to use the test in an office setting without being certified as a clinical laboratory. Approval for payment by insurance companies, including Medicare, came shortly thereafter. As with any new test that becomes widely available it took a couple of years for clinicians to figure out the full extent of the meaning and application of the results. The short version of this part of the story is that tear osmolarity testing has become an integral part in both the diagnostic work-up and ongoing follow-up of DES patients in any advanced DES clinic due to its clear therapeutic value. It also fits into the prevailing financial model and patient mindset in which diagnostic testing is an insurance covered benefit.

What’s the problem then? Our largest professional organization, the American Association of Ophthalmology (AAO) publishes a series of PPP’s addressing many common entities in eye care, and DES is one of them. The latest version was published in 2013 after more than a year of discussion in committee based on practice patterns  and publications from 2011 when Tear Osmolarity was not yet in widespread use. The PPP made much of the fact that this at the time new test had not yet been widely adopted and that there was still some discussion about its true clinical worth. BOOM! In rushed a Medicare administrator in January 2015 with a proposal to withdraw payment for this “non-essential” test of “unproven” value.

The problem, of course, is that Tear Osmolarity is now widely and quite rightly accepted as a part of today’s “Best Practices” of DES care. Ironically, the use of Tear Osmolarity is actually an example of EBM, but that evidence has emerged subsequent to the initiation of the PPP process. Removing insurance payments will erect a barrier between patients and their best chance at treating their disease.

Thought leaders in my field as well as other, more nimble professional organizations than the AAO have offered assistance to TearLab to prevent a change in the insurance payment for tear osmolarity testing. Both eye doctors and their patients will likely survive this misguided attack on an extremely useful technology. It does make one wonder how many other instances exist where a seemingly good idea (PPP, EBM) is misused in the eternal battle between those who provide medical care and those who are charged with allocating the monies used to pay for that care. Funny, isn’t it, how the medical powers that be, professional organizations like the AAO, are always a bit behind the times, and the payment powers that be (and often plaintiff’s attorneys) use that to their advantage?

Preferred Practice Patterns and many examples of Evidence Based Medicine need to come with an expiration date, or at least a warning that using them cannot be construed as either “Best Practices” or cutting edge. Even at the time they are first published.

 

 

Sunday musings 7/20/14: The Risk of Unshakeable Belief

Sunday musings…

1) Fonzie. Henry Winkler is 68 years old. Ayyyyy…

2) Open. Oldest golf tournament in the world coming to a close as I type. Sergio comes up jusssst a bit short. Again.

Dude’ consistent. Gotta give him that.

3) Aviary. Mrs. bingo is the “Bird Whisperer.” Who knew there were so many types of birds in suburbia?

I remember when a robin was an exotic creature.

4) Change. The only thing that is constant is change. This applies everywhere to everything. Next weekend will bring the latest edition of the CrossFit Games. There will be change. Count on it. I have absolutely no inside information whatsoever, but you can make bank on this. There will be change.

How could I possibly know this? Well, a part of it is just a basic fact of life. Stuff changes. The other part is simply history. If you’ve been paying the least bit of attention the last, oh, 10 years or so, you’ve notice that the folks who run things in our little CrossFit world are ever and always changing things up. I’m not really sure if the Black Box is outwardly (or inwardly) any different, but the leadership team is constantly changing up the left side input to see what comes out of the right side. From where I sit each change has brought a net improvement. The only thing we know for sure is that there will be change next week at The CrossFit Games.

Now in reality, unless you make your living from The Games of from CrossFit, this particular change is more interesting than integral in your life. It’s the fact of change, the constancy of change, and more so how you handle it both tactically and emotionally, that determines your destiny. Prepare for change and plan for change, because change is what you’re gonna get.

5) Unshakeable. This week I spent some time talking to a couple of folks who, unbeknownst to them, were talking about each other. Well, talking to them is not really accurate–they were having a discussion and I was having a listen. Both were talking about the effects of a particular happening on a particular person, effects that both could surely see if only they cared to remove their blinders and look. They told wildly different stories. Their belief sets were so unshakeable, so impervious to penetration by petty inconveniences like facts and reality, it was as if they wore not lenses to clarify but masks to obscure.

The blind running from the blind, if you will.

I’m fascinated when I see this, and I do see this almost every day when I am plying my trade. So much of what is “known” about medicine isn’t really known at all but “felt”. I constantly run up against an unshakeable belief that is often expressed in a statement that begins “well, I would think that [you] would…” Indeed, I heard this from both folks telling me what was transpiring. I’m fascinated and exasperated in equal parts when I am on the listening end of this equation because of how completely this unshakeable belief nullifies the otherwise logical power of observable, measurable fact.

If I step back and think a little more deeply about this phenomenon I am also terrified that I, too, may harbor similarly unshakeable beliefs that blind me to the truths of a fact-based reality. This weekend brought a gathering of true experts in a particular field of my day job, one I was quite flattered to attend. There were a couple of points that I’m just convinced my colleagues got wrong, points of view it looks like I shared only with myself. Am I right? Is my insight so keen, my ability to analyze the data presented so much better, my advice so advanced that I am just a full step ahead of the rest of the group? Or is it rather that I am clinging to a point of view supported only by the virtual facts created by beliefs I am unable or unwilling to walk away from? The simple awareness that this may, indeed, be the case does place me in a better position than either of my conversational partners as far as ultimately being right, but is that enough?

Blinders of not, I guess we’ll see, eh?

I’ll see you next week…

Posted by bingo at July 20, 2014 11:06 AM

Does “MD” = Manic Depression?

“Manic depression is touching my soul.”

You’re up;  you’re down. You’re happy; you’re sad. You have the best job in the world; thinking about going to work makes you sick to your stomach. You’re so good at what you do, everybody loves you; everyone is out to get you.

You are an American physician.

Recently I’ve been asked at least a dozen times why I became a doctor, or why I became an eye doctor. I’m not really sure why this has come up now, because most of the people who are asking have known me in some way for many years. Why I became an eye doctor is really rather simple, and I have written about it HERE. The question “why did you become a doctor” is much more complex, much more involved, and frankly I’m beginning to wonder about that myself.

“Why do you want to be a doctor” was at the same time the easiest and most difficult question for me to answer, especially during medical school interviews. I grew up in a small, dying mill town in Massachusetts. The happiest, most fulfilled, most IMPORTANT people in that town were the doctors, of which there were very few. The busiest surgeon in town, Dr. L., could possibly have been the happiest person in the entire town. Beautiful wife, attractive, intelligent, athletic children, really big house. He was even a decent golfer! I don’t think I ever saw him without a smile on his face.

It was Dr. Roy, though, my pediatrician, who really clinched it for me. There must have been another pediatrician in town–heck, there were 24,000 people there. For the life of me, though, I can’t ever recall any of my friends seeing any doctor other than Dr. Roy. He was confident. Secure. Always with a gentle smile whether in the office or on Main Street. My mom later told me that he was perhaps the most influential politician in town as well. Everybody looked up to Dr. Roy, no matter how young or old they might be. His was a happy, contented, full life, largely because he was a respected physician.

Can you name a single pediatrician now living and practicing in the United States whom you would describe like that?

Nevertheless, that’s mostly why I wanted to be a doctor. I want to be Dr. Roy. I wanted people to look up to me because I was good at doing something that was important, something that was meaningful to their lives. All of the doctors in town were like that.

Now? Well, I’m a 51-year-old eye surgeon and I am just like every other physician in the United States. I swing between the euphoria associated with a good outcome or a happy patient, and the bitter black hole that appears when a disease wins. My world is actually pretty good in this regard: for every defeat there are literally hundreds of victories. For every patient who is dissatisfied or unfulfilled there are hundreds who can’t wait to tell everyone in their lives how good their experience was. It’s just that there seems to be a couple more people who are less satisfied. A couple more each year.

Again, the success rate in my particular specialty is incredibly high, and these people who are less than satisfied have actually had an extraordinary good outcome if you look objectively. I think it all tracks back to the creeping consumerism in health care. It’s not good enough to have an outstanding outcome, it’s only truly even good enough if it meets the expectations of the consumer, the patient, no matter how outlandish or inappropriate those expectations might be.

I’m up. I’m down. The downs seem to hurt more because they are so much more, I don’t know, personal now.

I always got the idea that there was pretty much nothing to the business of being a doctor. All the docs seemed to have enough money, although none of them seemed wealthy. There was only one “girl” in the office and she made the appointments, gave you your bill, and took your payment. No back office or billing department. No special personnel responsible for charting, compliance, insurance communications. My “chart” was a couple of 5×7 cards stapled together.

Now? Oh man…the squeeze is coming from all directions. Private practice or big group practice, it doesn’t matter. You either deal with the external forces conspiring to make it more unpleasant to make a living as a doctor (insurance companies, the government, malpractice attorneys) or you deal with your boss (or more likely your boss’ secretary since you’re just another employee, after all). Your chart is now a legal document littered with land mines meant to ensnare even the most pious and dedicated among us.  Most docs do OK financially, maybe not 1%’ers but pretty well. It just seems like so many folks go so far out of their way to make us feel like we don’t deserve our pay. Any of us. Any of it.

I’m comfortable; you don’t deserve it.

Now, if you are not a doc you could sit back and rightly say “quit yer whinin”. I’d get it. I just can’t shake the feeling that Dr. Roy, and all of the Dr. Roy’s of the day, got and gave more out of what medicine could offer than any of us do now, despite the fact that those of us who practice now have so much more at our disposal on the medical side of the equation. It just doesn’t feel as good. There’s just too much that comes between doctors and that sense of service, of satisfaction in those bygone days. It just seems so much like work now. I don’t think Dr. Roy ever went to work. I believe he would have practiced pretty much the same way if he’d inherited a million dollars.

You’re up; you’re down. You have the best job in the world; you can barely make yourself open the office door. Everybody loves you;  you don’t deserve it.

“Manic depression is a frustrating mess.”