Random Thoughts from a Restless Mind

I am on call this month for the largest community hospital on the West Side of Cleveland. Covering a semi-suburban ER is quite different from covering a true big city ER, especially when the semi-suburban hospital has gutted both its trauma and eye services. My on-call role now is little more than that of foot servant, covering the loose ends of other people’s arses in the pursuit of a perfect chart. Bellevue, at least the Bellevue I knew in the 80’s, was quite a different story. Although it was July it was July in New York, pre-Guliani New York, and it was Bellevue Hospital.

There are only two kinds of people in New York City: Targets, and people who hit Targets. At Bellevue we took care of the Targets.

It’s the first weekend in July. For most people in America that means the 4th of July and everything that goes along with that. Barbecues. Fireworks. Festivals and ballgames of all sorts. And beer. Lots and lots of beer. But in that curious sub-culture of medical education the first weekend in July means the first time on call for newly minted interns, newly promoted residents and fellows of all sorts. Everyone and everything is new, just in time for July 4th and its aftermath.

Funny, but I ended up on call for every 4th of July in my four years of post-med school training. I’m not sure which, or how many, of the residency gods I offended, but whatever I did I apparently did in spades ’cause I hit the first weekend jackpot every year. I have no memory of my first on call as an intern, but the “Target Range” was open for business those first couple of years at Bellevue, for sure! In fact, if memory serves, the phrase “Target” was coined by yours truly that very first weekend of that very first year as an ophthalmology resident.

“Hey Eye Guy! We got a John Q. Nobody who got shot in the temple just standing on the subway platform. Says he can’t see. Whaddaya want us to do with him? By the way…welcome to Bellevue.”

Crowds and beer and heat and stuff that explodes. Welcome to Bellevue, indeed. Some poor schlub survives the bar scene after the parade, makes it through pickpocket alley intact, gingerly stepping over detritus living and otherwise, only to get shot in the head as the A Train approached the station in a random act of anonymous violence. The bullet entered through the right temple, destroyed the right eye, and wreaked havoc in the left eye socket before coming to rest against the left temple. Right eye gone and malignant glaucoma in the only remaining left eye. And there I was, all of 3 days into my opthalmology residency, backed up by a chief resident of similar vintage. Whoa…

There’s no way to avoid it. After all, med students have to graduate and residencies have to start some time. There’s just this unholy confluence of weak links in the system all coming together in time for the second (after New Year’s Eve) most difficult ER day in our big, academic hospitals. Get sick or injured on June 4th? Everyone’s on top of their game and everyone’s in town. July 4th? The fix is in, and the game is as rigged against you as any carnival game attended by a dentally challenged carnie.

As I sit here, an Attending on call for yet another 4th of July weekend, covering the ER and cowering each time the phone rings, the Tweets and Facebook posts heralding the arrival of a new crop of interns and residents send me back to Bellevue. Year 2, cursed again, covering the spanking new 1st year ophthalmology resident (was it Dave?) as he got his welcome “gift” from the ER. “Hey Eye Guy. We got a Target down here for ya. 10 year old girl. Some dumbass tossed a lit M80 to her and she caught it. Went off before she could get rid of it;  blew off her right hand and looks like her right eye is gone. You from NY? No? Welcome to Bellevue, pal.” Yup…there’s something about the 4th of July in every teaching hospital in the U.S., and just like everything else, whatever it is, there was more of it at Bellevue.

Only two kinds of people in New York, Targets and people who hit Targets. At Bellevue we took care of the Targets.

In 2011 I wrote an essay in response to an article I read in the WSJ on the coming physician shortage. In short I agreed with a letter that pointed out the effect of physicians working fewer hours than they had traditionally worked. In that letter the effect of the changing demographics in medicine (more women physicians, generational shifts) was pointed out. My essay agreed with the points in the letter. My thesis is that you can’t “have it all”, in medicine or anywhere. Someone, somehow, always pays.

While reading about “Equal Pay Day”, the day on which the “average female wage earner” achieves the same amount of pay as the “average male wage earner” acquired in the previous 12 months, a couple of things strike me. First, the general thesis of my essay continues to be accurate, at least in medicine. Income is determined by the choice of specialty, as always, but beyond that it is driven much more so by the number of hours a physician works and how productive that physician is during those work hours. Work more hours, get paid more money. Perform more of your doctorly duties in each one of those hours, get paid more money. There are fewer and fewer physician jobs in which seniority on its own drives income, thereby negating any lack of seniority which may be caused by a career “pause” to have or care for children. Physician income is largely gender-blind. As an aside, the dirty little secret of physician pay is that production-based compensation is the norm everywhere, even at those institutions that claim otherwise.

The second thing that strikes me is the malignantly erosive effect of ineffectual, unnecessary external regulation on the practice of all medicine on effective physician work hours. In 2014, whether you are a man or a woman, the bureaucratic load associated with practicing medicine is oppressive, and hours that just 5 years ago may have been spent caring for patients is now spent caring for charts, bills, and other paperwork. These hours generate no real health benefits for patients, and do not produce any revenue that pays the doctors for working them. In a particularly cruel example of Murphy’s Law, or at least the Law of Unintended Consequences, the specialties that are hardest hit by this relentless onslaught of the unnecessary are those that tend to pay physicians the least. Fields like Family Practice and Pediatrics. On “Equal Pay Day”  it is particularly ironic to note that those hardest hit specialties tend to be staffed by the highest percentage of female doctors.

A final note as I read this post 3+ years after the initial writing: the choice of “Mommy-Track” to describe those women who graduate from medical school and work fewer hours than their male peers because of their choice to prioritize their families seems needlessly pejorative and provocative. I’ve left it in for this Epilogue because to edit it today seems dishonest in a way. Besides, I’m a little bit better at writing in 2014 than I was in 2011. I can be plenty provocative now without resorting to the pejorative.

A recent study looked at survival statistics for colon cancer. While >90% of patients with early stages of colon cancer survive at least 5 years, the 5 year survival rate for advanced cancer is only 12%. One of the conclusions from that study is that the increased survival rate of cancer detected early justifies wider scale screening for this deadly disease. Makes sense, right? Find the cancer early and you live longer. The problem here, of course, is that the incidence of colon cancer in a broadly chosen group of individuals is actually rather small making both the cost of making the diagnosis as well as the “cost” of any complications from the screening test prohibitive. Whether or not to screen is a very complex question. This is a version of “better care” but it is probably not worth the cost unless we can find some way to identify an at-risk population.

Let’s say there’s a brand new test that allows you to identify another, different, important disease years, perhaps decades earlier than is now feasible. It is possible to narrowly define a population of patients at high risk of having the disease. Utilizing this test will provide physicians the opportunity to treat this disease before it causes irreversible destruction of vital organs, destruction which renders present day care of this disease when it is presently diagnosed little more than palliation.  The effects of this disease in later stages cause dramatic negative changes in the lifestyle of affected patients. There appear to be ways to treat the disease in its earliest stages in order to prevent the ravages of its late stages. Do you initiate testing in the at-risk population?

Let’s think about it.

What if the test is relatively easy, relatively painless, but relatively pricey? Remember, you can identify a population for this test that is at risk to have the disease based on patient history and physical exam criteria, making the percentage of people afflicted (incidence of disease) relatively high in the tested group. The weakness of many screening programs (routine colonoscopy for colon cancer for example) as noted above is that the disease is either relatively uncommon, or it is impossible to identify a truly at-risk group. This is not a problem with our hypothetical test. Let’s make the test very accurate, too, say 95% sensitive and 95% specific in any study group; the number of both false positives and false negatives would be very low. This would make it more useful than serum lipids when screening for cardiac risk, for example. While we’re at it, this test is extremely safe with no real risks. It sounds like a pretty strong case to roll it out, right?

Now would be a really good time to go back to one of the earliest things every medical student is (was?) taught about ordering a test: the result of your test should in some way influence your care of the patient. A positive test result should prompt you to do something differently from a negative result. If your course of action would be identical with each/every possible result it is entirely reasonable to ask why you are doing the test in the first place. Our new test meets this threshold. A negative result means continue with “standard operating procedure”, treating a patient with the constellation of symptoms and signs you have identified as you have been. A positive test, on the other hand, obligates you to enlist the assistance of another specialist, and furthermore to insist that your patient receive treatment that is not yet in any way considered standard. Therein lie the problems.

Many, if not most complex medical problems require the engagement of a specialist in order that the patient receive the most up to date and effective  treatment. Contrary to the popular notion that we only have a shortage of Primary Care doctors in the U.S., every family doc will tell you that it is nearly impossible to find a rheumatologist, dermatologist, neurologist, endocrinologist or various other medical specialists to take care of a new, complex patient. Imagine if you have a new test that identifies 1 million or 2 million or MORE new patients whose disease requires one of these specialists to run the show? What if the effective treatment that will be proposed is off-label (FDA approved for something else) and extremely expensive? What now? Remember, failure to identify these patients early and treat them before irreversible damage occurs dooms them to progressive misery as they age. What’s the call?

This would be truly better care. Is it truly worth it? Who should make the call?

In the abstract it’s a different question, and without the context of knowing what disease is involved also makes it somewhat more difficult to analyze this in any meaningful way. Let’s face it, some diseases simply carry more emotional weight than others, and this would likely increase the amount of money that anyone faced with this question would be willing to spend. The question itself is hardly abstract at all, however. Just today I read about tests for Alzheimer’s Disease and Sjögren’s Syndrome that will allow for extremely accurate diagnoses made dramatically earlier than we are now capable. Unaware of the diagnosis physicians and patients have no opportunity to consider treatment; if you can’t take a temperature you can’t find a fever. Without the ability to make an early diagnosis pharmaceutical companies have no incentive to evaluate treatments that will prevent the scourge of late-stage disease. This is the situation on the ground today.

The challenge will come as these tests are put into routine use and we identify large numbers of patients whose eventual course in the absence of treatment is well-known. Who will care for them if we already face a shortage of specialists in these fields? Uncertain of a return on the investment necessary to prove the efficacy of treatments for these diseases, what pharmaceutical company will do the studies that will show the benefit of treatment? With these new treatments likely to be very expensive, will insurance companies and the government pay the costs of the care? In the abstract these tests and the treatments that will follow certainly constitute better care. Will it be worth the cost?

Who makes that call?

Skyvision Centers has a subsidiary company called the Skyvision Business Lab. We do business process research for pharmaceutical companies, medical device companies, and other medical businesses in the eye care arena. One of the companies we have worked for is a very cool company that produces animated educational videos for  ophthalmologists and optometrists. I had an interesting experience while talking to their chief technology officer. It was interesting because the conversation proved our basic reason for existence at the Business Lab, that it is impossible for any company to develop, sell, and install any kind of product in our world without understanding the ins and outs of every day activities in an eye care practice.

Of course, I always find it extremely interesting when I’m right!

It was a tiny little point, really, but how could you know something as small and seemingly insignificant as our discovery unless you had spent time on the “frontline” of medical practice? The chief technology officer for the video company was frustrated because doctors and their staff were not using this really cool product that they had purchased. Furthermore, because they weren’t using it, they were failing to buy downstream products from the video company. As it turns out the salespeople for this company were telling the doctors that this particular product should be “turned on” by the staff at the front desk of the office. This is exactly the wrong place because the front staff personnel simply have neither the time, nor the understanding, nor any incentive whatsoever to do this. The product actually works beautifully if it is “turned on” by the back-office staff. Bingo! Problem solved.

So what does this have to do with Electronic Medical Records (EMR), and for heaven’s sake what does this have to do with underpants? It’s simple, really. When was the last time you bought a totally new type of underpants, underpants that you had never seen before, and underpants that you had certainly never worn before, without trying them on? Furthermore, what’s the likelihood that you would allow someone else to design, fit, and choose a style  of underpants for you if that someone has not only never met you but has never even seen a picture of you?!  That’s the image I get every time I read an article about EMR.

In theory the concept of an electronic medical record that would allow permanent storage of every bit of medical information, with the ability to share that information between and among doctors and hospitals involved in the patient’s care, is so logical and obvious that debating the point seems silly. If you have ever seen my handwriting, for example, you’d realize that the entire field of EMR was worth developing just to make doctors stop using pens and pencils! Trust me on this… the doctor hasn’t yet been trained who is also a specialist in penmanship.

I actually trained at  two of the pioneering hospitals in the use of electronic medical records, and indeed in the use of computers in medicine in general. Dr. Larry Weed and Dr. Dennis Plante at the University of Vermont were pioneers in the concept of using computing power to make more accurate medical diagnoses. Both the University of Vermont Medical Center and the Maine Medical Center were among the very first institutions to develop and implement digital medical records for the storage and use of clinical data like lab reports and radiology reports. In theory both of these areas make sense, but in practice the storage and display of clinical data is all that’s actually helpful in day-to-day practice.

If this is the case, if the acquisition, storage, and retrieval of critical data is helpful, the next logical step must be to do the same thing with the information obtained in doctor’s offices, right? Well, in theory this makes a ton of sense. The problem is that nearly none of the EMR systems now in place have been designed from the doctor/patient experience outward; they’ve all been designed from the outside in, kind of like someone imagining what kind of underpants you might need or might like to wear, and making a guess about what size would fit you. With a few exceptions, tiny companies that are likely to be steamrolled in the process, every single EMR on the market is the wrong fit for a doctor and a patient.

Why is this? How could this possibly be with all the lip service that is being paid to the doctor /patient relationship and the importance of getting better care to patients? It goes back to that same tiny little problem that the medical video company tripped over: it’s really hard to know how something should work unless you spend some time where the work is going to be done. Electronic medical records in today’s market are responsive to INSTITUTIONS, insurance companies and governments and large hospital systems. System before doctor, doctor before staff, staff before patient. Today’s EMR’s have been designed with two spoken goals in mind: saving money and reducing medical errors. Should be a slamdunk at that, right? But even here the systems bat only .500, producing reams of data that will eventually allow distant institutions to pare medical spending, but neither capturing nor analyzing the correct data to improve both medical outcomes and medical safety. Fail here, too, but that’s another story entirely.

So what’s the solution? Well for me the answer is really pretty easy and pretty obvious. Send the underwear designer into the dressing room! Program design, programs of any type, are one part “knowledge of need” and one part plumbing. How can you know what type of plumbing is necessary unless you go and look at the exact place where the plumbing is needed? How can you know what size and what shape and what style of underwear will fit unless you actually go and look at the person who will be wearing the underwear? It’s so simple and so obvious that it sometimes makes me want to scream. Put the program designers in the offices of doctors who are actually seeing patients. Set them side-by-each. Make them sit next to the patients and experience what it’s like to receive care.

THEN design the program.

I’m available.The  Skyvision Business Lab is available. I have a hunch that the solution will hinge on something as simple and fundamental as my example above — front desk versus back office.  It doesn’t necessarily have to be me, and doesn’t necessarily have to be us, but it absolutely is necessary for it to be doctors and practices like Skyvision Centers, places where doctors and nurses and staff members actually take care of patients. Places where patients go to stay healthy or return to health. Places where it’s patient before staff, staff before doctor, doctor before system.

For whatever it’s worth I’m 5’8″ tall, I weigh 150 pounds, and I’m relatively lean for an old guy. I guess it’s a little embarrassing to admit this… I still wear “TightyWhiteys”, but I’m open-minded. I’m willing to change.

Just take a look at me first before you choose my underpants for me.

The technology is fabulous. I mean, Femtosecond Laser Cataract Surgery (FLCS) is really, REALLY fabulous. It deserves a full roll-out. It is nothing less than the logical next step in a progression of medical treatments that extends back in time to the days of the Pharaohs and Cleopatra. Yet we debate its merits (Is it better? Is it safe?) in a sad and tawdry replay of the introduction of its predecessor technology, a chapter in the august history of ophthalmology that is still cringe-worthy among the vanishing actors still alive from that tragicomedy. That original sin, the denigration of the technique of cataract removal called Phacoemulsification (Phaco) by the establishment could at least stand on technical grounds;  Phaco 1.0 was rather rough stuff. Here we have no such ground on which to stand; the new technology of FLCS at launch is at LEAST as safe and effective, and promises to become more of both as it develops.

Why, then, my obvious angst?

The problem lies not with the technology but with the business model, and by extension how that is dividing the community of cataract surgeons. You see, what was really tragic about the the response of the ophthalmic community during the transition to Phaco for cataract surgery was the outright character assassination of those on the forefront of adopting Phaco by those still entrenched in the status quo. In my opinion the same is starting to happen now, only it is those who are adopting the new technology who are subtly smearing those who have yet to do so.

At the turn of the most recent century a company called Eyeonics (since purchased by Bausch & Lomb) and its CEO Any Corley ushered in a new era in cataract lens implants. With these new implants came an equally revolutionary new business model. Through the tireless work of Corley and his associates patients were given the option of paying an additional charge to add an UNCOVERED service on top of a medically necessary service that was otherwise fully covered by insurance. While the costs of the basic aspects of cataract surgery (remove the cataract; replace the removed natural lens with an artificial implant) would continue to be paid by health insurance (including, most importantly, Medicare), a patient now had the option of paying to add an additional service such as the treatment of astigmatism or presbyopia (the ability see up close as well as at distance) without the need to wear glasses.

Mr. Corley and Eyeonics did the grunt work of convincing the bureaucrats in what is now CMS that this was OK, and this  success launched some of the most vibrant technological advances anywhere in medicine. We now have no fewer than 6 “premium” lens implants, with at least another 6 in development. This is really exciting stuff and it is the direct result of the lobbying work done to create this new business model: extra charges for services that are beyond the basic, standard services necessary to accomplish the treatment of a medical necessity, in this case the removal of a cataract.

So what’s the problem? In a nutshell, the industry that has given us the FSLC is conflating this advancement in the fulfillment of the basic aspects of  cataract surgery (FSLC) with the provision of additional services that are not medically necessary (treatment of presbyopia). Indeed, such luminaries in my world as Eric Donnenfeld, Dan Durrie, and Steve Slade are on record as saying that FSLC is already safer than traditional Phaco, and that it already produces superior outcomes in ALL circumstances, specifically including the implantation of a standard lens implant. How then is this a “premium” service? Why is FSLC not being sold as the next development in the long line of successful improvements in cataract surgery for the masses? For Heaven’s sake, if FSLC is truly safer than what industry and industry consultants have taken to calling “manual cataract surgery” (despite the inconvenient fact that FSLC still involves some pretty tricky manual steps), how can one justify calling this a “premium, non-covered procedure” for which a patient must pay more? Seriously, pay more for safety? Pay more for better outcomes?

THAT my friends is the problem. In order to get what may turn out to be the safest surgery, for the first time in history patients must now pony up. Think about how this would play in, oh, heart surgery. “Well Mrs. Jones, your heart surgery can be done with the older technique and covered by your insurance, but for $2000 extra we can do the better, safer laser version for YOUR heart.” Nice, huh?

Our ophthalmic device manufacturers, including interestingly the same Andy Corley I previously lauded, have taken the easy route. Rather than “man up” and go before Medicare and the other insurers to justify a request for insurance coverage of the additional cost of what the podium speakers are calling a safer, better procedure, they have instead opted for the cynical, cowardly route of mis-applying the “Corley Rule” and having the patient pay. Worse than that, there is a very clear message coming from the podium (though not necessarily Donnenfeld, et al.)  and various editorials that those of us who have achieved stellar visual outcomes with spotless safety records are somehow now failing to provide our patients with the new “standard” if we opt to wait at this stage of development. Really. That’s what they are saying. Indeed, even some who are old enough to have been the targets of this kind of behavior in the 70’s and 80’s  say that out loud.

Listen, I get the excitement about a new technology that will probably win out as both better and safer. Heck, new often wins just because it’s new, or because people THINK it’s better and safer even if it’s not (read: Femtosecond laser LASIK  flaps vs. modern mechanical keratomes). I’m good with that. At 53 years of age I will almost surely perform FSLC for a significant part of the rest of my career once I begin. But don’t try to tell me that this is anything other than the latest step in a progression of procedures that began with “couching” in ancient Egypt. Don’t expect me to feel OK with the cynical decisions that everyone in the pipeline have made in order to avoid having the battle on insurance coverage for something they are already calling a “standard”. You simply can’t have it both ways. You can’t say that this is a safer surgery with better outcomes and then say that the regular Joe or Jane should reach into their pocket and pay EXTRA for the next better version of regular surgery that has always been covered by insurance, and then expect me to get in line and salute the “Jolly Roger” you’ve just hoisted.

The technology of the Femtosecond Laser Cataract Surgery is great. The cynical business model is not. Let’s not tarnish this wonderful new technology by repeating the bad behavior of the 70’s during the transition to Phaco by speaking ill of our colleagues who may not be as willing to jump on the bandwagon of a cowardly industry unwilling to do the right thing in support of of its own creation. It is our job as ophthalmic surgeons to demand that the device industry do the hard work to come up with a more appropriate business model if they want to sell their lasers.

As far as I’m concerned it is also our duty as colleagues to not forget the trauma we inflicted upon ourselves in the Phaco transition by smearing one group or another, however subtly or quietly that might be done. Both sides of this controversy must do whatever it takes not to repeat that tragic history as we move inexorably toward the universal adoption of the newest heir in the cataract surgery lineage. In general I’m a fan of our industry partners, but they created this issue by abdicating when it came time to support their invention.

It’s up to us to force them to own up to that and fix it.

The announcement came in the mail, by email, and proclamation at a dinner. My good friend (and personal physician) would be retiring from the practice of medicine at age 55 to take a position as a very senior hospital administrator. This news was delivered by another physician friend, a 55 year old orthopedic surgeon who put my wife back together after a Humpty Dumpty fall off a horse, during a dinner at which he described his intent to drastically reduce his call schedule and ER coverage. That morning in the OR I was chatting with an industry rep who was telling the story of an extraordinarily talented 45ish year old cataract surgeon who has limited his daily volume to 6 cases (that’s what he’s contracted for with Kaiser) despite the fact that he is able to complete this schedule by 9:30 AM. I thought of all of this while I, a 52 year old eye surgeon somewhat famous for my ability to handle a crushing workload without sacrificing either outcomes or a pleasant patient experience, was mapping out my 2014 office and OR schedule with a reduced work week and additional vacation days.

Have you noticed? There are fewer of us out there doing our jobs. Fewer doctors, that is. We’re slipping away, young and old. The last vestiges of the physicians who lived through the Golden Age of medicine are hanging up their spurs, taking down their shingles, and riding off into the sunset. They are being replaced by an almost equal number of youngsters just out of training, young bucks saddling up yearlings and slowly joining the rodeo. Those of us in the middle, mid-career docs of all sorts, we’re still there. Sorta.

The stands are full. All sorts of spectators and commentators are there to see the healthcare rodeo. The reporters and the pundits, the bloggers, those who dwell in the halls of academe and the basements of the bureaucracy fill the bleachers, prepared for much back-slapping and self-congratulation as the fruits of their intellectual labors, the young buck docs, take over for the much-maligned Marcus Welby generation. The kids’ll be OK, better than OK, because the audience has successfully changed everything about how doctors are trained and made it the way they, the audience, think it SHOULD be. No need to worry about the newbies and all of the non-doctor “healthcare providers” and how slow they are in general, or how they work fewer hours, or take more time to handle a visit–those docs in the “sweet-spot” in mid-career are there to take up the slack until the audience’s brilliance is born out. Sorta.

Everything seems to be a bit chaotic at the healthcare rodeo. There are so many more things that need to get done. It’s not enough to rope and tie that diabetic, there seem to be too many diabetics now. Those young docs spend an awful lot of time just outside the ring doing non-doctor stuff. Where are the grooms, the seconds, the helpers? Why aren’t they doing all that stuff outside the ring so the doctors can get in there and ride? It looks like there are a bunch of those mid-career guys and gals over there outside the ring too, doing non-doctor stuff. It sure seems to take a lot of time. The young bucks seem to take that all in stride. Maybe a stray shrug of a shoulder, but not much more. It’s all they’ve ever known. The mid-career docs seem to be making do. Sorta.

Something’s just not quite right, though. The numbers just aren’t quite working. Matching the number of docs retiring with the number of newly-trained docs seems to be coming up short. All of those newly empowered other “healthcare providers” don’t seem to be making much of a difference, either. There seem to be too many patients, too many people who need both sick and well-care, and too few doctors to provide it. The pundits and the professors say the solution is not more doctors but more other “healthcare providers” and new technology. Help is on the way they say. Preparing the path to this end seems to involve a PR campaign that not only minimizes the contribution of doctors in general, it denigrates the efforts of the one group of docs that is keeping it all afloat: the mid-career physicians who are neither old enough to retire nor young enough to not know any better.

The whole house of cards depends on these men and women going to work and doing just what they’ve been doing for 20+ years. Seeing lots of patients in any given time slot. Performing lots of surgeries efficiently and well. Showing up in the ER for a consult or answering the phone at 3 AM. All for lower pay and less respect. The whole thing rests upon the presumption that they will continue to do this regardless of the non-medical impositions of the new “way it should be”, regardless of the continual battering of their self-worth. Thus far that’s how it’s playing out. Sorta.

There’s something afoot, though. Quietly and without much fanfare, the mid-career doc is slipping away. She’s sliding out the side door and taking a job in administration. He’s slipping in a 4-day weekend every month, on top of the 4-day week he started working a couple years ago. While nobody noticed she started to limit the number of surgeries she would do in a day, ducking out at noon on OR day instead of 2 or 3, the backlog of cases now building up to months rather than weeks. Oh sure, they are still counted as a full-time doc on everyone’s ledger, it’s just that they aren’t as full-time as they used to be, as full time as the system is counting on them to be. The net effect is that with the same number of doctors counted we actually have FEWER docs available to see more patients.

You see, the mid-career physician is also listening to what the editorialists and the bloggers and the academics and the bureaucratic minions are saying, about the “way it should be” and how they really feel about worth of doctor work, and in response they are slip sliding away.

Told to do more for less some of those mid-career warhorses are just doing less. All those men and women who are the equivalent of “innings eaters” on a Major League pitching staff are no longer as available, effectively reducing the number of physicians available to take care of patients. If the new “way it should be” is correct this should pose no problem, right? Just have all those folks who used to be seen by a physician seen by a “healthcare provider.” Got a sore throat? CVS or Walmart is just around the corner and they do the same quicky Strep test your doctor would have done. Surely the AP nurse will notice that tender spleen, or that especially swollen tonsil encroaching on the midline like your 55 year old doc with 25 years of experience would have. No worries. You can follow up with that nice new doctor in the big clinic, that ACO thing you’ve read about. There’s an opening in 12 weeks. Your old doctor who would have stayed late in the office to see you in follow-up in a day or two is no longer available.

He started a new career selling veterinary supplements at rodeos. Slip sliding away…

“Eating healthy is too expensive.” How often have you heard some version of that phrase. Whether it be Zone, Paleo, Whole 30, or just “stay out of the middle of the grocery store”, this is uttered with some degree of exasperation and oppression with a kind of mind-numbing, self-fulfilling frequency. I recently gave a talk to a group of CrossFitters and, as always, this was the instantaneous response from the crowd.

How so? Per the folks at Whole Foods, regularly skewered for being too expensive (seriously, they sell fancy potatoes), on average we in America spend 7% of our disposable personal income–that’s SEVEN–on food. 50 years ago that number was 16%. We now spend less than 1/2 of the after-tax income on food compared with what we spent 50 years ago.

And eating well is too expensive?!

If we dig deeper into that stat alone we see that modern food production has decreased the cost of food relative to both income and inflation. The cost of producing food of all kinds has risen much more slowly than income. Why? Partly because junk carb-laden food is cheap. High-fructose corn syrup costs a fraction of grain sugar. Corn-fed protein with or without pharmaceuticals is grown faster and cheaper than grass-fed. Stuff like that. Less expensive to produce/incomes risen at a greater rate across the entire spectrum, top to bottom.

How then is it too expensive to eat a more healthy diet? We have 9% of our after-tax income to play with, right? 16% 50 years ago minus the 7% we now spend. Is some other necessity (shelter, transportation, medical care, etc) eating that up? What are we doing with that 9% that we can’t find some of it to eat better? Ah, Grasshopper, now we begin to see. It’s a ‘Nando thing, superficial. It’s not how healthy you are, it’s how you look, or something like that.

Some stuff might be more expensive, but the seemingly obvious culprits are actually false targets (eg. healthcare which for this audience represents only a tiny % of new cost c/w 50 years ago because of insurance, govt. programs, etc.). Housing as a percentage of take-home pay is roughly flat. Basic clothing is no more expensive than it was 50 years ago, and in some instances is actually less. That 9% hasn’t been shifted to another necessity.  How we CHOOSE to spend that freed-up 9% is the issue.  .

Think about that household in the 1960’s or even the 70’s. One car. One TV. One radio. Once purchased all data was free. A pair of shoes and a pair of boots. Sneaks if you were a jock. You didn’t get your hair done if you were a guy, you got a haircut. You didn’t get your acrylics touched up every 2 weeks; if you wanted long nails you grew ’em. Stuff like that.

Fast forward to today and think about the stuff you’ve acquired, stuff you are convinced you can’t live without, stuff that costs money that you choose to spend every single day. The ratio of drivers to cars in a household is seldom more than 1.5/1 and closer to 1/1 in Middle Class America. The ratio phones to people over the age of 10 is seldom less than 1/1. It’s not enough to have a phone, or even a phone with an unlimited text plan, nope, it’s gotta be a phone that will let you post your thoughts on today’s weather in Bimini to FB. Right now, from anywhere. If you don’t have Netflix available on each of the 4 flat-screen TV’s in the house you are considered a Luddite. Look around; you know I’m right.

Listen, I certainly am not saying that all that stuff isn’t great, that it’s not a ton of fun and really convenient (as I type on one of the Apple products that literally litter our household, through my WiFi network, in front of my LightBright lamp), or anything like that. What I most certainly AM saying, though, is that people who whine about how hard it is to afford to eat better almost always do so via a FB post from their iPhone 5 while sitting in the salon having their hair done, hungover from too much Bellevedere they consumed last night while noshing on Doritos smothered in Cheez-Wiz.

9 %. The stark reality is that we have let our things become more important than ourselves. Our choices speak for themselves.

You’ve heard this before: the more solutions you have for a single problem, the less likely it is that the true solution has been discovered. Once a real, conclusive solution is discovered it is accepted and implemented by essentially everyone who is presented with that particular problem. This process occurs unfettered in an open market or open system, and the cost of a particular solution depends on a combination of need for the solution and the economic incentives that exist to solve the problem.

Unfortunately, in healthcare in the U.S. this “rule” is not always the case.

Here’s a story about a solution that is NOT being used to the extent it should because private surgery centers are punished financially if they do the right thing. This example is truly a case of perverse economic incentives violating what we think of as a law of nature, that the discovery of a solution for a vexing problem will be adopted by all who suffer the problem if it is shown to be superior to all other solutions. Let’s look at the “Floppy Iris Syndrome” (AFIS) in cataract surgery.

The iris is the colored part of your eye, and the pupil is simply an opening in the iris, much like the shutter of a camera. The pupil is dilated prior to cataract surgery so that the cataract, a clouding of the lens that sits in back of the iris, can be reached and removed. Six or Seven years ago cataract surgeons began to be ambushed by pupils which spontaneously constricted or shrunk like a pursestring closing, or by an iris that started to billow like a parachute placed over a fan. Dubbed the “Floppy Iris Syndrome”, it turned out that it was caused by exposure to a certain class of medicines used for the seemingly unassociated problem of urinary retention in men with enlarged prostate glands; it has since been found to be caused by an increasing number of other medicines. It was a disaster. The complication rate for surgeries with AFIS was 10X or greater than those with a normal iris and pupil.

The search for the cause was important because cataract surgeons could now be forewarned that they might encounter AFIS during surgery if their patient had ever been on one of the medicine culprits. Once the cause and the extent of the problem were known the race was on to find a solution. Unfortunately, all of the intra-operative tactics we’d used in the past to handle small pupils were largely ineffective against AFIS. In fact, some of the standard ways to address a small pupil actually made the surgery MORE difficult because of the floppy, flaccid iris. Every week brought one or two new ideas to add to the dozens already on the table, proving the rule that many solutions means that no true answer has been found.

Enter Dr. Maluygen and his marvelous eponymous ring. The Maluygen Ring essentially solved the entire problem by simultaneously expanding the pupil and stabilizing the iris, and it was both vastly superior to all other solutions available and technically within the capabilities of pretty much every cataract surgeon. Bingo. QED. Kudos, heartfelt thanks, and a bit of profit to Dr. Maluygen and the company that marketed his Ring, right?

Not so fast there, Cowboy. Every week we STILL see articles on how to deal with AFIS in surgery despite the fact that not a single surgeon has stated, on or off the record, that there is anything that is as good as the Maluygen Ring. Here is where the perversity begins. It turns out that only hospital owned surgery centers can bill insurances for additional or special items used during surgery, and the $125 that the Maluygen Ring costs is extra and therefore not reimbursed. The majority of cataract surgeries in the U.S. are performed in private surgery centers, mostly owned by surgeons who operate in them. To begin with, private surgery centers are paid roughly 60% of what hospital-owned surgery centers are paid. $125 represents in most cases 50% or more of the gross profit (before interest, taxes, depreciation, etc)  generated in a case.

That’s right, there is a 50% financial penalty for using the best and safest method to avoid a preventable complication.

It’s no wonder that the owners of surgery centers continue to look for an alternative solution to the problems cause by AFIS. In a misguided attempt to save money, Medicare has led the charge to pay independent surgery centers less than hospital owned centers, and along the way has stripped the independent centers of the ability to pass on the cost of items that represent the “best practices” for certain situations. Rather than use the acknowledged superior solution (the Maluygen Ring) we continue to see inferior techniques utilized despite the fact that they often prolong the surgical case and fail to completely solve the problem. All because policies are created by non-clinical personnel who are only  empowered to save money.

We should be mindful of these perverse economic incentives as our American system of curing disease undergoes an historic upheaval. Do we really want doctors and others considering the economics of utilizing true, proven best practices? Do we really want non-clinicians creating policy that turns medical decisions into economic ones?

Incontrovertible data does not always lead to the expected outcome. Take for example the much-trumpeted call for “evidence-based medicine”, choosing courses of action or care patterns that have been shown to be beneficial with regards to outcomes, reduced complications, or reduced cost when no benefit has been proven. The recent movement in which several national physician organizations have been asked to identify procedures or tests that should be eliminated for lack of proven efficacy is a presumed “no-brainer” way to reduce the cost of healthcare. In my eyecare world routine pre-admission testing for cataract surgery has been singled out as unnecessary, a waste of time and money for almost everyone involved. A New England Journal of Medicine article from 1990 is cited which unequivocally  shows no benefit to the patient or the cataract surgeon. The data comes from the NEJM. From 1990. This is only a tiny bit removed in both historical context and gravitas from a couple of stones and a guy named Moses. Why are we even talking about this in 2013? Why isn’t this already a done deal?

Ah…there it is…”a waste of time and money for ALMOST everyone involved.” Some very powerful someone has an economic incentive that does not rest on either an outcome or on safety. Someone is getting paid for all of those EKG’s and blood tests for pre-admission testing prior to cataract surgery (I am a cataract surgeon; it isn’t us),  and they have found a way to interpret various and sundry Medicare and OR accreditation documents in such a way that pre-op testing is mandatory. This blatantly ignores the evidence because the evidence ignores the economic incentives: a hospital is getting paid for pre-admission testing. All those patients are being robbed of their time, and every one of them who has an “abnormal” test result is then directed down the rabbit hole to chase a “cause”.

I know, I know…you’re shocked. SHOCKED! As bad as that example may be, and as perverse as it is that the champions of evidence-based medicine ignore the evidence when money is on the line, a story of a hospital doing something extra to get paid more is kinda boring; it just seems to happen all the time. In the private world of free-standing surgery centers that are not associated with a hospital pretty much everyone gets the joke about pre-admission testing and would do pretty much anything to be able to quit. You see, the private surgery centers don’t get paid the same way and pretty much lose money on pre-op testing. If they could get away with it they would all drop pre-admission testing for cataract surgery. The barrier is the economic incentive for the hospitals that own surgery centers and their influence on how regulations are interpreted.

In the face of data that provides a pathway to cost savings in healthcare, evidence-based medicine will only be utilized if the incentives are such that the invested players stand to gain, or if lights bright enough and cries loud enough arise to point out the perversity of the economics at hand.

Transparency is the new buzzword in medicine. Systems should be transparent with regard to prices, if not costs. Doctors and other providers of healthcare services should publish their costs and fees, too. Various ratings and measurements have been developed in an attempt to measure that nebulous and elusive entity “Quality”. Calls have been made for transparency here as well; hospitals, doctors, and others are browbeaten to release any and all manner of quality measurements so that we might create something one could call an “informed patient”.

The first, and therefore most important challenge in the quest to measure quality is to agree on a definition of just what quality is. Like all rational discussions the first order of business is to agree on terms and the terms of engagement.

Let’s take the question of evaluating the quality of an individual surgeon. What are the salient metrics? Are we concerned with only outcomes? You know, success rates, complication rates, stuff like that. Is there more to the measurement? Should we be concerned with EFFICIENCY, the ability to obtain high quality outcomes in a more timely manner? How about VALUE, the soft and difficult to measure combination of quality and COST? In this day and age of “economic credentialing” in which doctors, hospitals, and other providers are held responsible for the cost of care, not only on an individual basis but also a societal one, it seems as if value is an inescapable aspect of quality, at least in the eyes of our government and the people who actually pay for healthcare.

Quality measures will be different for surgeons of different stripes; we will want to evaluate different complications and their rate of occurrence for an ophthalmologist versus, say, a cardiothoracic surgeon. Even similar adverse events like infection rates will have a different meaning across specialties. One classic example of a surgical complication is post-op infections. From my limited reading about heart and chest surgery it appears that the post-op infection rate is around 1-2%. This would be scandalous in eye surgery where the post-op infection rate is 100X lower, closer to .01-.02%. Stuff like this should be fairly easy to uncover, or at least you’d like to think so. It turns out that even this metric is rather hard to come by since multiple doctors will participate in the treatment of post-op infections, and literally no one offers up these stats uncompelled. Similar issues apply to specialty-specific complications (vitreous loss, graft leak) for similar reasons.

Right away the difficulty of measuring quality is obvious: even the simple quality measures appear to be something other than simple to discover right now.

Outcome measures are even trickier. Since I know eye surgery best let me stay in that arena and use cataract surgery as my example. For our discussion let’s assume that we have magically been granted unfettered access to every eye surgeon’s charts (and that they are all legible, and that they all contain the same basic information). It should be a rather simple proposition to draft meaningful criteria–let’s say “how well do the patients see after cataract surgery.?”  Would that it were so. The answer to that very simple question–how well do you see after surgery–depends on several variables, and further varies if you ask the question slightly differently. How much improvement did the patient achieve compared with pre-op? How fast did the improvement come? How well does the patient see without eyeglasses?  Is the patient more or less dependent on eyeglasses following surgery? What level of vision constitutes a success? Does the surgeon get the same results with complex cases?

I imagine these issues are not specific to ophthalmology. I can see the same types of questions and complexities in orthopedic surgery, for example. Think about hip replacement–along with cataract surgery and cardiac bypass surgery, hip replacement is arguably one of the most significant medical developments when we think about the quality of life enjoyed by an older person. What defines success in hip replacement? How long do you allow for success to occur for it to be deemed one for the  “win” column? Do we give bonus points for speed in the OR, both from a patient’s standpoint and an economic one? How about a surgeon’s ability to achieve the same level of success in a thin 70 year old tennis player and an obese, cart-riding smoker?

Seriously, if docs can’t come to an agreement about what constitutes “quality”, how can we in good faith measure it? Furthermore, if we WON’T define it we have no one but ourselves to blame when some nameless, faceless 30 year old sociology major in D.C. does it for us.

Nobody asked me (again), but as long as I’m here let me offer up a 3-part proposal to measure and promote quality using surgeons as a theoretical template. Let’s start with a thought exercise borrowed from CrossFit. Fitness training using the CrossFit methodology involves high intensity exercise while trying to maintain near-perfect movement and form. One is shown three targets from a shooting range. The first has random bullet holes all around the bullseye, the second has every shot dead-on perfect, and the third has 95% of the shots within the center bullseye and 5% on-target but not perfect. Which one represents the most desirable CrossFit training strategy?

In CrossFit the answer is “C”, 95% accuracy with the misses still close because this represents the optimal combination of form (accuracy) and intensity (speed). Is this directly applicable to surgery? Well, that depends on how far outside the bullseye the misses land, doesn’t it? And in surgery I think we also need a more accurate measurement of intensity; we need a clock. Speed matters, from both a medical standpoint and a financial one. The shorter a surgery lasts while still hitting the target, the less physically and mentally taxing it is for the patient, and the fewer costly resources (OR time, staff time, doctor time, supplies, etc.)  you are consuming during surgery. All things being equal, the surgeon who achieves the desired outcome faster without increasing her complication rate is the better surgeon.

Put surgeons on the clock.

A successful outcome must be explicitly defined for each common surgical procedure. Pre-operative factors that reduce the likelihood of success should certainly be taken into account (e.g. a morbidly obese cart-riding smoker and hip replacement), but care needs to be taken so that a measurement can’t be gamed (two guttata do not constitute a corneal dystrophy and increased likelihood of swelling) in order to work with a lower standard. Surgical societies should show some spine and make a call, define what constitutes a high-quality outcome, regardless of the howling that will emanate from the mediocre and the incompetent. It’s gonna happen anyway, and physicians making the call would be orders of magnitude better than MBA’s and philosophy majors.

Lastly, quality should be measured, publicized and praised, and those surgeons (and other doctors) should be explicitly rewarded with as many cases as they can (or wish to) handle. They should also be paid more. Once we decide what constitutes quality we can measure it and publish the data. People will understand this, just like they understand the data in a box score. Why is it so OK for the baseball player with the highest batting average or lowest ERA to be paid more based on his success, yet somehow the most efficient surgeon who has the best outcomes is labeled a “money grubber” who must somehow be doing something wrong if he is also very busy? We want that high batting average guy at the plate in the 9th inning of a tight ballgame, and we pay him more because of his higher quality outcomes. Why aren’t we doing the same thing with surgeons? The very least we can do is stop accusing surgeons of being successful!

It’s time that we apply basic theories about quality to medicine in general and surgery in particular. Indeed, it should be easier to do it with surgeons. Make a call–define a successful outcome. Pull out a stopwatch. Faster, more efficient surgery is less expensive and generally less taxing physically for patients. Once the data is available be transparent and publish the results. I know what Miguel Cabrera is batting this year; my patients (and potential patients) should know my “batting average” in the OR. While I hold out little hope of being heard on this last point, uncountable articles support the benefit of the carrot at the expense of the stick when it comes to promoting excellence. Higher quality should beget higher pay. At the very least we should stop with the assumption that the busy surgeon is somehow “getting over”, guilty of somehow gaming the system (eg. doing unnecessary surgery) until and unless proven innocent.

She may just be better.