No Matter What, We Pay for Others’ Bad Habits

An essay published yesterday in the Times:


“I’m tired of paying for everyone else’s stupidity,” is a comment I read on the Internet last week after the health care bill was passed. It summed up the views of many Americans worried about shelling out higher premiums and taxes to cover the uninsured. Why should we pick up the tab when so much disease in our country stems from unhealthy behavior like smoking and overeating?

In fact, the majority of Americans say it is fair to ask people with unhealthy lifestyles to pay more for health insurance. We believe in the concept of personal responsibility. You hear it in doctors’ lounges and in coffee shops, among the white collar and blue collar alike. Even President Obama has said, “We’ve got to have the American people doing something about their own care.”

But personal responsibility is a complex notion, especially when it comes to health. Individual choices always take place within a broader, messy context. When people advocate the need for personal accountability, they presuppose more control over health and sickness than really exists.

Unhealthy habits are one factor in disease, but so are social status, income, family dynamics, education and genetics. Patient noncompliance with medical recommendations undoubtedly contributes to poor health, but it is as much a function of poor communication, medication costs and side effects, cultural barriers and inadequate resources as it is of willful disregard of a doctor’s advice.

A few years ago surgeons in Melbourne, Australia, were refusing to provide heart and lung surgeries to smokers, even those who needed the operations to stay alive. “Why should taxpayers pay for it?” said one surgeon quoted in media reports at the time. “It is consuming resources for someone who is contributing to their own demise.”

Though some were outraged by this stance — the Australian Medical Association called it “unconscionable” to ration services based on personal habits — many doctors agreed with it. Like the majority of Americans, they saw nothing wrong with patients paying for the consequences of their actions.

The problem is that punitive measures to force healthy behavior do not usually work. In 2006, West Virginia started rewarding Medicaid patients who signed a pledge to enroll in a wellness plan and to follow their doctors’ orders with special benefits, including unlimited prescription-drug coverage, programs to help them quit smoking and nutrition counseling. Those who did not sign up were enrolled in a more restrictive plan that, among other things, limited drug coverage to only four prescriptions a month.

The program, by many accounts, is failing. As of August 2009, only 15 percent of 160,000 eligible patients had signed up. Patients with limited transportation options were having a hard time committing to regular office visits. And experts say there is no evidence that restricting benefits for noncompliant patients has promoted healthy behaviors.

As a cardiology fellow, I once took care of a young man with severe congestive heart failure. We were supposed to start him on a blood thinner early in his hospitalization, but it got overlooked. Fed up with the delays in getting his blood sufficiently thinned, he left the hospital against medical advice. He said he had to go home to care for his toddler.

He came to the clinic a week later looking very embarrassed. He had left without prescriptions, so he had been taking no medications since he left, leaving him short of breath. To compound the problem, he had been eating cold cuts, cheap and readily available, which made his condition even worse. But the attending physician refused to give him prescriptions. She said that he had to go to a walk-in clinic. She said he had to learn personal responsibility.

Healthy living should be encouraged, but punishing patients who make poor health choices clearly oversimplifies a very complex issue. We should be focusing on public health campaigns: encouraging exercise, smoking cessation and so on. Of course, this will require a change in how we live, how we plan our communities.

“It’s the context of people’s lives that determines their health,” said a World Health Organization report on health disparities. “So blaming individuals for poor health or crediting them for good health is inappropriate.”

I must admit I often feel like my colleagues who grouse about spending all day treating patients who do not seem to care about their health and then demand a quick fix. I do not relish paying more taxes to treat patients who engage in unhealthy habits. But then I remind myself that we all engage in socially irresponsible behavior that others pay for. I try to eat right and get enough exercise. But then I also sometimes send text messages when I drive.

The whole point of insurance is to reduce risk. When people inveigh against the lack of personal responsibility in health care, they are really demanding a different model, one based on actual risk, not just on spreading costs evenly through society. Sick people, they are really saying, should pay more. Which model we eventually adopt in this country will say a lot about the kind of society we want to live in.

Curbing Hospitalization Costs

Our healthcare system is perversely structured to encourage behavior that is detrimental to health. For example, doctors are usually paid for every visit they make while their patient is in the hospital, which sometimes encourages delays in discharge. However, it is widely accepted that long and/or frequent hospitalization harms patients due to unnecessary procedures, hospital-acquired infections, and so on. This article addresses one aspect of this problem and examines a possible remedy.

http://www.nytimes.com/2009/12/01/health/01essay.html?ref=health

Doctor as Businessman

An essay I wrote in today's Times.

A Doctor by Choice, a Businessman by Necessity

To meet the expenses of my growing family, I recently started moonlighting at a private medical practice in Queens. On Saturday mornings, I drive past Chinese takeout places and storefronts advertising cheap divorces to a white-shingled office building in a middle-class neighborhood.
I often reflect on how different this job is from my regular one, at an academic medical center on Long Island. For it forces me, again and again, to think about how much money my practice is generating.

A patient comes in with chest pains. It is hard not to order a heart-stress test when the nuclear camera is in the next room. Palpitations? Get a Holter monitor — and throw in an echocardiogram for good measure. It is not easy to ignore reimbursement when prescribing tests, especially in a practice where nearly half the revenue goes to paying overhead.

Few people believed the recent pledge by leaders of the hospital, insurance and drug and device industries to cut billions of dollars in wasteful spending. We’ve heard it before. Without fundamental changes in health financing, this promise, like the ones before it, will be impossible to fulfill. What one person calls waste, another calls income.

It is doubtful that doctors and other medical professionals would voluntarily cut their own income (even if some of it is generated by profligate spending). Most doctors I know say they are not paid enough. Their practices are like cars on a hill with the parking brake on. Looking on, you don’t realize how much force is being applied just to maintain stasis.

I recently spoke with a friend who dropped out of medical school 20 years ago to pursue investment banking. Whenever we meet, he finds a way to congratulate me on what he considers my professional calling. He often wonders whether he should have stuck with medicine. Like many expatriates, he has idealistic notions of the world he left.

At our most recent meeting, we talked about the tumult on Wall Street. Like many bankers, he was worried about the future. “It is a good time to be a doctor,” he said yet again, as I recall. “I’d love a job where I didn’t have to constantly think about money.”

I didn’t bother to disillusion him, but the reality is that most doctors today, whether in academic or private practice, constantly have to think about money. Last January, Dr. Pamela Hartzband and Dr. Jerome Groopman, physicians at Beth Israel Deaconess Medical Center in Boston, wrote in The New England Journal of Medicine that “price tags are being applied to every aspect of a doctor’s day, creating an acute awareness of costs and reimbursement.” And they added, “Today’s medical students are being inducted into a culture in which their profession is seen increasingly in financial terms.”

The rising commercialism, driven in part by increasing expenses and decreasing reimbursement, has obvious consequences for the public: ballooning costs, fraying of the traditional doctor-patient relationship. What is not so obvious is the harmful effects on doctors themselves. We were trained to think like caregivers, not businesspeople. The constant intrusion of the marketplace is creating serious and deepening anxiety in the profession.

Not long ago, a cardiology fellow who had been interviewing for jobs came to my office, clearly disillusioned. “I was naïve,” he said. “I never thought of medicine as a business. I thought we were in it to take care of patients. But I guess it is.”

I asked him how he felt about going into private practice. “I’ll be too busy vomiting for the first six months — I won’t have much time to think about it,” he replied.

Of course, there has always been a profit motive in medicine. Doctors who own their own imaging machines order more imaging tests; to take an example from my moonlighting work, a doctor who owns a scanner is seven times as likely as other doctors to refer a patient for a scan. In regions where there are more doctors, there is more per capita use of doctors’ services and testing. Supply often dictates demand.

But financial considerations have never been as prominent as they are today, probably because so many hospitals and doctors, especially in large metropolitan areas, are in financial trouble. More and more doctors are trying to sell their practices, or are negotiating with hospitals for jobs, equipment or financial aid.

At hospitals, uncompensated care is increasing as patients suffering from the economic downturn lose health insurance. Admissions and elective procedures — big moneymakers — are declining. Hospitals are cutting administrative costs, staff and services.

“More and more you’ll see people in medicine get M.B.A.’s,” a doctor told me at a seminar, in a prediction borne out in my experience. “We are in a total crisis, and I don’t know the answer.”
I must admit that part of me wants to see doctors master the business side of our profession. When I hear about executives at health companies getting tens of millions of dollars in bonuses, I am nauseated by the blatant profiteering. As a loyal member of my guild, I want to see doctors exert more control over our financial house.

And yet the consequences of this commercial consciousness are troubling. Among my colleagues I sense an emotional emptiness created by the relentless consideration of money. Most doctors went into medicine for intellectual stimulation or the desire to develop relationships with patients, not to maximize income. There is a palpable sense of grieving. We strove for so long, made so many sacrifices, and for what? In the end, for many, the job has become only that — a job.

Until I went into practice, I never had an interest in the business side of medicine. I sometimes yearn to be a resident or fellow again, discussing the intricacies of a case rather than worrying about the bottom line. “You need to learn a little of the private-practice mind-set,” a doctor friend recently advised me. “You can’t survive with your head in the clouds.”

But something fundamental is lost when doctors start thinking of medicine as a business. In their essay, Dr. Hartzband and Dr. Groopman talk about the erosion of collegiality, cooperation and teamwork when a marketplace environment takes hold in the hospital. “The balance has tipped toward market exchanges at the expense of medicine’s communal or social dimension,” they write.

How this battle plays out will determine to a great extent what medicine will look like in 20 years. This is about much more than dollars and cents. It is a battle for the soul of medicine.

On Referrals

An essay I just had published in the Times. Reax?

SJ

I was chatting recently with a doctor friend who was depressed because he thought he had lost a referral source.

“This internist was sending me patients,” he told me, as I recall. “Then last month he sent me only one patient. And this month only one patient.”

I nodded hesitantly, unsure what he was driving at.

“So I understand something must have happened,” he said.

“Like what?” I asked.

He threw up his hands, exasperated by my obliviousness. “He met someone else! He developed a relationship with another cardiologist.”

I smiled at the overwrought response, with its connotations of a romantic breakup. But to my friend, this was no joke. Like most specialists, his livelihood depends on referrals. And like most, he will go to great lengths to preserve his referral sources.

Physician-to-physician referrals are the currency of day-to-day transactions in medicine, but as with any currency, they can be manipulated.

Logic says that a referral should depend only on a patient’s needs and the reputation and skill of the physician to which the patient is referred. But medicine is a business too, so that isn’t how it always works in practice.

The talk springs up in every doctors’ lounge: “Dr. X is opening shop — let’s give him some business.” When my wife told me she wanted to start an endocrinology practice, I reassured her that I would send patients to her, and that so would my brother, also a doctor, and his friends. As far as I can tell, there are no restrictions on such a practice.

Studies suggest that physicians receive up to 45 percent of new patients by referral, usually from other physicians. Referral rates to specialists in the United States are estimated to be at least twice as high as in Great Britain.

The rates reflect several aspects of American medicine: increasing specialization, the lack of time for any doctor to give to complex cases, and fear of lawsuits over not consulting an expert. At the same time, referrals are a way for cash-strapped doctors to generate business.

When I was in training, simple referrals from internists, like patients with only mild hypertension, bothered me as a waste of time. Now that I am in practice, I welcome them. I haven’t changed my mind that these referrals are probably unnecessary, and there is plenty of evidence that wasteful expert consultation is adding to health costs and creating redundant care. But as a full-fledged doctor, I appreciate the business. It is hard not to view a referral as an overture from another physician, and it is equally hard not to return the favor.

A sort of paradox is at work. Specialists are better paid than primary care physicians, but they are also less autonomous because, unlike primary care physicians, they depend on other doctors for referrals. There is pressure on specialists to keep referral sources happy, especially in doctor-saturated metropolitan areas like New York City.

There are limits, of course, on the autonomy of referring physicians, too. For instance, by federal law a doctor cannot refer patients to himself or to a business in which he has a significant financial stake, like a laboratory or imaging center, and he cannot be paid for a referral. The reasoning is that such behavior can interfere with clinical judgment, decrease quality and increase costs.

In 2006, Tenet Healthcare Corp., based in Dallas, agreed to pay $21 million to settle a whistleblower lawsuit asserting that a hospital it owned in San Diego had paid kickbacks to physicians for referrals. (Tenet did not admit wrongdoing.) That same year, a New Jersey teaching hospital was investigated for giving sham salaries to community doctors in a reported attempt to increase the number of referrals to its cardiac surgery program. Two cardiologists pleaded guilty to federal fraud charges.

But there are gray areas in practice. The Office of the Inspector General in the Department of Health and Human Services has investigated office space rentals, for example. Across the country, mobile medical imaging companies have made arrangements with internists to perform, in their offices, cardiac ultrasounds, which the companies send to cardiologists for interpretation. Insurance companies that cover the imaging pay the companies, and the companies pay rent to the internists. By law, these rent payments must reflect fair market value and be unrelated to the volume of patients referred by the internists for imaging. But according to doctors familiar with these agreements, that isn’t always the case.

“Obviously you get more rent if you provide 50 patients than if you provide 5,” an internist on Long Island, who did not want his name used, told me.

When I asked whether it wasn’t just a form of a kickback, he shrugged.

“When the companies take more time, they have to pay more rent,” he said. “You don’t say it is per patient; you say per hour. But patients equal time.”

Though he no longer participates in these contracts, he was open about the payments — about $100 per patient — and he saw nothing wrong with them. “As internists, we don’t bill for procedures, so we have to figure out another way to make money,” he said. “Every little bit helps.”

Whether the rent payments amount to indirect kickbacks is an open question still being investigated by the inspector general. The real issue, I think, is not the rentals but a referral system that is too easily corrupted. There is so much pressure to generate referrals that lines become crossed.

Our health care system needs a different approach, one in which patients are not treated as commodities.

One possibility is what Gail Wilensky, a health policy expert, argued for this year in The New England Journal of Medicine: a single payment that would cover all physician services and hospital care for any one patient. A major driver of referral proliferation is that doctors are paid piecework. There is less of an incentive to increase volume if payments are bundled rather than discrete for every service.

A bundled-payments system is already in place for hospitals, dialysis centers and nursing homes. Extending such a strategy to individual doctors’ payments seems to be the logical next step.

PEN World Voices Festival

I recently participated in the PEN World Voices Festival of International Literature, which took place in New York City from April 27-May 3. PEN is an organization of writers that is working to advance literature, defend free speech, and promote literary fellowship. I was delighted to be invited to join in their annual festival.

Monday was the opening night party at the French Embassy, where I had photos with my wife, Sonia, snapped by a guy named Beowulf (seriously). On Tuesday, Sonia and I attended a reception at the American Museum of Natural History, where PEN President and Princeton professor Kwame Anthony Appiah delivered an impassioned address about freedom of expression. My event, the Inspired Scientist, was on Wednesday at the Instituto Cervantes. My fellow panelists were Majora Carter (Macarthur “genius” for her work on environmentalism in the South Bronx), Harriet Washington (National Book Critics Circle Award winner for her book Medical Apartheid), Kimiko Hahn (author of 7 collections of poetry), and Tijs Goldshmidt (author of Darwin’s Dreampond). This is the video link.

The week was rounded out by receptions at the Instituto Cervantes on Friday and a swanky party at Greenwich Village townhouse on Sunday. All in all, a very fun week talking about literature and celebrating with fellow writers.

"The Soul of Medicine" Book Review

Here is my review of Sherwin Nuland's new book, The Soul of Medicine, published today in the Sunday Times Book Review.  Not the best offering, in my opinion, of this remarkable and trailblazing physician writer.

SJ

April 19, 2009

Physicians’ Tales

By SANDEEP JAUHAR

THE SOUL OF MEDICINE

Tales From the Bedside

By Sherwin B. Nuland

214 pp. Kaplan Publishing. $26.95

“A story like the one I’ve been telling you is unimaginable nowadays,” a physician proclaims in “The Soul of Medicine,” Sherwin Nuland’s new collection of medical tales. The stories — modeled on “The Canterbury Tales” — are intended to “describe that sacrosanct connection between two people that we call the doctor-patient relationship,” Nuland writes. Indeed, the tales, narrated by physicians recalling their most memorable patients, evoke a bygone era in medicine, though one that is thankfully over.

In “The Surgeon’s Second Tale,” a young man is whisked to the operating room to have a ruptured spleen removed on the basis of a history and physical exam — unthinkable nowadays, when a patient with a simple headache cannot get out of the emergency room without a CAT scan of the brain (though the diagnosis was correct). Another surgeon performs a radical mastectomy on a young woman who believes she is getting only a breast biopsy and a simple vaginal procedure, without even waking her up from anesthesia to tell her that the biopsy indicates cancer. Four hours later, the entire breast and mass of contiguous tissue have been removed. “There’s something we have to talk about,” the surgeon tells her at the bedside.

It is horrifying what doctors used to get away with. Nuland himself recalls a young man whose bowel had perforated into his chest, spreading fecal material around the lungs, causing a life-­threatening infection. He graphically describes cutting down to the bone, excising part of a rib and draining the light-brown feculent pus. But what is amazing is not the infection or the way it occurred but that Nuland, a resident at the time, and his intern performed the surgery by themselves, apparently without any attending supervision. Nuland proudly tells the chief of the surgical service about the case the next morning. But where was the chief the previous night?

Indeed, more than a couple of doctors in these tales would be brought before a state medical board today, if not put in jail. In “The Anesthesiologist’s Tale,” a surgeon with bipolar disorder stops taking his medications and loses his mind during a routine gallbladder operation, cutting wildly, lopping out part of the stomach, lacerating the aorta, eventually being jumped and restrained by orderlies, all the while threatening to sue. In “The Chest Surgeon’s Tale,” a self-described scoundrel boastfully recalls bedding student nurses while a young married surgeon; lying to get a nursing supervisor fired; and, in the most disturbing anecdote, purposefully thrusting an ungloved hand into the chest of a 14-year-old boy undergoing a heart operation.

Nuland writes that these stories are “the lessons of humanity itself, with all its wondrous gifts and its failings.” But this collection suffers from the lack of an overarching theme or idea. If you’re going to write a book of stories with this conceit, the reader has the right to expect more: engaging narrative, insight, reflection. Nuland does provide commentaries to some of the tales, which bring out some historical tidbits, but they have a sort of ad hoc, cobbled-together quality. It would have been better to integrate the commentaries into the tales themselves, and Nuland doesn’t help the situation with gushing encomiums to some of his narrators, physicians he has encountered in the course of his career.

As a great admirer of “How We Die,” which won Nuland the National Book Award, and “Lost in America,” a soul-searching memoir of his immigrant father, I was hoping for much more from this slim book. Still, despite its antediluvian elements, there are some timeless lessons here, like the story of an 85-year-old man who undergoes a colonoscopy that reveals a cancerous polyp. The doctors decide to operate, and during the induction of anesthesia, the man dies of cardiac arrest. In his frail condition, he had a probable life expectancy of only three years, much less than the time it would have taken for the cancer to do him in. The fact that we can treat disease, Nuland suggests, does not always mean we should. Would that more doctors today followed this basic maxim.

Residency Match Day commentary--Should Residents Take Naps?

It was 3 o'clock in the morning, and Mrs. Williams needed a CAT scan. I rolled her stretcher into the radiology department, where a burly technician and I tried to put her onto a table. But there was a problem: Her intravenous tubing wasn't long enough. The technician asked me if we could stop the IV drip she was receiving. "Sure," I replied automatically. I was mind-crushingly tired. As a new medical intern, I'd been working for 21 hours straight, with hardly time even for a toilet break. I wasn't really thinking about what was going on.

Midway through the scan, Mrs. Williams started moaning that she was having chest pain. When the scan was finished, I quickly reconnected the IV line and turned the machine back on, but all I got were beeps and flashing red lights. Then it hit me square in the gut: I had stopped Mrs. Williams' nitroglycerin, used to treat angina. She was having a heart attack.

 

Across the nation at noon today, fourth-year medical students will receive a piece of paper telling them where they will be spending the next 3 to 7 years of their lives training to become doctors. During this period, called residency, they will work 80 hours per week and stay up every fourth night or so on call — all while managing complicated patients like Mrs. Williams with little supervision.

 

Though they probably don't know it, they will also be entering a controversial debate about how many hours they should work. In December, a panel of educators convened by the prestigious Institute of Medicine recommended a mandatory 5-hour nap time for residents on call, as well as shifts no longer than 16 hours. This sounds like a good thing — for doctors themselves and especially for their patients. But work limits come with their own set of vexing problems — problems that could actually be worse than an epidemic of tired doctors.

 

You see, in response to work limits, teaching hospitals have been forced to increase cross-coverage — in a nutshell, caring for patients when their primary resident is not on duty. Most have created the position of "night float" — residents who work the night shift so others can sleep. The problem is that this system necessitates frequent patient handoffs, which can result in the transfer of faulty or inadequate information.

 

I'll never forget a patient I once took care of on night float who had esophageal cancer — and also intractable hiccups. A nurse mentioned a drug called chlorpromazine that was sometimes used to treat hiccups, so I wrote an order for it. Walking through the nurses' station, I casually checked the patient's chart. There, amid his papers, was a brief note. He had once suffered a severe reaction to this particular drug. It wasn't documented as an allergy on my sign-out sheet; I had been extremely lucky to stumble across it.

 

In medicine, as in aviation, most errors occur at transitions: by pilots, during takeoff and landing, and by doctors, after handoffs. Because of work limits, during an average monthlong rotation, an intern might be involved in more than 300 handoffs, which are susceptible to breakdowns in communication, thus potentially creating errors. Work limits have other troubling consequences as well, including interruption of resident learning and the creation of a kind of shift-work, clock-watching mentality among young doctors.

 

It is possible, in short, that work limits are weakening medicine more than exhausted interns ever did. I worry that, thanks to work limits, the current crop of interns is missing out on valuable lessons. As for patients, they are probably no better off — and maybe even worse.

 

Mrs. Williams, by the way, turned out just fine. She wasn't having a heart attack, and my fatigue-induced error was quickly corrected by a nurse. Of course, I don't deny that a doctor who has gone too long without sleep can make a grave error. But it is possible to overcorrect for even the most serious of problems. And in trying to get young doctors a bit more rest, we may have come up with a cure that is worse than the disease.

www.sandeepjauhar.com