Struggling with the (relative) value of humanistic medical care –

I just arrived in San Francisco. I am here for the 2014 Heart Rhythm Society sessions.

The meeting begins today. A poster session this evening is overflowing with notable studies. Stay tuned. I’ll be working hard for theheart.org to bring you the best stories.

First, though, here’s a little appetizer.

On the eve of the biggest EP meeting of the year, my friend Wes Fisher, also an electrophysiologist and writer, posted this provocative piece, When We Reward Regulators More Than Doctors, on his blog. Wes did some investigating and learned that doctor-executives in the testing industry reap remarkable salaries. Ever the techie, Wes graphically displayed the salaries of those who regulate versus those who care for people (e.g. doctor). In a country where the notion of inequality and value are in vogue, the differences were striking. Wes is not shy. He uses the word greed, which seems strong; but he is talking about human behavior.

I wrote briefly on this topic in March during the ACC meeting. Wes, however, is the leader. He has led the charge in opposing the current “board certification” process.

I read his post last night and had time to think about it on a long plane trip. I’ve also thought a lot about the issue of evaluating doctors in the past months and years.

Wes is surely correct to point out inequities of pay between real doctors and doctor-executives. It’s truly awful what reform has done to the humanity of health care. My family doctor works harder than any person should have to; he’s trying to practice medicine the way it was, the right way, according to him. This means coming to the hospital to see his patients at 11 PM–after he finishes a ‘normal’ office day. He’s an anomaly; normal doctors don’t roll this way. Most normal doctors jump off the treadmill before it gets this fast.

The irony of undervaluing the care part of healthcare is that it runs counter to what reform was supposed to accomplish. We meant to help those most in need, but, in many cases, we did the opposite. The shortage of caregivers in poor rural communities, like so many in my state of Kentucky, gets one thinking hard about what we value–about relative value.

Why is US society this way? It’s not just about doctors; what about teaching our children? Why do we collectively look past the obvious?

The other thing I struggle with in this debate is the view of the patient. There must be some way for the public to know his or her doctor is a capable and skilled professional. These are human lives that turn on our skills–like the pilot who landed our plane in windy San Fran last night.

This is where I struggle with complete opposition of a certification process. I want to be tested. I want to compete for business on a level playing field. I’ve made it my life’s work to be the best doctor I can be.

Yet…and this is utter nonsense: If a loyal group of referring doctors change to the competing hospital system next month–I’m out. I could be the Atul Gawande of AF ablation and I’m still out. There’s more. Consider that in our fee-for-service model, where producing RVU (relative value units) is how employers measure doctors productivity, the doctor who thinks too much or asks hard questions could easily be replaced by the quieter young doc who simply likes to do procedures. There’s no column for thoughtfulness on a productivity spreadsheet. Think too much–and you could be out.

From the day I started private practice in 1996, there has never been a legitimate way for a patient to discern good doctors from lousy ones. To use big words, our doctor-evaluation system is devoid of meritocracy. And it’s getting worse.

Ironically, the so-called “quality” measures and patient satisfaction scores only obfuscate the task of finding the best doctor. Do you want a doctor who is skilled at clicking boxes and complying with [perhaps flawed] guidelines, or, do you want a doctor who knows the exact torque to place on a catheter in your body? Or, the doctor who can see your elderly father as a suffering person rather than a list of diseases in need of repair?

Tough questions to get on a test.

These are some of the thoughts running in the background of my mind as I attempt to learn (and teach you) the newest and greatest from the leaders of electrophysiology this week.

JMM

Comments

  1. Lisa says

    Word of mouth is about the only way a patient has to evaluate a doctor. By that I mean old fashioned word of mouth (my friend told me) not questionable reviews on a website. And then I’m trusting my friend to know what a good doctor is. Being personable doens’t constitute a good doctor. If it did, my EP would never even have gotten a second appointment. If the doctor blogs, I can get a feel about how much they know if they write on the subject that I’m going to see them for. Like you, I would probably not consider calling your office. Not because I think you are a bad doctor, but you only write about afib. You don’t write about ventricular arrhythmias. Finding that my doctor blogs rarely happens, it isn’t a good measurement. Usually the best recommendations I get are from the nurses I know. When I told my friend who works a the same hospital that my doctor works that I was being sent to Dr. X and she was highly enthusiastic. i knew then that I would be in good hands. That is the only measurement tool that I have.

  2. Dr. Wes says

    John –

    Absolutely spot on and so nicely articulated. increasingly doctors are seeing quality, safety, and certification regulations as cudgels to care. I find it abhorrent that regulators use the threat of poor quality or poor “professionalism” to coerce doctors into performing functions that enrich their bottom line in the hopes of better “business care” rather than helping us do better “patient care.” Patients value wisdom, caution, and experience, not regurgitation of meaningless factoids. The notion that doctors are incapable of maintaining their knowledge in today’s internet era flies in the face of reality, especially when liability concerns are already hanging over our heads.

  3. Robert Wayne Lewis says

    Nice post, very thoughtful and contemplative. I didn’t know medical doctors could be so finely in tune with metaphysical and philosophical concepts in relation to treating patients but apparently some are :)

    Again, great post and a thoughtful read I’ll be sure to recommend to my friends.

    Robert

  4. Gerald says

    As a patient, evaluating a doctor is the most important element in seeking treatment. After having been misdiagnosed with AFIB, I speak from experience in how I select medical treatment. Obviously, I want a doctor with experience working with my particular issue but I also want him/her to be able to communicate with me and one who keeps up with the latest research. I want shared responsibility for my treatment program. This is how I avoided the trap of unnecessary treatment and over medication for a condition that I did not have. I discovered this blog earlier on and believe that I am ultimately responsible for my own wellness. The doctor is my guide.

  5. marisha chilcott says

    Dear Dr. John -
    I’m a primary care doctor in California and just found your blog by searching for info on non-ischemic cardiomyopathies and high performance cycling. In searching for the technical, I found the ever-more-important personal. I too measure the success and meaning of my work in hugs, smiles and little notes left on my chair… I’ve just finished a 12 hour overnight shift in the hospital, admitting people with DVT’s, new onset Afib, NSTEMIs and FUOs; I had a glass of good Italian red wine and a few bites of tri-tip for breakfast while reading your notes and before sleeping a few hours so I can get up to ride my road bike. Thank you for the re-affirmation of what we do as vocation.
    Marisha Chilcott