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  • Why Doctors Quit.

    Posted by Michael Kennedy on May 29th, 2015 (All posts by )

    Today, Charles Krauthammer has an excellent column on the electronic medical record. He has not been in practice for many years but he is obviously talking to other physicians. It is a subject much discussed in medical circles these days.

    It’s one thing to say we need to improve quality. But what does that really mean? Defining healthcare quality can be a challenging task, but there are frameworks out there that help us better understand the concept of healthcare quality. One of these was put forth by the Institute of Medicine in their landmark report, Crossing the Quality Chasm. The report describes six domains that encompass quality. According to them, high-quality care is:

    1) Safe: Avoids injuries to patients from care intended to help them
    2) Equitable: Doesn’t vary because of personal characteristics
    3) Patient-centered: Is respectful of and responsive to individual patient preferences, needs and values
    4) Timely: Reduces waits and potentially harmful delays
    5) Efficient: Avoids waste of equipment, supplies, ideas and energy
    6) Effective: Services are based on scientific knowledge to all who could benefit, and it accomplishes what it sets out to accomplish

    In 1994, I moved to New Hampshire and obtained a Master’s Degree in “Evaluative Clinical Sciences” to learn how to measure, and hopefully improve, medical quality. I had been working around this for years, serving on the Medicare Peer Review Organization for California and serving in several positions in organized medicine.

    I spent a few years trying to work with the system, with a medical school for example, and finally gave up. A friend of mine had set up a medical group for managed care called CAPPCare, which was to be a Preferred Provider Organization when California set up “managed care.” It is now a meaningless hospital adjunct. In 1995, he told me, “Mike you are two years too early. Nobody cares about quality.” Two years later, we had lunch again and he laughed and said “You are still too years too early.”

    We are now in the third year of Obamacare and its troubled implementation. One feature of Obamacare is a mandate to adopt the “Electronic Health Record.” Naturally, the term used is not “Medicine” or “Medical.”

    I hear this everywhere. Virtually every doctor and doctors’ group I speak to cites the same litany, with particular bitterness about the EHR mandate. As another classmate wrote, “The introduction of the electronic medical record into our office has created so much more need for documentation that I can only see about three-quarters of the patients I could before, and has prompted me to seriously consider leaving for the first time.”

    You may have zero sympathy for doctors, but think about the extraordinary loss to society — and maybe to you, one day — of driving away 40 years of irreplaceable clinical experience.

    The comments to the article in the Washington Post are about what one would expect from that readership. What are the results of this mandate ?

    One thing that everyone agrees on is that advances in technology can contribute greatly to our attempts to improve quality and value in the healthcare system. And this is where electronic health records (EHRs) come into the picture. The EHR is the instrument at the center of most organizations’ plans to drive lower cost, better care. In fact, huge amounts of money have been invested in these EHRs, and organizations are understandably concerned about what their return on investment will be.

    The adoption of the EHRs in clinical systems should help drive the quality agenda. But it’s important to recognize that EHRs alone may not be sufficient to deliver data intelligence, to really deliver data to clinicians in a meaningful way that will help them improve value.

    I was an enthusiast about the electronic medical record when I was in practice and was a member of the national association, The American Medical Informatics Association.

    There is a program called “10 x 10,” Which seems to focus on distance treatment by the use of video and remote care can make great use of such techniques. Native Alaskan village clinics can use “telemedicine” to improve care.

    Previously, data sent from a rural clinic traveled from its location to a ground station, to a satellite orbiting beyond the earth, and then to a ground station on the receiving end before reaching it’s destination.

    Data that timed out during that process had to start again. Sending an image could take several tries, upwards of 20 or 30 minutes.

    Now, information travels by fiber optic cable or microwave tower. For many YKHC clinics, that means it travels from the clinic to Bethel out of Bethel by fiber optic.

    The same image that once took half an hour can be sent in a matter of seconds.

    This is where EHR can make major contributions.

    The EHR that Krauthammer writes about, however, is a burden with very little to recommend it.

    “EHR technology can make it easier to commit fraud,” as in Medicare fraud, the copy-and-paste function allowing the instant filling of vast data fields, facilitating billing inflation.

    That’s just the beginning of the losses. Consider the myriad small practices that, facing ruinous transition costs in equipment, software, training and time, have closed shop, gone bankrupt or been swallowed by some larger entity.

    This hardly stays the long arm of the health-care police, however. As of Jan.1, 2015, if you haven’t gone electronic, your Medicare payments will be cut, by 1 percent this year, rising to 3 percent (potentially 5 percent) in subsequent years.

    Here is where the compulsory nature of government mandates comes into play.

    One study in the American Journal of Emergency Medicine found that emergency-room doctors spend 43 percent of their time entering electronic records information, 28 percent with patients. Another study found that family-practice physicians spend on average 48 minutes a day just entering clinical data.

    At faculty meetings I hear stories of clumsy interfaces that, for example, require a diagnosis be entered before any data can be recorded. That is not how medicine works. After the patient is worked up, the erroneous diagnosis cannot be deleted. That is foolish and may be dangerous.

    As with other such arbitrary arrogance, the results are not pretty. EHR is health care’s Solyndra. Many, no doubt, feasted nicely on the $27 billion, but the rest is waste: money squandered, patients neglected, good physicians demoralized.

    What it is doing is driving me out of teaching students and it is driving many older doctors to drop out of government medicine altogether.

    Who are the winners and lost of Obamacare ? technology is a big winner. Whether it works or not.

    Digital health. The digital health sector is young and is booming. Especially hot right now are affordable technologies that help people better understand their health. While a number of these devices have skirted the need for FDA clearance (such as the FitBit and other fitness trackers), there is a steadily growing number of digital-health enabled medical devices, such as the Agamatrix iBGStar and AliveCor’s mobile ECG technology. Also included in this sphere are genomics firms that could revolutionize the field of diagnostics in years to come by enabling truly personalized medicine. While this field overall has high potential, many digital health startups seeking to enter the traditional healthcare market still face significant challenges and competition from traditional players in the space.

    The EHR developers are hoping for more.

    Using an advanced analytics application to analyze our data, we discovered that 10 care processes accounted for 53.2% of our organization’s variable cost. This knowledge helped us prioritize our improvement efforts. We knew exactly which care processes—such as asthma care, appendectomy and more—gave us the greatest opportunity for reducing variability and waste.

    Here is the real incentive. Like all discussion of “quality” by government or payer organizations, it is all about cost. I have no objection to cost reduction where reasonable, but technology is a major cost driver and young doctors are losing the institutional memory of older ways of doing things. I know my students, or at least those I will not be teaching, may lose what I might have been able to impart.

     

    17 Responses to “Why Doctors Quit.”

    1. David Foster Says:

      “Using an advanced analytics application to analyze our data, we discovered that 10 care processes accounted for 53.2% of our organization’s variable cost. This knowledge helped us prioritize our improvement efforts. We knew exactly which care processes—such as asthma care, appendectomy and more—gave us the greatest opportunity for reducing variability and waste.”

      Getting this information should not require the EHR or an “advanced analytics information.” If someone really wanted to know, the information could have been obtained to a reasonable degree of accuracy by sample surveys.

    2. Mike K Says:

      I don’t object to this use of EHR. I did a study at Dartmouth of dialysis access surgery. we showed that the most important factor in the survival of the grafts that connect patients to dialysis machines was Zip code.

      Zip code was an obvious indicator of the surgeon and his/her skill.

      I could not get funding to do a national study. We estimated it could save Medicare about 5 Million dollars a year. Chump change,

    3. dearieme Says:

      “I can only see about three-quarters of the patients I could before”: that’s the recent experience in our local NHS university teaching hospital. They actually say things like “Sorry, you’ll have to wait for an appointment because we can’t see so many people now because of the new IT system”. I was in for an all-day test a few months ago and witnessed the shambles: the nurses spent far more time fannying on the computers and phoning for help than they did with the patients. The doctors cursed, not always under their breaths.

      On the other hand the health records system that links the local GP practices together, and links them all to that same hospital, is a genuine success.

      Personally, I carry a self-prepared summary of my own medical history and hand it to any doctor I go to see. They seem surprised and pleased. But is a layman’s guesswork at which episodes are worth recording not a little dangerous?

    4. Mike K Says:

      One side effect of all this is the destruction of medical records after 7 years or less. The law requires they be kept until a child is 18 but we find over and over that they are destroyed with no regard for patient welfare. Keep your own records.

    5. TMLutas Says:

      Mike K – Such a study (dialysis access) could be funded privately via kickstarter or indiegogo these days. How much would it cost?

      Dearieme – You can get much of that money back if you get somebody to transcribe the doctor in real time into the EHR.

    6. Mike K Says:

      The dialysis access study was a grant application, of which Dartmouth would take 40% for over head. Not the type that could be done by private organization. A group in Michigan had a contract for end stage renal disease research and they were probably a big reason we got turned down. One factor would require access to the Medicare claims database, another reason to involve official government organizations.

      A better example of private funding doing a better job at this is the “Human Genome Project” and Craig Venter’s “The Institute for Genomic Research,” which actually deciphered the human genome. The government project was a leisurely gentleman’s club with a multimillion dollar budget.

      Venter’s group was privately funded and had to share the credit with the government group at Clinton;s insistence. The fact that Venter’s group had done the analysis of the semen stain on Lewinisky’s blue dress probably had nothing to do with the decision ;)

    7. Mike K Says:

      “On the other hand the health records system that links the local GP practices together, and links them all to that same hospital, is a genuine success.”

      This is the reason why I was an enthusiast. However, implementation has not gone that way. For example, the EHR at Cedars Sinai medical center where most staff members are UCLA faculty, is not compatible with the UCLA EHR system. They are all proprietary. I would suggest a uniform system until I remember what a hash the feds made of Obamacare data processing.

      Back when I was involved, there were protocols for the different EHR systems to interface. After all, the FTP has worked pretty well for 50 years. The hospitals want to make doctors serfs and the records are a way to keep them bound to the hospital system. Hospitals made a big bet on Obamacare and are the most enthusiastic participants.

    8. MaryB Says:

      From a patient’s perspective, EHR does affect patient/doctor communication. My doctor spends most of our brief time together peering at the computer screen and typing. There is very little eye contact with me and I often feel inhibited about continuing the conversation. There is an unwelcomed 3rd party in the room.

    9. ErisGuy Says:

      The history of IT is strewn with ill-conceived, gargantuan projects that drag on for years spending millions and billions without success. One more.

    10. Mike K Says:

      Mary, it is so frustrating to me trying to teach medical students to interact with patients as people that I am giving up.

      I finished my training in 1972 and began a clinical faculty position at USC that year. For 20 years, I was surgery faculty and assisted residents in evaluating patients and doing the surgery. For 20 years, I spent every fifth Saturday night in the hospital all night. When I retired from practice, I was interested in continuing a teaching role and started with medical students. I have done that 15 years. This is the last year. I have been threatening this for the past four or five but student evaluations kept me coming back. This is it. I even wrote a letter to the Dean last year about how the EHR has interfered with teaching and he called me. He said, “This can’t possibly be true !” I asked him if he had done any teaching.

      NO answer. Deans raise money.

    11. grey bear Says:

      If Jesus were to heal the sick today in the US, he would be arrested and crucified for practicing medicine without a license, performing/using unauthorized procedures and medicines, and having illegal IT record keeping.

    12. Mike K Says:

      Grey Bear, I’m not sure what you propose. China went through a stage of “barefoot doctors” and gave it up as the society grew more educated. We have an extensive extra -medical culture of chiropractors and naturopaths that people see for routine medical matters. Nurse practitioners and PAs do a lot of primary care.

      Most cases of “Practicing Medicine without a license” involve actual harm. Many illegal aliens got to untrained practitioners but they only get prosecuted when they kill somebody.

    13. grey eagle Says:

      Dr K,

      Communication between doctor and patient has gone down hill in the past 55 years because lawyers began to practice medicine in the courtroom as well as by passing laws and making rules.

      Sadly there are people who prey on the sick and the dying and, as you note, they still prey today. sometimes these evil doers co-opt the government officials assigned to regulate them. And sometimes regulators suppress miracle workers because they have poor form. The difference between prayers and preyers is not always clear.

    14. Assistant Village Idiot Says:

      We must know folks in common. Geisel (Dartmouth) Medical School provides our hospital’s psychiatrists and their students intern here. We are just now switching over to EHR. As with most required changes, the purported benefits are described in a world where everything goes right. Well, lots of things work in that world. The overoptimistic projections are what worry me. My son’s hospital in Nome went to EHR last year. They are still having enormous problems.

      EHR might turn out to be a net plus, even after the cost is figured in. It’s just not there yet, and it’s dishonest of folks to pretend that it is, just because it should be in a perfect world.

    15. RonaldF Says:

      People who squeaked by with a C average in management will soon be telling doctors how to practice medicine. Obama will have his two tier society – those who evolve to the upper strata and the rest of us. The fact that people will vote this in is quite astounding.

    16. Mike K Says:

      “telling doctors how to practice medicine.”

      This is an old problem that dates back to the 70s when the feds began with “PSRO, Professional Standards Review Organizations.” The standards were always cost, not quality. Nothing has changed and I finally gave up on trying to do something about quality. Most of us mean well and try to do a good job. The crooks, and there are not that many of them, are almost immune to the state medical boards because the crooks have better lawyers. The medical malpractice bar actually does a better job and, if the system is reformed, as California did in 1975, it works pretty well.

      Insurance companies and Medicare/Medicaid are totally uninterested in quality.

    17. ErisGuy Says:

      If Jesus were to heal the sick today in the US, he would be arrested and crucified for practicing medicine without a license, performing/using unauthorized procedures and medicines, and having illegal IT record keeping.

      No, he wouldn’t. I know (second-hand) people who have been cured by faith healing. None of the priests and none of the family who prayed have been prosecuted. Then there would be the demonstration: Jesus would succeed, after which there would be no prosecution.