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EBM Assesment in the Real World; or Critical Assessment on the Internet

A little discussion on Twitter led me to elaborate on red flags. Back in the days when I taught at a residency program, the Internet was exploding and it was important to apply the principles of critical assessment in order to evaluate the credibility of such vast access to new information. These are the same skills and principles we use in evidence-based medicine (EBM). The whole thing begins by not believing what you hear or read and being systematic and rigorously in analyzing the reasons not.

This Twitter interchange pretty much followed the same pattern. Shelley Petersen is a London based journalist and social networking marketer who focuses on innovative medical technologies and maintains an active twitter feed chock full of medical science articles. One of her articles raised a lot of red flags for me and when she asked me what those flags were I thought it was too much for 140 characters. It was time to tramp back over the article and provide a detailed analysis of what struck me as improbable and unreliable about the information.
The article was from a Pittsburgh paper and was fairly balanced, presenting some contrary perspectives, so the red flags were about what the principal was saying. In brief, the CEO of a private company was discussing how a long recognized function of telomere shortening and how it explained aging and all the diseases associated with aging.
1. Everyone has an inherent bias, mine is to be skeptical. The CEO of a company is to sell something. In this case, I suspect it is to sell a narrative to investors. I am dubious at the get-go, so red flag number 1.
2. Most research happens at universities. Scientists know that some of the best research happens at smaller universities, but when the only experts cited in any article are from Harvard and MD Anderson, I begin to suspect spin. Certainly I would expect some degree of balance between “name” institutions and other excellent university departments which are less of household names. Over-citing can raise flags.
3. Telomeres are not new. Telomere shortening is not new. When one individual claims he has insights that nobody else has been smart enough to figure out over decades, it is wise to be suspicious. Moreover telomere shortening is an epigenetic phenomenon. Nobody believes that epigenetic phenomena occur at the same pace everywhere in all tissues at the same time. Telomere shortening in fibroblasts does not predict telomere shortening in ovaries, or any other tissue. So wildly expansive claims should leave the reader incredulous that decoding this one phenomenon will end aging, cure all cancer (where telomere shortening may eventually pan out to a mechanism in one or another subtype of cancer), get rid of heart disease, cure wrinkles and fix your stiff knees..
4. Activating the immune system is a phrase that is a throw-away for naturopaths and quacks. Ask anyone with allergies or rheumatoid arthritis. An active immune system is not a good thing and depending on your definition, may well lead to a cancer, like say… lymphoma, a cancer of the immune system. Let’s face it, we all need a well-regulated immune system, but “activation” is meaningless in any scientific context.
5. Anyone who tries to market an innovative pharmaceutical product as a supplement is selling snake oil, plain and simple. The FDA evaluates specific therapeutic claims for specific pathological entities. They do not even evaluate absolute efficacy, drugs only need to demonstrate superiority over placebo. No such regulation exists for supplements, so many companies that do not have the ability to go through a rigorous review and demonstrate scientific merit will circumvent the process and come to market as a supplement. With the notable exception of nutritional deficiencies, there is usually no merit to claims that vitamins, supplements or minerals cure cancer, heart disease or any other disease, except maybe obesity and weight loss issues supplemented by means of ECA stack, etc. The idea that taking something as simple as a supplement may be appealing but has no basis in fact, since it is still an exogenous product, natural or otherwise. 
The principles of critical assessment are to assess date, author, quality of the publication and citations. Biological plausibility is important in assessing a scientific article, along with the link between the data and the claims made. This can be applied to journalistic information as well and when claims are expansive or vague, skepticism should take over. Any attempt to circumvent well-established processes to verify and certify scientific findings completely invalidates the speaker’s credibility in my mind. Being skeptical means you will believe only a small fraction of what you read, but this is not necessarily a bad thing. There is very little truth in much of what you come across on a daily basis, but there is plenty of hype and plenty of reasons for people to try and attract your attention.
Shelley’s work exposes me to a wide variety of information, which I find useful. The article itself was well-balanced and prudently presented, but the company and the spokesman were presenting snake oil under the guise of science.
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Family Medicine in the New Healthcare Landscape

A couple of weeks ago, I was invited to our local residency graduation party to give a few words on behalf of the Clark County Medical Society. It was more of a party than anything else, but there was so much I wanted to say. It was supposed to be about the residents, they had a keynote speaker, and I had five minutes to promote the society. I also kept getting ideas right up to the time of the speech. I cannot tell you how many rules of public speaking I broke. I read most of the speech, way too fast, couldn’t keep eye contact with the audience and improvised on the fly… not really sure if the main points came through. It was probably more of an essay, probably more multi-layered than it should be for a simple five minute talk.
So here it is in blog format.


You are graduating into the single most exciting period in the past century of medicine. Sweeping changes to how healthcare is delivered is being contemplated and actually being enacted.
The last time this much change was going on at the same time was.. well, it was when I was graduating. They told me the same thing. From my  In the late 1980’s and early 90’s, a pharmaceutical revolution had reduced hospital stays and the technological revolution of minimally invasive surgery was about to threaten the need for beds across the country. HIV had been isolated and drugs were emerging that could potentially provide hope for a treatment. The practice of medicine was coming to be viewed more and more as a business and restrictions on physician advertising were being rolled back, along with the introduction of pharmaceutical direct-to-consumer advertising that was just starting at the time. Managed care was growing, HMO’s were felt to be the inevitable wave of the future and the first wave of integrated health systems was about to begin, with physicians selling their practices to hospitals that were reaching out blindly to won as many practices as they could.
Since then, we saw the boom of primary care in the HMO era, the consumer backlash that followed, and the unwinding of integrated health systems. It was painfully apparent by then that FP’s did not always have a good business sense and many lost money taking on capitated patients with exposure to too much risk. The hospitals realized they needed to pay attention to what they were buying when they bought a practice and for more than a decade, they were very cautious in such enterprises. The pharmaceutical industry seems to have split in two: the “me-too” drug manufacturers and the biotechs. The success of specialty drugs is perhaps nowhere felt more than in oncology where survival started increasing in the most stubborn of cancers like lung and pancreas. Indeed breast cancer is now more of a chronic disease than an acute illness and this may yet occur with other conditions. In fact, think of HIV/AIDs which is a persistent, annoying and important public health problem, now also best managed as a chronic disease. Some of our internal medicine colleagues, not known for being well remunerated have entered a golden age of their own, think of rheumatologists and the spread of biologicals in lupus and RA.
So maybe I’m wrong, maybe every age is the most exciting age in the history of medicine and the pace of change is merely accelerating. That means you will have to be accustomed to constant change throughout your careers. Such a thought can be a little sobering, because we all need some constants in our life. Living with constant change sometimes feels like living in the eye of a hurricane.
On the other hand, consider the following… no matter how much the content and context of medical care changes around you and your patients, some things do not change… a physician and a patient behind a closed door discussing their health. The generalist physician, in particular, is the one who does the troubleshooting. This never changes. Family medicine defined this way, is an integral part of the health care system. Worldwide, many experiments are under way in horizontal care with nurse practitioners, physician extenders, community health workers and the like… At the center of any program is a generalist physician who encourages, fosters and actively participates in caring professional relationships with people who may or may not know what kind of healthcare they need.
A mature specialty does not ask for the respect of its colleagues; it merely acts knowing that it is contributing to the well-being of everyone it touches by the individual acts of its practitioners.
A mature specialty does not criticize its colleagues for acting according to their immediate pecuniary interests. It recognizes its inherent power to guide and direct patients to where they will get the greatest value for their money. It also recognizes that much of its credibility in the eyes of the populace rests in the network of specialists to which they have access. People see value in getting to the right specialist quickly.
Primary care will be at the center of the future healthcare system and the fact that family physicians alone see all patients along the age spectrum provides a huge market advantage. I speak as an employer now. I have asked family physicians to step aside if they were uncomfortable with caring for certain age groups to step aside. I’d rather have an internist.
So how about some free advice to be valued as such from a doc who is now old enough to be looking downfield for a Hail Mary pass:
Family Medicine will be fine as long as you focus on certain things:
  1. Focus on the health of the population. In so doing, you will always be able to see the amount of value you are contributing to the communities where you work, no matter how little you actually get paid!
  2. Focus on the fact that without generalist physicians, the goal of a safe, efficient, effective health care system cannot be achieved.
  3. Focus on the fact that you need to work well with everyone in the allied health fields: PA’s, NP’s, pharmacists, home health aides, radiology technicians, lab porters… Medicine was never supposed to be a turf war and what you do depends on the contributions of so many, it is best to remember them in everything you do.
  4. Remember that nothing makes competition irrelevant than a change in the landscape. Your competition is not against PA’s, NP’s, specialists and the like… it is with them you must work to improve the health of populations.
  5. It is OK to say no to working more for less. There are settings where you can deliver better care with less effort and mean more to people. (And maybe make more money.)
  6. Stay involved.
    Medical and specialty societies are both important. In this county the WAFP is not as strong as the WSMA, but there are other counties where the opposite is true. Get involved in both. It’s not about how they represent you, but rather that when you get involved, you start driving how it represents you. There is nothing more important to understanding how a new relationship between family medicine and the rest of medicine will work until you see how family physicians are getting involved all the way up to the AMA.
I would like to leave you with this one final thought on how important your contribution is
“Family physicians are the guardians of the House of Medicine; the last credible proponents of sensible care.”
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Egypt and Democracy

It was not my plan to start off a blog by a physician, medical director and policy “wonkabe” with a commentary on international geopolitics, but I have been recently obsessed with my father’s ancestral land and had some interesting online interactions.

When Mohamed Morsi was deposed by a military intervention following a popular uprising, the question became if the military’s action represented a coup. More to the point, the question was which party was behaving undemocratically.

First let me get some disrespect out of the way; it is easy to make fun of the USC graduate who worked for NASA and yet appears to be unable to speak English on a televised interview. He is wooden in front of the camera, tentative and sometimes speaks in confused and inarticulate manner. Even those for whom Arabic is a fluent and native tongue find him confusing. He spoke about inclusive and democratic dialogue but shut people out when they disagreed with him.

Nonetheless, were demonstrations, mobs and civil unrest an appropriate democratic response to an apparent political incompetence to govern? Usually a coup involves a small group of people installing themselves over a large majority of the population and enforcing their power through terror and a police state. This may not have fully occurred in Egypt this week, but even trivial human rights violations give a bad taste. Given the Muslim Brotherhood’s decades of persecution and professed patient non-violent path to power, the apparent failure of democracy has deep and profound implications about effecting change though political action rather than the point of a gun.

My  early experience in Canada was with governments that folded under popular opposition and pressure. Sometimes it occurred when it looked like political capital was tapped out. Frequently the popular dissatisfaction with a particular political figure played out along party lines. Pierre Trudeau was forced to resign in 1980, but when his successor was defeated in a general election, he managed to return and regain the post. Brian Mulroney was forced to resign as his popularity plummeted. Canada’s first prime minister John A McDonald was forced to resign due to a scandal. A crisis in 1896 involving numerous cabinet resignations and chaos in Ottawa forced the resignation of McKenzie Bowell two years after taking office and never having won an election.

In England, I doubt that Gordon Brown would have been able to usurp Tony Blair’s position had it not been for scathing criticism, popular disaffection with his leadership and plummeting poll numbers. The 1970’s brought a time of great unrest in strike-bound Britain, with at least one government collapsing and a snap election being called (Edward Heath 1974). Some would argue that Neville Chamberlain had to resign after losing face in a campaign of appeasement towards Hitler’s Germany.

In 1979, Indian PM Morarji Desai was forced to resign in the face of tumultuous internal party strife accompanied by numerous manifestations. More recently internal party strife has led to Australia’s Julia Gillard and Kevin Rudd flipping the post and they are even on the same side, belonging to the same party.

But all these are parliamentary democracies and things may not work the same in republican democracies. What happens in the US? We have the example of Richard Nixon leaving office for an unelected, quickly appointed vice president due to overwhelming public opposition and popular resistance to his rule. We also have a militia culture in some parts of the country that view themselves as the final arbiter of what the federal government can and cannot do. If recent attempts to pass gun control legislation had been judged too obtrusive by some segments of our society, civil disobedience would have been a real possibility. Even though I support this type of legislation, it is probably just as well we were unable to pass it because it was divisive. Much to the surprise and dismay of those in other democratic settings, the existence of a potentially violent resistance in the US is omnipresent but has not been a factor thanks to the structural and constitutional checks and balances that prevent any branch of government from accumulating too much power.

It has struck me in the past that the function of democracy is not to get things done, but to prevent any large group from doing something stupid. Democracy is the anti-accomplishment method of running a government.

But this has not been the purpose of the Muslim Brotherhood and the style of political Islam which appears to have only succeeded in Turkey. Islam in political terms is much like American “Fox News Conservatism” which seeks to remake society in ideological terms. The question posed by Deena Adel (@deena_adel) and Yamine El Rashidi (@yasminerashidi) in a recent twitter exchange is how a democratic system can be inclusive of a group bent on violence. The question I responded with is how can you integrate a group whose goal is the establishment of a totalitarian theocratic state.

The fundamental failure of Morsi, The Freedom and Justice Party and the Muslim Brotherhood was attempting to govern as though winning the election was a mandate for them to act as they wished. The fundamental platform, based on faith that their actions are always just as long as they further the interests of Islam, is that good people representing Islam are above the law and the constitution. This seems to me the assumption behind the constitutional slight of hand of late 2012. Understandably the Islamist statists do not see these actions as justification for military action or even having their candidate succumb to popular pressure to step down. “It is not fair, I was elected, ” Mr. Morsi said in one of his prolonged speeches. The manifestations of democracy begin and end with the election.

Of course the last sentence is not true. Democracy is a messy give and take between majority and minority power centers reflecting the balance of power in a society at any given point in time with the given understanding that it is a constantly shifting power base anyway. Civil society is based on the presence of stable institutions reflecting vested interests, whether the Cato Institute or the local chapter of the Soroptimists. Plural societies can organize around groups that even embody conflicting values within limits. Democracy requires constant cajoling, realingnment, arm twisting, threatening and rewarding. It requires the recognition that fundamental freedoms are never abrogated by the democratic process itself.

In an article by the Brookings, Hadi Shamid reflects on how 2013 will fall into the pantheon of Islamist betrayals like 1992 in Algeria, among others. But as I recall, the problem in 1992 was that the election was allowed to proceed in the first place with he Islamic Salvation front. It was a party that specifically and freely acknowledged a goal of introducing an Islamic totalitarianism. The failure of secular forces was to expect them to be defeated, so that when they won there was no choice but to forcibly shut them down like the anti-societal totalitarians they were.

The Islamists proper grievance is that the rules seem to change once they get in power. Attempts by liberals to demonstrate their openness to any and all opposition groups leads them to extend courtesies where consideration will bear no fruit. It is inadvisable and unwise not to be clear from the beginning: that any action which undermines a pluralistic, diverse and civil society will result in exclusion from the political process. This is what happened to Mr. Morsi and we are now left in the awkward position of trying to explain why the military in Egypt is the entity to forcibly enact principles of democracy.

The fact that David Brooks’ Defense of the Coup is so insulting in reference to “lacking the most basic mental ingredients” for a democratic transition reflects this basic dynamic. We explain democracy as we understand it, using Western terms with our education and a half millennium of enlightenment thinking. The messages are being received by a group whose intellectual heritage missed the enlightenment altogether and whose logic remains in a theocratic constraint where logic does not need to be rooted in any verifiable empirical evidence. Mr. Brooks makes the correct observations, but comes to the wrong conclusions. The problem is not DNA, it is intellectual heritage. The problem may be an elitist perspective bred by education and an inability to reach out to the less instructed.

I am cautious to point out that the US must play its cards right in order to secure the entire world’s future stability. The fault for the terrorist attacks on 9/11 rests only with the terrorists themselves, but the sequence of events that unleashed our current Islamist nightmare may well be traced back to Western goofs over the past century. They may also even include Nasser’s 1954 crackdown on the Brotherhood as Hadi Shamid suggests.

I am equally cautious to point out that the root of Islamist excess today rests in Christian excess of the past. I remember reading an account from Turkey a century and a half ago, where a Muslim trader expressed resentment that every time he wanted to develop a business, he had to go through Christian middle men. The Copts in Egypt were in the majority a little over a century ago, but their [our] concern for the poorer Egyptian and mostly Muslim brethren’s social and economic well-being was perhaps at times less than admirable. The milk of Christian love must first look at oneself, not for fault but for root cause.

Today Coptic communities are poorer than ever, escaping Egypt for economic and physical security, and struggling to help create a better Egypt for all. I am personally a half-century removed from basking in Egypt’s summer sun, but I have drunk from the Nile and my thoughts ever go back. We all need to find a better way to communicate the meaning of democracy and our intolerance to attitudes that will not support a civil society. Islamist disappointment is quite justified, but this is because Islamist ideology is simply not compatible with democratic institutions and processes.

I hope this article leads to a respectful discussion of the role of political Islam in democratic Arab states. I hope it is not offensive to any parties.

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First Post

I used to write a blog several years ago under a pen-name. I became disillusioned around that time; not with blogging as much as with my job. I stopped writing as my anger was leaking into my writing. I was supposed to be “The Physician Executive” but found myself unable to hold a job, buffeted by my own ego and surrounded by some more than disingenuous people. Nothing in my career as a physician, teacher, manager or self-described policy commenter had prepared me for the foulness of the human struggle.

Yes, I got involved in a political battle at work and found myself oddly unprepared for the interpersonal and political battles which presented themselves. The blow to my confidence was such that my next job, accepted mostly because I needed a job, went just as badly. Well, ’nuff said.

I have since gotten back on my feet.I worked my way into a private practice, where I am now a principal and am working on developing a medical home and honing our quality performance. During my Master’s, I particularly honed interests in Outcomes and Management with a view to quality management. I feel reasonably well-integrated in the community; I get along with most people, but am already aware of some people who stand in opposition to my ideas, attitudes and practices. That’s OK, nobody in the world only makes friends without being a little obtuse.

Over time, I have regained confidence in my insights and my ability to communicate them. I no longer intend to write just about health care, management and policy items, or be in search of ideas for persuasive essays. This is not a blog with its own brand identity. Writing for a local magazine, I requested republication rights. Everything I publish should eventually come under the umbrella of dinoramzi.com.

My wife and I have started two companies, one was a consulting company that took in some revenue between jobs, and is now a small holding company with investments in several healthcare (and non-healthcare) fields. SanZoe Health is in pursuit of ideas that can improve the delivery of primary care, because it is the best way to improve the health of populations (at least as far as health services are concerned). SavingHealth.com is a web site that will deliver evidence-based medicine (EBM) insights from the perspective of a practicing physician. There was a time I would perform reviews for the teaching program when I was involved in teaching at Emory. I have published an evidence-based review in a large circulation continuing education journal. Now that I am in practice, I find I still use the skills. These skills may be scarce, but they are definitely not unique but nobody is actively blogging them. So we’ll get this one up when we get the time… between patients, you know.

We also started PanZoe, which should begin accepting donations within a month or two to help deliver innovative primary care to uninsured or underinsured Americans. We will begin locally, in the Camas/Washougal area, suburbs of Portland Oregon. This is our status as of June 2013 and I do not intend to update this first entry.

At this time I am also the President of the Clark County Medical Association, an alternate delegate to the Washington State Medical Association, and an active member and delegate to the Washington Academy of Family Physicians.

Politically, I am conservative, but you might not recognize my ideas as conservative given that the current crop of right-wingers are merely radicals to my eye. Many of them would call me a liberal. At the end of the day, I am an Independent who supports No Labels and the Congressional Problem-Solvers. Being a bit of a gadfly and calling out inconsistencies on both sides, I could be regarded as uniter of the parties; both sides can always rally behind the idea of throwing me out of the room!

The simple and effective communication of complex ideas is not at easy thing to do. It is a skill that requires a great deal of practice. I have not invested enough time in doing this, but have become aware that my head is exploding with innumerable multi-step ideas. There is no way to describe the role direct-primary care combined with reinsurance and a disappearing deductible for employers to avoid the Obamacare tax and improve the health of the population without building ideas one by one. I need this venue to develop the articulation of these ideas.

The greatest paradox and struggle of my life is that an intellectual path eventually takes you to a place of uncertainty, unknowing and doubt, which inevitably leads to either a sort of intellectual nihilism or on the other hand, to a succumbing to faith. I came backwards to the faith of my ancestors, to the world of Eastern Orthodoxy, mostly as a cradle Greek Orthodox. I accepted this world because of its inherent mysticism; although there is dogma in this church, there is much we acknowledge as unknown. All revelation is short of the blinding reality of God. I find echoes of Orthodox Christianity in the non-religious methodology of mindfulness meditation and most recently in “happiness” research and the concepts of “flow” and “social altruism.” My old professors are guffawing as I write, but this too is something by which I stand.

If by way of advocating for the things I am most passionate about, I run into something offensive, please forgive me in advance. It is not my primary purpose to advocate for any single entity; not for primary care or family medicine, not for the Clark County Medical Society, the AMA, the AFP or its state affiliates, my wife’s for-profit holding company or my non-profit foundation, EBM, mindfulness meditation or the Orthodox Church. But these things are reflections of who I am and what I care about.

I hope you will enjoy the blog and follow its evolution.

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Why Should Physician Rankings Impact Quality of Care?

Dr. Stanley Feld at Repairing the Healthcare System has been writing his blog for over a year and most would agree that he is a very thoughtful physician. Even without an MBA or an advanced management degree (that I can tell), he presents the kind of insights that non-MD executives and business people would do well to carefully heed.

His most recent series has been on physician ratings, especially the ratings produced by the insurance industry. He follows up on an article in the Washington Post that reported physicians’ reputations beings harmed by the inaccuracies of insurance company data.

Dr Feld writes,

“In our dysfunctional healthcare system tensions are building to great heights between the insurance industry, patients and physicians. The appearance of this article makes me think that the insurance industry subconsciously has a death wish to completely destroy the Healthcare system. The insurance industry is totally insensitive to patients and physicians. Its only concern is its bottom line and seducing employers to buy its product.”

Right on the money!

Of course, one could ask what a for-profit entity should try to accomplish if not increase profits? [Full disclosure: I currently own 100 shares of United Healthcare, a company that was raked over in the Post article.]

It is doubtful that United or the insurance industry is trying to destroy the healthcare system; it is much more likely that the corporations that run health plans are pandering to one or more of their stakeholders, especially Wall Street. Employer groups, who are much more vocal than individual patients, have been clamoring for more physician ratings and greater transparency in health care. They have nothing to lose publishing imperfect physician ratings:

  1. If the data are accepted they get kudos for being proactive and their efforts are appreciated by wall-streeters who judge it a positive development for the company. Investors be sold on the idea that it is a worthy attempt to reduce costs (meaning payments to providers). One of Dr. Feld’s point that deserves high-lighting is that the insurance company’s real customers are human resource directors and benefits managers. These people make their CEO’s happy when they take care of their employees at the lowest cost with the fewest complaints. After all most consumers don’t get to chose an insurance company unless it’s on their employer’s menu.
  2. If the data are rejected, the insurance companies can simply blame physicians. They can tell the world physicians are impairing transparency in healthcare. This effectively deflects that the lack of transparency is mostly a by-product of the insurance industry working with hospitals. Be clear about this: it is not in the insurance industry’s interest to promote transparency.

I happen to believe in data and performance improvement. Collecting data is never a bad thing, as long as you keep away individuals who do not understand the limitations of numbers! The only ‘bad’ data is the data are the data that policy-makers take inappropriate action with.

One of the major objections on the part of physicians is that they do not directly control patient behavior and they can’t be accountable for the health outcomes of their patients, most of whom do not follow physician direction, no matter how meticulously it is presented. These are valid arguments against pay-for-performance, which in turn, is the logical extension of physician ratings. Our understanding of what constitutes quality in healthcare is incomplete, definitions are not really operational except in defining negative incidents, the data is imperfect and the the measures would not meet the most superficial test for validity. Despite all this, there are forces afoot that would move the process forward because that is how systems learn. Systems make mistakes, adjust, refine and correct themselves.

Another counter-argument to physicians who feel they are being held accountable for outcomes that are beyond their ability to influence is the variation in outcomes. Some doctors simply do better at changing people’s behavior and achieving certain results.

For example, it is a reasonable argument that low-income patients with poorer health status and greater health literacy needs and enormous racial and ethnic disparities would have poor health outcomes. However, data from the Health Disparities Collaboratives would suggest that Federally Qualified Health Centers can blow away the competition in most measures of health outcomes according to the chronic conditions measures. [Full disclosure: the facility I help manage participates in the Collaboratives and I have only seen data on diabetes.]

Bottom-line: some physicians appear to get better outcomes from their patients, no matter the initial health and socio-economic status. I know one doc who has spent considerable time learning about motivational interviewing and even before this training had an uncanny connection with some patients. She was capable of getting patients to do things most physicians had enormous trouble with. She could get people to quit smoking and exercise and collect body fluids for 24-hour urine tests and stool collections where most patients produced contaminated or incomplete specimens. They would get their mammograms and even come back for repeat Paps when they were unspeakably scared of what they might find. They would take their pills and could be seen walking to the mall!

Health outcomes and health behaviors are multifactorial and -make no mistake – physicians can have a huge impact. This should be reflected in pay for performance, physician evaluations, ratings etc. However, it needs to be a relatively small component of the overall rating to reflect the fact that patient behavior is not entirely determined by the physician. The patient remains part of the picture. The bulk of the rating should reflect the process: i.e. on the referral for mammography, not how many patients actually followed through. (Process measures not outcome measures.)

There are quality measures that look at processes (did you do the test?), and quality measures that look at biological outcomes (did the patient’s test result improve?). These two categories are at opposite ends of what is directly in the physician’s control and what is not. Behavioral outcomes are probably somewhere in the middle. Each of the three should have different weight in a physician rating. For example, 75% on the referral and 20% on if the patient went and 5% on the actual outcomes, but that’s pretty arbitrary.

The conundrum is that all quality measures are really proxies for quality. Nobody really knows that the definitions of quality truly represent the notion of quality. Half a physician’s value, at least in non-procedural specialties, is due to intangibles. The practice of medicine is all about relationships: if a patient has a good relationship with their doc, they’ll do better. No performance measures can capture that. We also know that patient satisfaction measures are subject to the halo effect, affected as much by the age of waiting room magazines are and the attractiveness of the staff. These are not direct measures of how good the physician is! I suspect the main reasons physicians resist and are disengaged from the process of performance improvement is the intuitive understanding that both patient satisfaction and performance improvement activities have serious limitations. Data are good, but physicians question if the data is good enough to be actionable. Experience has taught them that such efforts are not often based on good science, but can be reflection of societal pressures and the political struggles behind them. It has progressively made their lives miserable. Data is intended to be used to make policy, but rarely does data drive the policy!

Unfortunately, physicians have not had much reason to embrace quality and performance improvement. The us wastes and incredible amount of resources on healthcare and gets very little outcome on a population basis. Physicians should engage; they are a better source of solutions than we have now. Physicians can point out the strengths and limitations of data on their own practices.

If physicians are disengaged because they are skeptical, outcomes are less likely to improve. My advice is get involved and back a single horse to smooth out the standards. (There are currently over 10 organizations and agencies in the US that encourage the use of one or another standard for measuring quality of care. The National Quality Forum is my fave. The Post article points out that there are subtle differences in the wording and cutoffs of the standards, which leads to confusion.)

Moreover, once the data are part of a performance improvement project, the are often used to reward high-performing physicians and punish another. One of the primary principles put forward by Donabedian in the 1960’s was not to use such data punitively or you’ll never be able to collect valid data again! The goal isn’t to make people look good or bad, it is to improve care overall. Everyone who is working to collect data knows the data isn’t perfect and that it doesn’t need to be perfect to be useful. But it better be accurate enough to be actionable.

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Socialized Medicine – Business Medicine

There is a lot of buzz lately over government’s role in health care. As usual, it seems to me that the arguments align predictably with ideology. Some feel health care is a right, others that it is a business and any effort for government intervention is tantamount to socialized medicine.

Physician executives and other health care executives are caught in the classic “Catch-22” of an obligation to provide care where it is necessary (morally, legally and ethically) while struggling to justify the radical expectation that they should actually be paid for services provided.

The conclusions are a natural consequence of the assumptions with which people approach the argument. The arguments are always logical and internally consistent, but logic is useless without constant attention to assumptions, so I’d like to see how they stand up. The first two statements below are polar opposites of the next two and are among assumptions that are typical of the right and the left.

  1. Health care is not a right
  2. Medicine is not a calling
  3. Health care is not a business
  4. Medicine is not about improving one’s own living status

I suspect most readers would either agree or disagree with each of these four statements, some will even react violently. The reader might also wonder why they are written in the negative. My point is that’s the only way for all four statements to be true… read on.

Health care and medicine are an unusual sector of the ECONOMY where a social good coexists with a business activity.

The health care sector is responsible for one seventh of the country’s economic output but recipients of health care may see other economic consequences. I believe there are economic benefits of access to good health care, including future economic production. However, the closest I ever got to seeing the proof was a reference to an ancient pilot study that purported to show an improvement in income following the introduction of improved Medicaid services. Well, I never found the original study and I bet it was fraught with problems. I suspect economic benefits of health care access is an extremely difficult point to prove, which is why it is simply not part of the debate.

The relationship between economic productivity, health status and poverty are clear, but the effects of intervention (i.e. improved access to health care) are certainly not adequately fleshed out. Moreover, is there any reason to believe that the researchers would not bring their ideological biases to any such investigation?

Other social activities bear a similar burden of dual roles (social good and economic engine), like road construction and education. Free markets and competition sometimes exist in these sectors, but only by virtue of the type of regulation that levels the playing field and defines areas of potential abuse and profiteering. The same can occur in health care.

Medicine IS a business AND a calling. Health care is a right AND an economic engine. Only after acknowledging this will the rhetoric cool and pragmatic intelligence drive a pragmatic capitalist solution to social needs.

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Michael Moore, Fair and Balanced

I came across this post from hippocrates, which is one of the most fair and balanced assessments I have read about SiCKO. Brilliant really, as much as the film was entertaining.

The whole SiCKO phenomenon underlies much of my fascination with the health care debate. Both the right and the left come to the issue with predictable preconceptions. Michael Moore manipulates facts beautifully… nearly as effectively as Fox News and the pop culture caricatures of conservative thought. In SiCKO, Moore strikes me as much more honest and less the propagandist than in his prior films. No solutions here, but this film has brought the debate to the fore. Only time will tell if it will galvanize anything.

After all neither Upton Sinclair nor Michael Moore are to be taken seriously as policy makers; this is not the Flexner report that forever changed the face of medical education. Michael Moore is an entertainer and a darn good one at that.

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Welcome

I find many things fascinating, not the least of which is the incredible noise that rises from various media about health care. The cacophony is hardly intelligible, characterized by an incredibly naïve and the kindest warm-heartedness (albeit potentially counter-productive) on one-hand and selfish market-centered arguments on the other.

Although learning about and expounding on policy, ideology and philosophy can be enormous fun, any physician turned manager is ruled by a pragmatism dictated by where the rubber hits the road.

I am a radical, affirmative centrist and a pragmatist who manages to upset ideologues of either stripe, right or left. I really don’t like ideology taking precedence over truth or right.

The mission of medicine as a calling is equally as valid as the business of medicine. When the rubber meets the road, we must absolutely set aside our political and ideological differences and focus on achieving fundamental goals. But we can have fun arguing!

Apart from the dialectic, I hope this blog will bring to bear the unique perspectives of a practicing physician and health care manager to the worlds of management and policy. I have accumulated anecdotes and stories over years of journaling. Some of these stories shed light on the world of medicine that hopefully will add to the worldwide debate on health care.

I am the medical director of mid-sized, multi-facility, primary-care based, multi-specialty safety net Community Health Center on the East Coast of the US. I am not (yet) a US citizen and have graduated from a global top 10 or 20 medical school depending on which magazine you read. I have a management degree from a top-5 School of Public Health. I also have a background in residency education, having served in various roles over more than a decade at two different University based family medicine programs.

I will write this blog pseudonymously due to controversies associated with health care for the underserved (Medicaid, minority and immigrants) since I would like to avoid adverse consequences for my job, my patients or the community. As an anonymous blog, it is difficult – if not impossible – to provide additional reassurances that no other conflicts of interest exist. All I can do is promise full disclosure as we proceed and hope the frequent disclaimers will not be overly distracting.