More (or less) Hope and Change (for the worse) In Healthcare: Are Doctor Shortages Really All Due To Training Bottlenecks?

There is no doubt that Affordable Care Act has changed the landscape of medicine in the US.  Now, private practice is becoming a thing of the past. Financial pressures, increasing regulatory requirements, electronic medical records and outrageously complex coding systems are forcing long time private physicians to enter into agreements with academic centers and large hospital systems in order to survive.  As a result, medicine today is more about increasing patient volumes, completing reams of paperwork and administrative duties than it is about interacting with patients and providing superior care.  The American Academy of Family Practice (AAFP) estimates that there will be a significant shortage of primary care physicians in the next several years unless we increase the number of primary care trainees by more than 25% over the same time period.  In fact, the AAFP suggests that the primary care workforce must increase to 260K physicians by the year 2025–which translates to an additional 52K primary care doctors.

Given the need for more physicians and the pending shortage (particularly in primary care), many analysts have suggested that the reason for the shortage is a lack of training slots in primary care.  The ACA will add an additional 32 million patients to the pool of insured and primary care doctors will be at a premium.  In the New York Times this week, the editorial board collectively penned an article discussing their thoughts concerning the doctor shortage.  The NYT editorial board suggests that the shortage is all about an imbalance between Residency training slots and medical school graduates and can be easily corrected by federal funding of a larger number of training positions.  However, I think that the issue is much more complex and the solution is far from simple.

Primary care is an incredibly challenging specialty and requires a broad knowledge of much of medicine.  Reimbursements for primary care work continue to lag and physicians are now spending more time with administrative duties than they are with patients.   I do not believe that the so called post graduate training “bottleneck” will come into play.  I would suggest that many primary care training slots will go unfilled over the next 5-10 years even without increasing the numbers of available positions.  Increasing training slots for primary care specialties may do nothing to alleviate shortages if there are no students who wish to train.  While medical school enrollments have increased over the last decade, much of this increased enrollment may be due to a lack of jobs available to recent college graduates.  Moreover, as the ACA continues to evolve, physicians are now realizing lower compensation rates, increased work hours, more administrative duties and LESS time spent caring for patients.  Many physicians are forced to double the number of patients seen in a clinic day–resulting in less than 10mins per patient–in order to meet overhead and practice expenses.  In a separate article in the New York Times, author and cardiologist Sandeep Jauhar discusses the increased patient loads and subsequent higher rates of diagnostic testing that is required in order to make sure that nothing is missed–ultimately increasing the cost of care.

For most of those who have entered medicine, the attraction to the profession is all about the doctor-patient interaction and the time spent caring for others.  I would argue that the primary care shortage (and likely specialist shortage) will worsen in the future.  Many bright minds will likely forego medicine in order to pursue other less government-regulated careers.  In addition, many qualified primary care physicians will opt out of the ACA system and enter into the rapidly growing concierge care practice model.  The answer to the physician shortage may be more political than not–politicians must realize that laws and mandates only work if you have citizens willing to devote their time, energy and talents to the practice of medicine.  Going forward, more consideration must be given to physician quality of life and autonomy must be maintained.  In order to make healthcare reform sustainable, those in power must work with those of us “in the trenches” and create policies that are in the best interest of the patient, physician and the nation as a whole.  Cutting costs must be approached from multiple angles–not simply reducing the size of the physician paycheck.

Medicine remains a noble profession.  Those of us that do continue to practice medicine are privileged to serve others and provide outstanding care.  In order to continue to advance, we must continue to attract bright young minds who are willing to put patients and their needs above their own–at all costs.  I think that there is still HOPE to save medicine in the US.  It is my HOPE that our government will soon realize that in order to continue to propagate a workforce of competent, caring physicians we must provide time for physicians to do what they do best–bond with patients and treat disease.  (as opposed to typing into a computer screen and filling out endless reams of electronic paperwork).  It is my HOPE that those physicians in training  that will follow in my generation’s footsteps will realize the satisfaction that comes from impacting the health and lives of patients over time.  It is my HOPE that the ART of medicine can be saved before it is too late….

 

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Privacy in the Era of Mobile Tech and Social Media: Facebook Fallout and New Innovations for Protecting Your Privacy

Did Facebook cross the line when conducting human behavior social experiments last year?  I think so.  When conducting scientific research on human subjects investigators are held to very high standards.  Currently there is global outrage over the experiment and government regulators from several countries are currently looking into the matter a bit more closely.  As I described in my blog a few days ago, Facebook recently published a paper in the Proceedings of the National Academy of Science reporting on a study that they conducted in September 2013.  In this study, researchers purposefully manipulated the News Feeds of randomly selected users in order to determine effects on mood and emotion.  None of the subjects were aware of the experiment and none had provided specific informed consent.

Many academic investigators as well as social media experts from across the globe have taken issue with the lack of specific informed consent and the utilization of subjects without any notification–until the paper was published in a well respected academic journal this last week.  Some groups have petitioned the Federal Trade Commission (FTC) and Facebook has had very little to say–other than “we are sorry…and we are adopting stricter internal review standards for future research.”

How can we avoid situations like this in the future?

Obviously, with the Facebook situation, public outrage and potential regulatory action by governments in many parts of the world may help limit these types of activities by social media platforms in the future.  Currently, several countries including both the US and many throughout Europe are discussing ways to limit privacy incursions such as the Facebook experiment in the future.

Unfortunately, the utilization of data by large social media platforms and organizations may not be the biggest threat to you and your privacy.  Hackers and other criminals are grabbing data from consumers–without their knowledge–from mobile devices such as tablets and smartphones.  These devices are placed in the hands of children, and often lie around the house and are frequently left “on” and unattended.

One inventor from New York City–Michael Sorrentino– has created a new device that can help keep you, your family and your data a little safer.

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Called the iPatch case, this device may change the way you think about your mobile device and its self contained camera.  Hackers and other criminals can actually utilize your own smartphone camera to take pictures of your home or office and can even build a 3D model of your house.  This can result in identity theft, theft of real property or utilizing your images without consent for whatever purpose the criminals deem necessary.  Disguised as a harmless camera application that is often downloaded, these programs can access your camera and obtain images without your knowledge or consent.  Other malware programs have been developed and innocently disguised as harmless games or apps for download.  Software has been developed (and sold by hackers for less than $50 dollars) that can infiltrate your device and control your cameras–stealing sensitive documents, creating models of a home or office or even snapping shots of your children.

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The device–called the iPatch is now in development.  Mr Sorrentino is currently working on the prototype and will be marketing the device once produced.  WIth the iPatch device one flip of a switch will cover and eliminate photo functionality from both the front and back camera of your smartphone.  The device is being developed through crowd-sourcing efforts and is expected to enter production this year.

Mobile technology is changing the way we interact and how we share information.  Issues such as the Facebook “experiment” should give us all pause to consider our safety as we continue to embrace social media, mobile technology and information sharing.  In the future, innovations such as the iPatch are likely to continue to emerge and will ultimately provide us with more options for staying safe while staying engaged and connected in our busy technology driven lives.  Most importantly, as parents, we must set good “mobile behavior” examples for our children and take measures to improve the security of our devices and our information.  Social Media is embedded in the fabric of our lives–and this is a good thing–we must, however, take care to continue to be vigilant and protect ourselves and our families from the new world of cyber-crime.

 

Experimenting with The Emotional Impact of Facebook: New Issues Surrounding Social (Cyber) Studies Without Specific Consent

Facebook, twitter and other social media platforms have become a hotbed of data for marketers, business and product development experts.  In addition, social media has created a new way to observe and investigate some of the intricacies of human behavior and social interaction.  Last week, a study conducted using Facebook users as subjects was published in the Proceedings of the National Academy of Sciences and reported this weekend by the Wall Street Journal as well as the New York Times.  This study, while interesting, has raised a new debate on the ethics of using social media users in social experiments without their consent.  While Facebook claims that they have all rights to perform such experiments under their terms of engagement–that all users sign when they create a Facebook account, many Facebook loyalists are upset and feel as though they have been manipulated and violated.

As an academically trained Cardiologist at Duke University and now faculty at the University of North Carolina, I have had a great deal of experience in medical research throughout my career.  There are basic principles and rules that must be applied when designing and conducting any investigation involving human subjects.  All scientific research on human beings requires informed consent.  In the University setting, we have Institutional Review Boards that provide oversight to any human experimentation–these boards function to protect the rights, safety and privacy of patient subjects.  When researchers manipulate variables and look to examine results, patients can be affected–either positively or negatively.  There has been a great deal of outrage over the recently published Facebook experiment.  Many debate whether or not Facebook has crossed ethical lines by performing a study involving manipulating variables without the consent of the user.  While the attorneys at Facebook will argue that its users give blanket consent to research under their terms of service– I believe that the rules that all of us must follow in any type of human experiment should apply.  Social media and networking is now a part of everyday life and spans all age groups–all of us are affected in some way.

This recent report is no surprise–We have known that Facebook and other social media outlets have gathered data on users for years.  Google and Yahoo have certainly utilized data obtained from individuals search preferences in order to promote advertising of certain goods and services on their homepages.  In fact, Facebook has an entire data science team that is given the job of collecting and analyzing data from nearly 800 million users worldwide.

In the latest investigation, researchers set out to determine if the content of posts on a user’s newsfeed could influence mood.  For one week in January 2012, the accounts of over 600K randomly selected users were manipulated by the research team.  According to Facebook executives,  the identities of the individuals in the study group were blinded and no personal information was shared. What they found was impressive–users whose news feeds were flooded with more negative postings tended to produce more negative content themselves and those users whose newsfeeds were  flooded with positive and inspiring news predominantly produced more positive content themselves.  Previous research in the area of emotional contagion seemed to indicate that in order to pass on a mood or emotion, in person contact and non verbal cues are required.  After conducting the Facebook experiment, the authors concluded that now emotion and mood can be passed on in an online environment without any in person contact at all.  Moreover, emotions shared on social networks can provide a system for large scale spread to millions simply as a result of negative or positive posts by others.   While this information is interesting and potentially quite useful to the both the business and scientific communities, this utilization of human subjects as “emotional guinea pigs” without informed consent has created outrage among many throughout the internet.  Manipulating the emotions of Facebook users within the framework of this experiment has been seen as an abuse of trust by many who are engaged in social networking and calls into questions the ethics of social experimentation via online platforms.

Beyond the ethical considerations that this type of investigation raises, I believe that this study actually may provide a very important message to those of us who utilize social media in medicine.  Social media is a powerful tool that allows us to communicate ideas, describe new technology and treatments and disseminate information.  This communication can be quite broad and the audience can be rather diverse–patients, colleagues and industry leaders.  As physicians, our voices can be heard well beyond our respective institutions and social media allows us to reach broadly.  Because of this reach, and the power of social and involves We must remain positive and hopeful.  Our words can greatly influence the outlook of those who read our blogs, follow us on twitter and check our Facebook postings.  We must inform, discuss and improve awareness.  We must remain positive in order to continue to inspire those who look to us for their care.

The issues raised by the recent Facebook study will need to be addressed.  Going forward, social media users, as well as those that manage major online networks such as facebook, twitter and YouTube (and others) must decide how and when to conduct social networking experiments in a way that provides both useful data and also protects the privacy and rights of those involved in the experiment itself.

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Data is (Em)Power(ment) for Patients: Using Fit Bit to Impact Disease Management

For scientists and researchers who are developing new treatments for disease, Data is power.  For patients, Data can mean empowerment.  Devices that track health indicators are readily available.  These devices can track heart rate, blood pressure, blood sugar and even respiratory rate and body temperature.

This week in the Wall Street Journal, the medical applications of the Fit Bit device are explored.  The Fit Bit is a basic pedometer that tracks movement, steps taken, calories consumed and (in certain models) sleep habits.  This device is commercially available for around 100 dollars and was initially embraced by serious athletes in order to improve performance.  Now, according to researchers, these devices may be able to impact health outcomes–both inside and outside of the hospital or healthcare setting.  These impacts may forever change how physicians and healthcare systems think about managing chronic disease.

As I have mentioned in previous blogs, I firmly believe that smartphone applications for medicine are going to be a part of mainstream medical practice in the coming years.  Providers will prescribe apps just as they do pharmaceuticals.  In the case of the Fit Bit device and others like it, data obtained from physiologic monitoring can be used to assess physical fitness and progress towards obtaining specific health goals.  In several recent studies, researchers at Massachusetts General Hospital in Boston, have found that the Fit Bit users who have diabetes are more likely to have better control of their blood sugars and achieve weight loss related goals better than those who do not use the device.  Many patients with type 2 diabetes can better control their blood sugars through reduction in BMI (body mass index) and the data provided from the Fit Bit device seems to have a positive correlation with weight loss in this particular patient sample.  In the hospital setting, researchers at the Mayo clinic found that in post-operative cardiac surgery patients, the Fit Bit was able to identify patients that needed more physical therapy intervention–by tracking movement in the early post-operative days.  It is likely that by identifying and intervening early in patients who are not progressing after surgery we will be able to prevent many common complications such as deep vein thrombosis (DVT), pneumonia and other morbidities associated with lack of activity after surgery.

At this point, the FDA has no immediate plan for regulation as long as they are not specifically created to treat a particular medical condition or disease process–however, I do expect regulators to act on all types of biomedical data collection devices within the next 5 years.  According to the WSJ, the health monitoring device industry is projected to exceed 5 billion dollars in 2016–largely due to our focus on patient engagement and prevention.  Concerns have been raised as to the security of data and as to the reliability of the data generated by these devices.  As with most new medical innovations, there is still much work to be done.  We must create secure servers where patient’s data can be safely deposited (and HIPAA compliant) and easily accessed by their healthcare providers in order to provide necessary changes to care.  In addition, the patient must be able to access their own data in order to assess progress, adjust goals and optimize their lifestyle changes in order to produce better health outcomes.  Additional concerns have been raised around the legal implications of a large repository of medical and physiologic data—are physicians responsible for every reading and every piece of data in the repository?  Will there be frivolous lawsuits initiated by ambulance chasers (or Fit BIt chasers) in the future?

I contend that more data is better.  Data provides me with the power to make better decisions for my patients.  Data provides my patients with real, meaningful feedback.  When we are sick, we often feel as though we have lost the ability to determine our own destiny and lose any semblance of control.  Data allows patients with chronic illness to actually regain some sense of control—and achieve ownership of their disease with the power to invoke change.

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Making Donald Ross Proud: Erik Compton Overcomes Adversity (and Two Heart Transplants) to Compete in the US Open

This week, the center of the golfing universe is centered on Pinehurst, North Carolina as the United States Open Championships get underway on Thursday.  Designed by Donald Ross and frequented by golf legends such as Bobby Jones, Harvie Ward and Ben Hogan, Pinehurst number 2 is an iconic layout for professionals and amateurs alike.  Golf, in general, takes meticulous preparation, dedication, discipline–and for those who are successful at the highest levels–an uncanny ability to battle and overcome adversity.  As a below average amateur golfer, I certainly have a healthy respect for the abilities of PGA professionals.

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These men and women spend countless hours practicing and perfecting swings and are quickly able to assess their own weaknesses and move to correct them in a timely fashion.  The world of sports can teach us many life lessons and can help better prepare us to do battle in our daily lives.  The traits of successful professional golfers are applicable to medicine in many ways.  Sports figures have always been a source of inspiration for me.  This week, one particular golfer in the US Open field should serve as an inspiration for us all—PGA professional Erik Compton’s daily courage and his willingness to overcome any obstacle can help each of us meet even the fiercest medical or business related challenges and provide better care for our patients.

At age 9, Erik Compton was like any other child.  He was active and loved sports.  However, he became ill with a cold like illness (just like many other kids that age).  Unfortunately, Erik’s cold symptoms lingered.  He began to become very short of breath and was no longer able to keep up with other kids his age.  Eventually he was evaluated by a specialist and found to have viral myocarditis and a significantly reduced left ventricular ejection fraction.  After three years of therapy and worsening congestive heart failure, Mr Compton was listed for a heart transplant and in 1999, he received a new heart.  Through hard work, goal minded behavior and dedication, Erik led a relatively normal life through high school and became one of the top ranked amateur golfers in the United States at the high school level.  He was recruited by many universities and attended the University of Georgia on a full athletic scholarship.  As a college golfer, Mr Compton not only battled the numerous golf courses, bunkers, water hazards and the like, but also battled fatigue and swallowed numerous anti-rejection pills each day. He worked his way onto the Nationwide Tour and eventually earned his PGA card.  Unfortunately, Mr Compton suffered a massive myocardial infarction (MI) in 2007 and was left with another cardiomyopathy in his transplanted heart.  While driving himself to the hospital from the golf course, he called his family to say goodbye.  The goodbyes were not to be–six months later, he received a second heart transplant.

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(Photo adapted from http://www.ErikCompton.com)

At this point, many of us would have simply given up.  “Why me?” we might ask.  Instead, Mr Compton embraced his next life challenge.  Within weeks, he began to walk and exercise regularly and he was determined to play competitive golf once again.

Mr Compton battled back from a second heart transplant and ultimately re-joined the PGA Tour.  Last season, he was awarded the inaugural PGA Tour Courage Award.  Two weeks ago, he sunk a putt in a sudden death playoff in order to qualify for the US Open field.  Mr Compton’s story is compelling for many reasons.  As a golfer and transplant survivor, he exhibits unnatural courage under duress.  For patients and physicians, Mr Compton’s example can provide insight into successfully battling disease and should inspire us all to do better with whatever gifts we are given.  I have never heard Mr Compton complain during an interview–rather, he chooses to focus on the positive–the fact that he is able to once again compete on the PGA Tour and he clearly enjoys EVERY single day, EVERY single minute.

Most importantly, Mr Compton’s story should serve as a call to action for all of us–we must do more to raise awareness for organ donations.  Last year, there were more than 4000 persons on the active transplant waiting list–yet only 2600 heart transplants actually occurred.  Every single year, patients die while waiting for an organ.  Factors such as blood type, body size and other immune system antigen compatibilities often determine how quickly patients are able to receive a heart.  Organ donation is simple–in most states it simply requires answering a question on your driver’s license application.  Organ donors are critical to providing life to those with diseases such as Mr Compton.  Fortunately, through innovation and research we have other therapies that can help patients with end stage cardiomyopathies–Left ventricular assist devices (LVADs) can now serve as destination therapy as well as a bridge to transplant in critically ill patients.  Although the artificial heart has not yet panned out as we would have liked, the advent of 3D printing of organs may hold real promise for the future.  However, until we have other solid alternatives, we must continue to raise awareness for organ donations and work to ensure that more people on the transplant list have organs available to them.  As healthcare workers, we must include questions on organ donation as part of our routine office visits in order to ensure that our patients are at least AWARE of the process and can contemplate decisions with their families while they are young and healthy.

Ultimately, many will die while awaiting organs this year.  Patients and families who have donated during times of tragedy are true heroes–they have provided LIFE for others from the hands of tragic and untimely death.  This week, I continue to be amazed at the ability of PGA golfers to tame the beast that is the historic Pinehurst number 2.  I am even more amazed by the fact that Erik Compton is among the field and walking in the footsteps of Donald Ross, Ben Hogan, Harvie Ward and Bobby Jones.  I think each of these golf legends would be quite proud. In fact, I suspect that Donald Ross himself would enjoy a round with Mr Compton—and would likely invite him to sit in the rockers on the world famous porch at the Pinecrest Inn (a legendary hotel in the village of Pinehurst once owned by Mr Ross) after an afternoon walk on Pinehurst Number 2.

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(Image from my personal collection.  Golfers from all over the world come to Pinehurst for a round of golf and recount the day on the course on the porch at the Pinecrest Inn)

 

Medicine in the Age of Mobile Technology: How Tablets Are Transforming the Patient Encounter

Medicine is becoming mobile.  Physicians, nurses and other healthcare providers must be able to quickly assimilate and react to an overwhelming stream of data.  Tablet technologies, such as the Apple iPad, have been incorporated into the workflows of many clinics, emergency rooms and hospitals.  Medical Schools and Residency programs are quickly adapting the technology for teaching.  While tablets do present some security challenges, most clinicians who are currently using them tout them as revolutionary and efficient. Moreover, there appear to be many new medical uses for tablet technologies in the pipeline that may forever change the way medicine is practiced.

Tablet Utilization:  Pros and Cons

Many hospitals are now using tablet technology to help physicians and other treatment team members prepare and interact with patients while on the move.  With healthcare reform and cost containment strategies, many hospital systems are looking for ways to streamline care and cut costs.  Potential advantages of tablet use include the ability to improve workflow on rounds, reduce staffing requirements, and increase productivity and efficiency without compromising patient outcomes.  In many centers, physicians are able to “sync” their devices wirelessly or via sync stations located throughout the hospital.  Rather than moving to a computer terminal to sit down and review labs, consult notes, test results, etc, a team can move through the hallways and discuss these findings via an interaction on the iPad.  There is virtually no downtime and less staff is required to see patients in an efficient way.  When interacting with patients in their room, caregivers can actually show them images and results and discuss findings with them.  In fact, a recent study from the University of Sydney showed that secondary review of radiology study images on an iPad was just as good as a standard LCD computer screen.  For patients, it improves education and engagement in the care plan when they are able to see an image or test result as they discuss the finding with their providers.  When patients have a better understanding of their medical problem and are able to participate in their treatment plans, outcomes improve.  Tablet technology helps facilitate this type of engagement.

Some centers are incorporating their EMR (electronic medical record) into the tablet via a mobile application and this allows for quicker documentation and immediate record of the day’s plan for the patient–available for all team members to access “real time”.  The EMR mandates put in place by the federal government have become a burden to many facilities and providers–by interfacing with these technologies via tablet technology, adoption of EMR and efficiency of documentation may improve.

As with any computerized medical record or medical application, security and HIPPA regulatory compliance are always a concern.  In addition, the small size and mobility of the iPad device makes keeping the devices in the hospital a challenge.  Although several major academic medical centers, including Massachusetts General Hospital have begun to incorporate tablet technologies into their practice, many others have not due to the cost of stocking the institution with the relatively expensive devices.  Now, many EMR companies, including EPIC (a major EMR player in academic centers) have created secure applications for tablets and other mobile devices that protect privacy and are HIPPA compliant.

Tablet Technology:  Future Applications in Medicine?

At this point, we are only seeing the tip of the iceberg when it comes to mobile technology in medicine.  Tablets are very powerful, portable, and user friendly.  I believe that these devices will become standard issue in medical schools across the country.  Rather than spending 1000 dollars per student on printed materials for a year of medical education, schools such as the Yale University School of Medicine are now issuing iPads to all students and utilizing the iPad for nearly all curriculum related materials.  According to the AAMC, tablet technology is being adopted all over the country and is being used to replace reams of learning materials on paper.  In a recent survey of medical students published in the Journal of the American Medical Library Association, most students go utilize electronic based medical resources at least once a day and over 35% use a variety of mobile devices to access information.

Applications continue to be developed that have important educational roles in medicine–apps for learning EKGs, reviewing histology, learning pharmacology and others are becoming mainstream and will likely be an integral part of medical education going forward.  A recently published study in JAMA: Internal Medicine evaluated the changes in resident efficiency when using iPad devices for clinical work.  In the study, the authors found that the utilization of mobile devices improved workflow and both perceived and actual resident physician efficiency.  In fact, orders on post call patients were placed earlier–before 7am rounds–likely resulting in improved care and more timely delivery of medications, treatment plans and orders for diagnostic studies.

For patients, tablet technologies may improve their visit experience and may help reduce medical errors.  I can foresee a clinic where patients check in for their appointment and are given an iPad to fill out forms and answer a wellness screening questionnaire prior to their visit with their primary care doctor.  With more “meaningful use” requirements imposed by government bureaucrats, these electronic screening opportunities will allow clinicians to not only meet regulatory requirements but also continue to spend meaningful time with their patients during a visit.  In addition, patients can have the opportunity to review imaging with their clinician at their side and actually “see” what the doctor is able to see.

For physicians, the possible applications of tablet technologies are endless.  Ultimately, I believe that these mobile technologies will revolutionize medicine and allow for care to be provided to patients who have previously been underserved.  Tablet based electronic patient encounters are on the horizon.  As physicians we must ensure that we continue to embrace technology and we must not resist change–medicine remains both a science and an art.  We must continue to strive to incorporate BOTH technology and human touch into our patient encounters.  Change is coming–we must adapt and embrace these technologies in order to provide our patients with the healthcare and caring that they deserve.

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Healthcare Industry CEOs and the Cost of Care: Too Many Men (and Women) in Black (Suits)?

Healthcare reform is a reality.  The ACA and its associated mandates have forever changed the landscape of medicine in the US today.  The Obama administration touts the goals of reform as providing affordable, cost effective, high quality care for all Americans.  Certainly these are noble and lofty goals–but have we completely missed the mark?  Today, many remain uninsured and the majority that have signed up for the exchanges are simply those who have lost their healthcare coverage from other providers.  Healthcare costs in the US remain above those of all other industrialized countries while physician salaries in the US continue to fall.  Even though the US spends more dollars per capita on healthcare than any other country on earth, our outcomes, when compared to other nations,  remain mediocre at best.

What about cost?  Who is actually delivering care?

Over the last 30 years, hospital administrators and CEOs have grown by 2500% while physicians have grown by only a modest amount.  In fact, according to the American Academy of Family Practice, there must be a 25% increase in primary care doctors over the next 10 years in order to keep pace with demand.  Multiple independent surveys (published by the AAMC) indicate a significant shortfall of all types of physicians nationally by the year 2020.  As administrators and insurance company executives grow, hospital staff and services continue to be cut—nurses and doctors are asked to care for more patients with fewer resources.  Executives continue to tout savings within their organizations and boards award these administrators with enormous financial bonuses.

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Source :  BLS and Hammelstein/Wool handler

Where are the Doctors in all of this?

The short answer is that physicians are caring for patients and managing the piles of paperwork that the government and other healthcare organizations and executives have created for them.  Doctors are now consumed with checking boxes, implementing EMRs and transitioning to a new coding system for billing—all while seeing increasing patient loads and meeting increasingly steep clinical demands.

This week in the New York Times, Elisabeth Rosenthal penned an article that spells out what many physicians have known for a very long time—the administrators and hospitals are the high wage earners–not the doctors.  As the numbers of administrators continues to rise exponentially, many independent physicians and physician groups are being driven to integrate with or leave practice altogether in order to remain fiscally viable.  According the the Times, the salaries of many administrators and CEOs (in both the hospitals and the insurance industry) are outpacing salaries of both general practice physicians, surgeons and even most specialists.  Astronomical wages such as those earned by Aetna’s CEO (total package over 36 million dollars) and others are a big contributing factor to the trillions of dollars that we spend on healthcare each year.  According to the New York Times, healthcare administrative costs make up nearly 30% of the total US healthcare bill.  Obviously, large corporations and CEOs will argue that these wages are necessary to attract the best and brightest executives to the healthcare industry.  What is there to attract the best and brightest scientists to medicine?  Certainly altruism is a big part of what physicians are about but economic realities must still come into play when bright young students are choosing careers (while accumulating graduate and professional school debt at record paces).

Why then does it seem as though physicians are the only target for reform?

That answer is simple–hospital administrators and insurance company CEOs are well trained businessmen (and women) with MBAs from prestigious schools.  They understand politics and how to effectively lobby.  They have been actively involved in reform and have participated in discussions on Capitol Hill rather than watch the change happen around them.  When costs are cut from the healthcare expenditures, they have made erudite moves–they have worked effectively to isolate themselves and their institutions from the cuts that are affecting the rest of the industry.   While reimbursement for office visits and procedures falls to less than 50% through many of the exchanges and other government based programs such as Medicare and Medicaid, CEOs and hospital administrators continue to financially outpace their colleagues in other sectors of business.

As physicians, we must continue to focus on our patients and their well being.  Individually, we must continue to provide outstanding, efficient, quality care to those who depend on us every single day.  As a group, however, doctors must begin to work harder to influence those in Washington for change.  While healthcare reform is essential and must be accomplished in a fiscally responsible way, it is my hope that those in a position to effect change will recognize that we must begin to better regulate and limit those in CEO and administrative positions in both the insurance and hospital industries.  Just as we reduce the numbers of nurses on the floor to care for patients in order to save healthcare dollars, maybe we should eliminate a few VPs with fancy offices on the top floors of our hospitals.  Which one do you think will positively impact patients more–fewer nurses or fewer dark suits?

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