Category Archives: The Business of Medicine

The Land of Oz: Engaging Viewers or Selling Snake Oil?

Dr Mehmet Oz, also known by many as America’s Doctor, is a very influential face within American medicine.  An accomplished cardiac surgeon and Columbia University faculty member, Dr Oz has impressive academic credentials.  However, in the last year, Dr Oz has received significant criticism for claims he has made about non traditional medical treatments on his nationally syndicated television show where he has called many of them “revolutionary” or “miracle cures”–many of his statements are without scientific merit and have no basis in traditional evidence based medicine.  Much of this culminated with his voluntary testimony in front of the US Congress this past summer.  During the hearing, Dr Oz was blasted for making sensationalized, misleading statements.  While I believe Dr Oz genuinely cares about helping others improve their health, I do think that he used poor judgement when speaking about these non traditional treatments.

This week, a study in the British Medical Journal (BMJ) examined the claims that have been made by Dr Oz and The Doctors syndicated television shows.  In the study, investigators randomly chose 40 episodes of each program and then attempted to find medical evidence for claims made about 80 separate treatments.  What they found was astonishing–only 50% of the therapies had either a study or case report to support the claims that were made by the television doctors.  More concerning was the fact that of the 80 recommendations from the Dr Oz Show, the data supported the claims only 46%.  In fact, nearly 15% of the time the best available evidence actually contradicted the claims that were made by Dr Oz on his show.  The Doctors television program did slightly better with evidence supporting their recommendations 64% of the time.   The investigators concluded that most recommendations from medical talk shows lacked adequate evidence to support their use and that television doctors do not provide adequate information on each treatment and do not disclose any potential conflict of interest.

This particular study has significant implications for both patients and physicians.  As physicians we are constantly confronted by patients who come into to the office to discuss treatments that they may have heard about on television.  We must not only be aware of these therapies but we also have to better educate patients and help them decide if any of the “Dr Oz treatments” are right for them and their disease process. Patients are bombarded with medical recommendations from television which are commonly sensationalized and oversold by television doctors and other well known personalities.  We must caution patients that when phrases such as “miracle cure” and “revolutionary treatment” are used on television when a particular disease or medical problem is discussed that the advice given is more than likely too good to be true.

As a physician that regularly appears on television to provide insight and commentary for medical stories and new medical developments, I am always careful to provide information that is based in fact.  Media personalities have a responsibility to report the truth–when giving opinion, we must be clear that we are in fact, making a statement of opinion that is based on fact and the best available medical evidence.  As physician journalist, I have an even greater responsibility to choose my words carefully–it is part of the American culture that TV appearances give on camera experts increased credibility and believability. While I believe that Dr Oz as well as the physicians who appear on The Doctors syndicated shows have the best of intentions, I do think that their zeal for ratings and viewers may lead to making less than accurate claims.  These shows have great potential–they bring medical issues to the forefront and actually help to engage patients in their own medical care.  We know that patient engagement is critical to improving outcomes–and these types of shows can play an important role.  Rather than reporting on non traditional therapies that have not been studied by randomized controlled clinical trials, television doctors such as Mehmet Oz could make a much larger impact by focusing on ways to prevent disease and reduce obesity among his viewers.  For now, viewers must continue to question medical claims made by Dr Oz and other television doctors.  And physicians who play prominent roles in the media must choose their words carefully and ensure that accurate, data driven information is provided to viewers–leave the snake oil at home.

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Controlling the Costs of Innovation: Let’s Refocus and Remember The Patient

In a controversial study released this week, Tufts University’s Center for the Study of Drug Development estimates that the cost to bring a new drug to market exceeds nearly 2.6 billion dollars.  The study, which was 40% funded by industry has been criticized for over estimating these costs in favor of industry and misrepresenting some cost estimates.  While we will not know fully the extent of the methodology of the study until later in 2015 when it is published in a peer reviewed journal, these preliminary findings were released in advance and have already begun to spur debate.

However, irrespective of these criticisms, I believe that the study does have merit and brings an important issue forward—is the FDA stifling innovation with excessive fees and paperwork?  Are smaller, less well funded researchers/corporations unable to significantly contribute without partnering with big pharma? Who will ultimately bear the increased cost of drug development?

Innovation is what has always made healthcare in the US great–it is what separates us from the rest of the world.  For decades, the US has been able to attract talent from throughout the world and this has resulted in numerous “game changing” breakthroughs in medicine.  Through continued development of new drugs, new technologies and new ways to better treat disease, we are able to improve outcomes and reduce death from preventable disease.  The US has always been a place where others from around the world have come to incubate and grow ideas.  Now, it appears that innovation must come at a substantial cost–the increasing capital required for drug development as well as taxes on medical device companies only serve to squeeze out the “small guys with big ideas” and limit our ability to continue to produce new, more effective therapies and cures.  In addition, these additional costs to the pharmaceutical industry are not simply added to their bottom line–they are pushed on to the healthcare consumer as well as Federally funded healthcare plans.  Ultimately, the taxpayer bears the brunt of the increased cost.

The process of drug development is long and arduous.  Government regulation, politics and greed have served to make it even more difficult.  Physicians in academic medicine, scientists, pharmacologists and leaders in industry have learned to partner and share ideas in order to bring basic science principles from the bench to the bedside—ultimately translating ideas into cures.  Certainly, big pharma is in place to make profits and increase market share.  But as costs increase, many drug makers are putting less and less profit back into research and development.  Growth can become stagnant and new ideas may never reach the bench or bedside.  Federally funded research–such as NIH grants–face big cuts and budgets are often embroiled in political battles.  Legislators use research dollars as bargaining chips and fund projects that appeal only to a particular interest group or a group of favored donors.  We must find a better way to promote medical innovation and reward research.  We must find better ways to choose the most promising projects for funding.  We must be good stewards of the R & D dollar and make every single investment count.

As with most things in medicine, we must always pause and remember to focus on the patient.  Advocating for the patient suffering with disease is the reason most of us became involved in medicine in the first place.  Whether the study from Tufts over-estimates the cost of development or not, it should still serve as a wake up call to us all.  We must work to control the cost of developing new therapies—we must limit excessive taxation, we must promote entrepreneurship and begin to fix the current system of FDA approval for new therapies.  We must separate politics from medicine and streamline processes—eliminate paperwork and promote efficiency–if we are to continue to lead the world in medical innovation.  We must continue to make room for the “small guy with the big ideas”–If we do not–ultimately it will be our patients that suffer in the end.

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Turf Battles and Collateral Damage: Are We Really Putting the Patient First?

Last week, Medpage Today reporter Sarah Wickline Wallan tackled a very controversial issue in medical practice.  In her piece, Ms Wallan explores the ongoing battle between Dermatologists and AHPs (Allied Health Professionals) over the performance of dermatologic procedures.  As independent NPs and PAs begin to bill for more and more procedures (thus potentially talking revenue away from board certified Dermatologists) specialists are beginning to argue that the AHPs are practicing beyond their scope of practice. According to the Journal of the American Medical Association, nearly 5 million dermatological procedures were performed by NPs and PAs last year–this has Dermatologists seeking practice limits–ostensibly to protect “bread and butter” revenue streams from biopsies, skin tag removals and other common office based interventions.

In response to this controversy and the article, I was asked to provide commentary for Med Page Today’s Friday Feedback.  Each week, the editors at MPT discuss a controversial topic and have physicians from all over the country share their feelings on the issue in order to provide readers with a mulit-specialty perspective.  This “Friday Feedback” feature is typically released on the web near the end of the day on Fridays and often spurs a great deal of social media activity and discussion.  Based on reaction to Ms Wallan’s article our topic this past Friday was “Specialty Turf Battles”.  Each respondent was asked to provide commentary on the growing angst between Dermatologists and Allied Health Professionals.    As I began to reflect on the issue itself and its potential impacts on all aspects of medicine, I felt that a complete blog would be a more complete forum to discuss my thoughts.

First of all I want to say that AHPs are essential to providing care in the era of the Affordable Care Act.  NPs and PAs are able to help meet the needs of underserved areas and do a remarkable job complementing the care of the physicians with which they work.  With the rapidly expanded pool of newly insured, as well as the increase in administrative tasks (electronic documentation) assigned to physicians, AHPs must help fill in the gaps and ensure that all patients have access to care.  In my practice we are fortunate to have many well qualified AHPs that assist us in the care of our patients both in the hospital as well as in the office.

We must remember, however, that physicians and AHPs have very different training.  Each professional posses a unique set of skills and each skill set can complement the others.  Many of us in specialty areas spend nearly a decade in post MD training programs and learn how to care for patients through rigorous round the clock shifts during our Residency and Fellowship years.  In addition, we spend countless hours performing specialized procedures over this time and are closely supervised by senior staff.  Most AHPs, in contrast, do not spend time in lengthy residencies and often have limited exposure to specialized procedures.  Turf battles have existed for decades and are certainly not limited to Dermatology–nor or they limited to MDs vs AHPs.  In cardiology in the late 1990s, for instance, we struggled with turf battles with Radiology over the performance of Peripheral Vascular Interventions.  In many areas, these battles resulted in limited availability of specialized staff to patients and a lack of integrated care.  Ultimately, the patients were the ones who suffered.

Fortunately, in the UNC Healthcare system where I work (as well as others across the country) we have taken a very different approach.  After observing inefficiencies and redundancy in the system, several years ago our leadership (under the direction of Dr Cam Patterson) decided to make a change.  The UNC Heart and Vascular Center was created–Vascular surgeons, Cardiologists, Interventional Radiologists, and Cardiothoracic surgeons–all working under one cooperative umbrella.  Patients are now discussed and treated with a multidisciplinary approach–Electrophysiologists and Cardiothoracic surgeons perform hybrid Atrial Fibrillation ablation procedures, Vascular surgeons and Interventional Cardiologists discuss the best way to approach a patient with carotid disease–all working together to produce the BEST outcome for each individual patient.  We have seen patient satisfaction scores improve and we have noted that access to multiple specialty consultations has become much easier to achieve in a timely fashion.  Most importantly, communication among different specialties has significantly improved.

Unfortunately, with the advent of the ACA and decreasing reimbursement I suspect that turf battles will continue.  Financial pressures have become overwhelming for many practices and the days of the Private Practice are limited–more and more groups will continue to “integrate” with large hospital systems in the coming years.  Specialists such as Dermatologists and others will continue to (rightly so) protect procedures that provide a revenue stream in order to remain financially viable.  However, I believe that our time will be better spent by working together to improve efficiency of care, quality of care and integration of care.  NPs and PAs are going to be a critical component to health care delivery as we continue to adapt to the new (and ever changing) ACA mandates.  We must put patients FIRST–turf battles and squabbles amongst healthcare providers will only limit our ability to provide outstanding, efficient care.  Let’s put the most qualified person in the procedure room–and make sure that ultimately patients get exactly what they need.

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“Thinking” About How We Lead: How We Make Better Decisions and Produce Better Outcomes

As physicians we are trained to assimilate data, analyze and interpret findings, and make the correct decision–every single time.  Often these tasks must be performed very quickly and in emergency settings.  For those who perform invasive procedures, decisions are often made “on the fly” and can have significant consequences.  In addition to our clinical duties, physicians are now thrust into executive roles as well.  Managing practices, budgets, government mandates and regulations have now become part of everyday clinical life for many practitioners.  The concept of the physician executive is now commonplace—and for many doctors and practices– a key to survival in an unstable and volatile healthcare market.  Improving skills in both decision making and communication can be critical to success in the new world of healthcare.  Learning to LEAD is critical to providing outstanding care for our patients every single day.

This week in the Wall Street Journal, author Andrew Blackman explores the inner workings of a business executive’s brain–exactly how the brain functions when making effective decisions in the world of business.  Researchers evaluated how executives make decisions under a variety of circumstances–they localized the biologic processes that occur in the brain via advanced neurologic imaging techniques.  From a biological standpoint, this research provides great insight into how successful decision makers formulate plans and solve problems.  In addition, the research provides insight into how leaders can make more effective decisions when under duress.  Using complex imaging to map the electrical connections in the brain when decisions are made, researchers are able to better quantify–biologically–what makes some leaders better than others.

By shedding light on how our brain functions when making good decisions, we may be able to one day “train” our brains to utilize particular regions during specific tasks.  For now, much of what Mr Blackman reports concerning optimal conditions for making decisions is applicable to physicians and other leaders in medicine in one way or another.

According to the Wall Street Journal, there are several things to consider when making important decisions:

(1)  Deadlines and Time Pressures may Limit Creativity and Innovation

In medicine, every day is a deadline.  Schedules of patients packed into the office or procedure list remain a reality.  Making decisions under pressure is a big part of what physicians do on a daily basis.  However, the recent neuroimaging research indicates that often the deadline pressure may stifle creativity and lead to poor decisions.  Stress induces more activity from the area of the brain associated with “task completion” and less activity in the areas responsible for new and creative idea generation.  According to Harvard researchers, one way to potentially combat this change in thought centers during times of stress may be to train workers and leaders to become more self aware and use “mini meditation” to help the mind wonder.  Although in medicine, we are trained to REACT to acute situations, it may be that while we REACT, we can also work to explore other creative centers of our brains in the process.  By combining both quick REACTION and creative thought, we may not only be able to stabilize a critically ill patient but also provide a unique treatment plan going forward.

(2)  Worry and Uncertainty can lead to bad Predictions and poor decisions

I have been accused of being “Chicken Little” on more than one occasion.   Uncertainty is something that is commonplace in medicine yet it makes most of us uncomfortable.  As physicians we rely on data to make good decisions.  However, uncertainty remains a significant part of what we do in medicine on a daily basis.  We often deal with limited data and must make a decision based on the best available evidence.  Clinical trials bring us some level of certainty  but our patients are biologic organisms, each with potential differing responses to treatments and disease.  According to researchers, the areas in the brain that are activated when you are working on problems that are cause you worry are often associated with anxiety and disgust.  Many poor decisions are made due to the “worst case scenario” line of thought.  While worry and uncertainty can never be completely avoided, psychologists argue that the way to avoid poor decisions during these times, is to learn to accept uncertainty and control the things that you can control.  No decision is ever final–even in medicine there are opportunities to act, refocus and change directions if necessary.

(3)  Good Decision Makers may look past the Facts and Incorporate “Gut Instinct”

Many decisions in medicine are made by considering the best available data and incorporating clinical judgement and instinct in order to make a determination as to the best course of action.  Interestingly, when MRI scans were performed on the brains of very successful business executives who were involved in making difficult decisions, the areas of the brain responsible for emotion and social thinking began to light up more than the purely analytical areas.  Researchers concluded that those leaders who relied not just on facts but on gut instinct and emotion tended to be more successful.  Social thinking–in simple terms–is the ability to look at a problem from numerous angles.  Seeing the potential impact of a potential decision from multiple points of view can provide invaluable insight and may lead to better decisions in the long run.  In medicine, involving other team members–nurses, technicians, and support personnel–in the care and formulation of the patient’s treatment plan may actually help a physician leader to make better decisions.

(4) Effective Leaders must stay positive and Inspire Teams

When leaders begin to inspire teams of people and lead with passion, certain other areas are activated in the brain–particularly those areas associated with positive emotions and social thinking.  Along with involving other team members in the care of the patient, it is essential for an effective leader and decision maker to incorporate “praise, encouragement and rewards” when motivating teams to perform at a high level.  Creating an emotional bond among members of a medical team can be as simple as asking for input from all involved parties and recognizing outstanding contributions to patient care.

The Bottom Line…

Business executives are adept at making determinations that affect millions (if not billions) of dollars and these decisions can move markets.  In medicine, we must make decisions every single day. While some decisions may be trivial, others may permanently impact the lives of our patients and their families.  Moreover, from a business standpoint, the management of a medical practice in today’s market requires impassioned leadership and great skill in order to remain viable. The work that is done with neurologic mapping in decision making may have provide us with guidance in the future as we develop new leaders.  It may be that through practice and coaching, we will one day be able to activate specific areas of the brain when we are working to make tough decisions.  The strategies and skills that we are able to glean from these types of research activity will allow us to be more effective physicians, leaders and executives in the years to come.

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The Advantages to Team Approaches to Patient Care: Extending NOT Replacing Physician Care

Let me start by stating that I am a supporter of team approaches to medical care.  Data from numerous observational trials has shown that patient outcomes are improved when a diverse group of healthcare providers work together to coordinate overall patient care.  In my practice, we rely heavily on the excellent care provided by both Physician Assistants as well as Nurse Practitioners both in the hospital and in the clinics.  These physician extenders are essential to coordinating admissions, evaluations testing and treatments.

Last week in the Wall Street Journal, columnist Laura Landro discusses the new push for team based care in today’s healthcare market.  As Ms Landro states, there are numerous advantages to the team based approach.  Patients benefit from the more intensive one on one time that they are afforded with nutritionists, pharmacists, nurses and other advanced practitioners.  In previous decades, most of this work was solely the responsibility of the physician.  However, increasing demands for documentation and electronic paperwork have begun to consume physician time.  While the ACA promises to flood primary care offices with even more patients, physicians are scrambling to perform all of the duties that are currently required of them (with more government mandates on the horizon).   Most of my colleagues prefer to focus on patient care (rather than administrative paperwork and government mandates) but are often frustrated by how little time they have to interact with their patients.  Managing chronic disease is a process and requires numerous “touch points” with the patient in order to be successful.  In reality, as a cardiologist, I am able to see most of my stable patients only once a quarter–unless they have an acute event or decompensation.

It is clear that patients now are living with more complex diseases and that we have far more advanced therapies to treat them with.  Many of these therapies rely on strict patient compliance and on patients having a thorough understanding of their disease process and its management.  For instance, a patient with Congestive Heart Failure (CHF) may need to be able to interpret daily weights and adjust diuretic dosing accordingly in order to prevent hospitalization from a more serious CHF exacerbation.   Now, rather than see a physician for medication discussions every three months, a patient can make an appointment with a Pharmacist in our office and see them on a more frequent basis to discuss concerns over efficacy or side effects of their medical regimen.  In our experience, this has improved patient compliance and improved metrics such as blood pressure control and time spent in the therapeutic range for chronic anticoagulation patients.  Other primary care physicians report similar results when managing diabetes via frequent nurse educator or NP visits–patients seem to have more consistent control and better HbA1C results when they have more frequent touch points.

While a team approach is quite effective, each team must have a leader.  The team leader must be experienced and well trained.  While physician extenders do receive extensive training in a 2 to 4 year program, nothing replaces the years of experience that MDs obtain during residency.  In order to maintain a high standard of patient care, these teams must still be led by physicians.  With the cost cutting efforts and the changes that are occurring in healthcare due to the Affordable Healthcare Act, I am concerned that hospital administrators and government bureaucrats will ultimately attempt to replace physicians with other healthcare providers in the interest of curtailing costs.  Physicians are trained in real life patient care scenarios over a period of years–many residencies last from three to ten years depending on specialty.  The experiences of call nights and handling real time emergencies over a period of years (under the supervision of more experienced attending physicians) cannot be undervalued.  My experiences during my 7 years of post-graduate training at both the University of Virginia and Duke University Medical Center certainly shaped my clinical judgement and certainly sharpened my diagnostic abilities–I call on these experiences even today when faced with complex cases.  Efforts to replace physicians with other healthcare professionals with less intensive training may ultimately harm patient care.

Patient care comes first–I believe that a team based approach is essential to optimizing outcomes.  We must all work together–Nurses, NPs, PAs, Pharmacists, Nutritionists, and MDs–in order to provide the best possible patient centered care.  However, we must not attempt to replace physicians and the experience that they bring to the clinical arena in the interest of cost containment.  While balancing cost and optimal care is a slippery slope, we must always focus on the patient–nothing can or should replace the Doctor-Patient relationship–we must all work together to preserve the core principles of our noble profession and put our patients first.

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The Electronic Medical Record Mandate and Managing Fraud: More Government Ineptness?

The Obama administration has clearly mandated that Electronic Medical Records (EMR) will be necessary in order to comply with Federal regulations for reimbursement for both hospitals and physicians.  The transition to EMR is an important step towards streamlining patient care–however, the current implementation of EMR is fraught with complications, workflow issues and system wide “bugs”.  At this point in the US there are numerous EMR systems and no absolute standard which continues to make communication between different hospital systems and physicians difficult at times.  I realize that the EMR mandate has spanned more than one administration and let me state at the very outset that I am 100% FOR the implementation of an electronic medical record system–However, I would like to see the transition be done in a stepwise, intelligent way that allows for universal portability within the US.   Moreover, the EMR should be electronically available to all patients via smartphone and tablet download from the mysterious (and hopefully secure) “cloud”.

The EMR when properly managed can provide detailed notes that are easily applied to templates for billing medicare and medicaid documentation (it allows MDs to correctly bill the level of service based on comparison of the patient’s newly created chart note to standards for required components).  However, the time involved in documenting via EMR (especially in the transition phase in a busy practice) can be overwhelming.  Physicians and other providers are already overwhelmed with offices full of patients–longer hours, more appointments and loads of new paperwork. The Affordable Care Act (ACA) promises to add loads of newly insured sick patients to the practice workload.  Add to that a cumbersome computer system and it is likely that errors will occur.

This week in the New York Times, Abelson and Creswell report on the new Department of Justice focus on EMR fraud activities.  The Office of Inspector General (OIG) for HHS released a report on Tuesday (the second in two months) warning of the potential widespread fraud and abuse occurring as a result of EMR implementation.  The warning specifically cites a lack of oversight and safeguards in the Federal government to prevent these from occurring.  The government has already spent nearly $22 Billion dollars on the push for conversion from paper to EMR in the US.  (sound familiar?  rapid roll out of new technology without proper evaluation).

According to the New York Times report, the central issue with the EMR and potential fraud has to do with the lack of regulations surrounding the common practice of “copy and paste” known as “cloning”.  For many physicians, the ability to cut and paste data and information from one place to another in a note or within a patient’s particular chart can significantly improve efficiency and reduce the amount of time that is spent inputting redundant data into a patient’s record.  Critics of this practice, including the OIG, suggest that in many cases the importation of data from note to note or chart to chart results in “overbilling” for services that were not in fact rendered.  For example, if a chart note from a follow-up visit of moderate complexity  is “cloned” with data from a previous visit where the level of service was more extensive than the current visit, then charges may be filed for an level of complexity that was not, in fact, provided.  The OIG statement goes on to warn that their “level of involvement in EMR cases [will] increase” and that dealing with documentation “fraud” via cloning in EMR will become a “top priority”.  In a survey conducted by HHS and released in a previous report, the OIG found that very few hospitals and medical practices have any guidelines or restrictions on “cloning” notes for documentation.

Once again, in my opinion, our government has missed its mark.  Instead of carefully creating a universally acceptable and streamlined EMR that allows for responsible and efficient data entry AND migration of data to subsequent encounters, federal regulators have issued yet another mandate without a clear vision of its implications.  As I stated earlier, I believe EMR is vital for patient information management and will ultimately help us provide more streamlined care that is evidenced based.  Unfortunately, the current EMR systems that are in place do not place a priority on ease of use, efficiency or portability.  Although I am sure that there is some intentional documentation fraud occurring, I would suggest that the majority of physicians and other providers are simply trying to “get the job done” and move on to more important patient care activities.  EMR documentation can be slow and arduous.  During transition phases, many providers report 2-3 extra hours added to their days for documentation activities.  No physician wants to continually take a practice laptop home in order to finish entering EMR notes during family time night after night.  Cloning data is a simple way to carry over information such as medication lists, past medical histories and other information in order to improve efficiency while at the same time providing adequate documentation.  As with most things, this type of data migration is easy to abuse if physicians do not pay special attention to ensure that the migrated data is both accurate and representative of the work that was performed.

As the current administration has clearly demonstrated with the rollout of the  ACA,  as well as with the new ICD-10 coding system and the EMR mandates, sweeping reform that is rushed to completion without a full understanding of its implications is doomed to fail.  Putting politics and power ahead of good sense has resulted in increased cost for these government mandated programs.  As a nation we must certainly work to prevent fraud and abuse as part of our efforts to curtail healthcare costs.  However, as we initiate reforms, we must do a much better job of anticipating issues with new technologies and work to deal with them on the front end–if we do not, we can expect costs to continue to rise.

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The Next Government-Based Healthcare Debacle: Coding for Orca Bites?

Due to the ineptness of the Obamacare team and the debacle that has ensued, the botched rollout of the Affordable Care Act has dominated the political and medical headlines since October.  However, other healthcare changes are on the horizon (and have gone virtually unnoticed by the public) that have the potential to further disrupt our ability to treat patients.  In fact, the technical and time consuming aspects of these new government mandated changes for 2014 may result in even larger scale computer glitches than those seen with the infamous Obamacare website.  (if you can believe that).  This week in the New York Times, author Andrew Pollack describes a new government medical coding system that must be implemented in 2014.

For decades the Center for Medicare and Medicaid Services (CMS) has established billing codes for documentation and reimbursement purposes.  These codes are created by the World Health Organization (WHO) for the purposes of standardizing diagnoses in order to track diseases throughout the world–it allows for comparative study.  However, several governments (such as the US, France, Germany, Canada, and others) have long adopted these codes as a way to standardize billing for medical procedures.  These codes have long fallen short of specifically describing what is actually going on with the patient and have led to difficulties in accurately charging for medical services and procedures.  In brilliant fashion, there is now a new iteration of the coding system known as ICD-10 that will be mandated by the US government effective this fall.   Luckily, there are now codes for injuries that occur while skiing on waterskis that are on fire as well as codes for orca bites.  As you may imagine, these codes will certainly streamline my ability to treat my patients with these very very common ailments.

So why is it that our government and its agencies think that there administrators are well qualified to develop codes for medical diagnoses?  How is it that bizarre codes for humorous and extremely unlikely scenarios are being included and programmed into the system?  

If you ask CMS administrators, they will tell you that these new codes were adopted by the US government after careful consultation with coding experts, CMS administrators and physician advisors.  However, I am not exactly sure which physicians were involved in signing off on codes for “balloon accidents”, “spacecraft crash injuries” and “injuries associated with a prolonged stay in a weightless environment”.  The issue at hand is the fact that government is once again working to regulate situations and concepts that they do not understand.  Moreover, they mandate changes without adequate input from experts in the field in which they plan to regulate (such as physicians…)

What are the ramifications of ICD-10 and how might it affect healthcare delivery?

Certainly, if the healthcare.gov website is any indication, I would expect that the technology side of implementation of the new coding system is likely to be plagued with errors and inefficiencies.  Imagine developing software that will assist in billing and coding of numerous diagnoses for each patient–including “struck by a macaw” and “bitten by a sea lion” (yes, these actually exist).  ICD-10 will increase the number of available codes from 17K to more than 155K.  From a physician/provider standpoint, the coding process will likely bring efficiency and productivity to a slow crawl as the new codes are phased in.  In a survey conducted earlier last year, 90% of physicians expressed significant concern over the transition and nearly 75% anticipate a negative impact on their practice (both operationally and financially).  Practices and hospital systems will now require new employees (at a cost that ultimately will be passed on to the consumer) that are trained and expert in applying the new codes in order to keep up with government mandates.  Over the last year, physicians have been subjected to online courses and training in the new ICD-10 coding system–many leaving the classes more confused than when they began.

Ultimately, physicians will have to change the way in which they document office visits and procedures in order to ensure reimbursement.  Altogether, these changes are likely to make an overloaded system even more cumbersome.  As we have seen with Obamacare and other government related policy changes, more work is created, more inefficiencies are exposed—in the end, the patient will suffer.  Providers will become overwhelmed by even more government related paperwork and documentation requirements.  More time spent on coding Orca bites means less time in the exam room chatting with a patient.  My how medicine has changed….

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Charisma In Medicine: Inspiring Others To Improve Patient Care

By its very nature, Medicine involves close personal contact with others.  Communication with patients, families, staff and colleagues is essential to success.  All physicians have different ways in which they communicate–some more effective than others.  The best communicators are able to inspire, engage, and cultivate trust.  Everyone is born with different skill sets and communication styles may vary widely.

Recently, I came across an article in Inc.com that discussed the importance of charisma and how it can improve the success of leaders in the business world.  Author Jeff Hayden goes on to describe 10 habits of very charismatic leaders.  As I read the piece, I began to reflect on ways in which these tips could make me and my physician colleagues better communicators and better leaders in the world of medicine…

As we always do when tackling an issue in medicine, lets start with the available data….

Websters defines charisma as :

1. A personal magic of leadership arousing special popular loyalty or enthusiasm for a public figure

2. A special magnetic charm or appeal 

So, how can this help us take better care of our patients?  If we are able to inspire and produce excitement amongst our team–from nurses, to physician extenders, to support staff–both our patients and our employees will have a better experience when working with us.  If we are able to appeal to our patients and their families we are able to provide much needed trust and are more likely to be able to partner with our patients in an effective way. 

As we examine Mr Hayden’s Tips for Charismatic Leaderships more carefully, we can find insight into ways in which we can improve our own communication with patients, colleagues and staff:  (In each case below, I have listed Mr Hayden’s Tips from his Inc.com article and then applied them to our space as physician leaders)

1. Listen more than you talk–This one is tough for many physicians.  In training we are taught to speak up when you know the answer.  We are often motivated to provide quick results and to communicate them readily.  We strive to quickly assimilate facts and produce a plan.  However, much can be learned by listening–to patients, to families and to other healthcare team members.  When team members see that their ideas are considered by the leader, the tend to be more engaged and more productive.  It matters not who gets credit for the individual pieces of the puzzle–it is more important that the puzzle is completed successfully and the credit becomes a group effort.

2. Do not practice selective hearing–It is essential that physician leaders treat all team members with respect.  Everyone has a role to play and it matters not what title or status a particular individual may hold in the team heirarchy.  By including everyone (and making each person feel like a contributor) we inspire hard work and more participation. Ultimately the patient receives much better care. 

3. Put your stuff away–In the age of mobile phones, ipads and computers on the hospital wards distractions abound.  However, when leading a team and listening to others express opinions and ideas, it is essential to leave the digital media in its holster–nothing makes others feel more unimportant than a disinterested leader.  Take time to engage each person on the team and avoid the distractions of a text, a phone call or a tweet.

4. Give before you receive–In medicine it goes without saying but be sure to put your patients and their families first.  Within the care team, allow others to take credit and receive praise for a job well done before any is directed your way as the leader.

5. Don’t act self important–Medicine breeds ENORMOUS egos–particularly in world-renown academic centers.  To be more effective, we must put ego aside– forget the fact that you may have published half of the manuscripts in the medline search that the medical student just performed.  Focus instead on others and what they bring to the team.  Remember, we are all human–we are all connected.

6. Realize that other people are important–As Mr Hayden states clearly–”you already know what you know..you can’t learn anything new from yourself”  Listen to what others have to say–focus on their opinions and learn from their biases.

7. Shine the spotlight on others–Everyone feels validated by praise.  There is never enough praise to go around.  As the team leader make sure that you are adept at deflecting praise from yourself to those around you.  Team members who feel that their work is recognized and appreciated as excellent tend to work harder and produce more.

8. Choose your words–How we go about asking others to perform tasks can greatly alter their perception of the task.  If a task is presented as an obligation, it is viewed very differently than if it is presented as an opportunity or a privilege.  By carefully choosing your words you inspire others and make them feel as thought their position on the team is a critical component for success.

9.  Do not discuss the failings of others–Let’s face it, the hospital is a fishbowl and people gossip.  However, nothing is more destructive to team dynamics that when a leader speaks negatively about a team member, a colleague or another physician.  This behavior undermines morale and does not inspire confidence.

 10.  Admit your own failings–It is essential for teams and leaders to feel connected.  Nothing promotes connection more than when a leader admits his or her own mistakes and failings to the group.  However, when admitting a mistake it is essential that the leader set an important example–when admitting a failing also admit what was learned through the event and what corrective actions you plan to take to avoid the mistake in the future. This sets a wonderful example for self improvement for the team and at the same time promotes connectedness within the care team.

What’s the Bottom Line?

Effective communication and inspiring leadership are essential to the success of any medical team.  When teams are engaged and focused on the ultimate goal–the care of the patient–outcomes improve.  It is the job of the physician and other team leaders to motivate people and form cohesive, effective teams.  As leaders, we can learn a great deal from the business and political world–charisma is a characteristic that can move markets and change the course of entire nations.  Charisma allows a leader with a vision to effect change.  Charisma can be the difference in connecting with patients, families and co-workers.  Charisma can ultimately improve care and improve the delivery of care–the key is to learn to focus on them….not on me…..

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The High Cost of Terminal Illness: Big Pharma Cashes In on Hope

As Obamacare continues to implode, issues with our healthcare system continue to expand.  We are fortunate in the United States to have access to the best technologies in the world.  We also spend more of our GDP on healthcare than any other industrialized nation in the world.  Although the ACA does address insurance costs (by passing on high prices to the young and healthy) as well as access (by providing access to care for all Americans even with pre existing conditions) it does NOT address the escalating cost of drugs and medical devices.  I believe that the lack of regulation of the pharmaceutical industry and the prices that they are allowed to set on newly developed drugs is yet another (in the very long list) of major flaws in the legislation.

This week in the New York Times, I was troubled by a story touting the release and FDA approval of a new drug for the treatment of a particular type of aggressive blood cancer known as mantle cell lymphoma.  Mantle cell carcinoma has a very poor prognosis and is very difficult to treat.  This new drug has been shown to help treat the disease but offers no cure.  Most patient who start therapy with the drug see 1.5 years of good results but then no longer respond.  For cancer patients time is everything–however the issue with this particular drug is the shiny new price tag–$120K annually.  According to analysts the drug could be worth nearly 6 billion in annual sales for Johnson & Johnson and their drug-making partners Pharmacyclics Inc.  The drug is expected to also be approved to treat a common cancer in elderly people known as CLL or chronic lymphocytic leukemia which will expand its indications to an even more common and larger group of patients.

 Doctors who specialize in the treatment of cancers are concerned about the astronomical prices.  Certainly, they are excited to have another treatment option (especially a new one that comes in pill form) but they are surprised at the cost of therapy.  The new therapy has been shown to be superior to current therapy in clinical trials–however the new drug does not offer a cure.  The company supplying the product argues that the cost of the new therapy “is in line with other new drugs for cancer”.  It seems to me that for pharmaceutical makers the cost is based on what the market will bear–given no limits for cost, they are free to charge whatever they like.  It is disturbing that those that make potentially life changing (and potentially life extending) therapies profit from the hopelessness and desperation of those suffering with a terminal illness such as rare and advanced cancers.  To me, it is reminiscent of the carpetbaggers after the Civil War. 

Why is it that physician payments are dictated by bureaucrats–Medicare, Medicaid, CMS and the insurance companies?  Why is it that hospital reimbursement  is dictated by the same?   In the same breath, politicians and others allow pharmaceutical makers to dictate their own terms as to the cost of their product.  Are there hands reaching into deep pockets?

At some point as providers of healthcare we must step in and advocate for our patients and loudly exclaim… “ENOUGH”.

As evidenced by a recent change in the law in the state of Maine, medical consumers are beginning to take matters into their own hands.  In landmark legislation, Maine recently legalized the import of prescription drugs from pharmacies outside the US.  As I discussed on Fox Business recently with Melissa Francis, there are inherent risks with obtaining prescription drugs from pharmacies outside of the FDA’s jurisdiction–there may be impurities and the quantities of the active compound may vary.  However, I believe that competition from outside the US is the only thing that will ultimately bring drug prices in the US back within sight.  Big pharma will argue that the cost of research and development requires a high price tag–however, I do not believe that the US consumer must foot the entire bill.

We MUST continue to innovate and produce novel, more effective therapies.  It is essential that we support our pharmaceutical industry colleagues in the research and development of new technologies through participating in clinical trials and examination of outcomes data.  However, we must stop short of providing big pharma with  a blank check to charge whatever they like for newly developed drugs.  I am opposed to big government and more regulation in general–but something must be done to control drug cost.  Maybe the answer lies in the beauty of the great state of Maine.  Maybe if we allow a little competition from the outside, prices may fall and ultimately more patients will have access to potentially life saving drug therapy and hope will not cost a life’s savings anymore.

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Finding Success AND Happiness in Medicine? Where Is The Holy Grail?

Medicine is a very rewarding career.  However, recent changes in the healthcare system have made the practice of business much more cumbersome and job satisfaction rates among physicians is at an all time low.  Fear over the unknown and how Obamacare may affect our ability to effectively and efficiently care for out patients has significantly contributed to the general unease in the medical community.  Most physicians are highly driven, highly successful individuals.  Much of my professional happiness (and I expect other healthcare providers feel the same way) is derived from developing relationships with my patients and achieving excellent clinical outcomes.  However, balancing success and happiness in medicine is now more challenging than ever.  More time is now devoted to additional government mandated paperwork, arguing with insurers and managing escalating overhead costs.  All told, these tasks begin to take away time normally devoted to patient care.

This week, in the online magazine Inc.com, I read an article discussing tips for ensuring BOTH happiness and success.  As I read through the piece, I began to reflect on my own balance of success and happiness–How can these two goals can be readily achieved TOGETHER?  Although primarily directed at the executive/business professional, much of the content is very applicable to medicine.  In today’s medical landscape, the most successful physicians have embraced the concept of the Physician Executive–developing a business skill set that allows one to be fastidious with a spreadsheet while also providing exceptional patient care.  I have addressed this concept in several previous blogs–now more than ever, it is critical for physicians to think like business people in order to navigate the changes that are being implemented on a daily basis.  Although much of our new executive-like tasks certainly take time away from patients, if we are able to find the right balance we can still find happiness and fulfillment in our jobs.  As stated in the Inc.com piece, in order to achieve both goals we must think in unique ways–try to do things differently and find out work works best for YOU.

In the article, author Steve Tobak explores six unique ways that one can develop BOTH a successful career and enjoy a happy life–believe it or not, they do not have to be mutually exclusive.  Here is my take on how each of these suggestions (that were created by Mr Tobak) can apply to those of us who have made our careers in medicine and healthcare:

1. Develop real relationships:  In the end, relationships matter.  In medicine, the most important relationship is that with our patients.  Understanding patients feelings, their families and their preferences improves our ability to care for them.  Celebrating their successes and their family milestones provides me with great happiness.

2. Groom yourself:  No, I don’t mean comb your hair–Try new things.  Engage in other activities as time allows.  Make sure that you make time for family outings and that you try skydiving–or horseback riding–whatever it is that interests you–give it a whirl.  It may change the way you look at your work and your life.  Ultimately, exposure to new things can make us all better leaders and provide more opportunities for success at work.

3. Do Nothing:  Medicine can be incredibly hectic.  Running between hospitals and clinics.  Hustling to see a new consult or dictate another note–all of this “noise” can take away from happiness.  Every single day, just take a few minutes to do nothing.  Sit quietly and listen to your own thoughts…meditate.  Even a brief respite can make you more effective and ultimately improve your mood.

4. Work for a great company:  Whether you own your own practice (a rarity in today’s medical world) or work for a university or hospital, make sure you believe in the mission of the organization.  Be involved and try to influence policy.  If you work in an organization that recognizes and appreciates your efforts, your job satisfaction will improve.  If you do not, you may need to consider taking a risk and making a change.

5. Do one thing at a time:  This seems like an impossibility for physicians today (guilty as charged).  However, if you are able to make a list and prioritize–focus on one or two tasks at a time–you will see the fruits of your labor.  Crossing a task off the list gives us a feeling of accomplishment and completion which can add to overall happiness and satisfaction.  Trying to chip away at several things at once can often result in no task done well.  In medicine, it may be that you spend a half day a week on administrative work–take time to separate yourself from clinical work and catch up on the rest.

6.  Be good to yourself:  As physicians we expect nothing but the best out of ourselves–we are often very critical of our own decisions and clinical outcomes.  In the current healthcare market  (world of Obamacare reform) there is much we cannot control.  We must remember to remain centered and remain “in the present” in order to achieve happiness.  Although providing perfect care is a noble goal–it is not attainable.  Be reasonable with expectations–always provide the very best of yourself to your patients and be satisfied with the fact that you do.

Happiness is critical to a successful and fulfilling career.  With sweeping changes in healthcare, many physicians are finding it more difficult to balance both success and happiness.  By applying these 6 unique principles and looking at the “big picture” it is my hope that all of us can continue to serve our patients, continue productive successful careers and remain satisfied and happy throughout our professional and personal lives.  If we are able to achieve the right balance then everyone–patients, family and YOU–will ultimately reap the benefits of a long and HAPPY career in healthcare.