Sunday, September 14, 2014

Some Thoughts From the Front Line of a Health Care Mega-Merger

"One day I was Jewish, the next day I was Advocate."

The senior cardiologist from NorthShore University HealthSystem who uttered this comment garnered a nervous laugh from everyone.  While the ripple effects of the proposed mega-merger between two of the larger health care systems in Chicago, NorthShore University HealthSystem (my employer) and Advocate Health Care, remained unknown, the immediate anxiety among workers was palpable.

"What do you think, Dr. Fisher?"

I had to stop and think for a moment.  What does such a merger mean to organization? What does it mean to local workers?  What does the merger mean to doctors as a whole in these two systems?  What does the merger mean to patients?

I suspect from an organizational standpoint, this was an important and necessary move to maintain viability in the increasingly competitive health care marketplace and one that was carefully planned to position each of the organizations nicely in the dog-eat-dog push for patient populations to manage.  Waiting until the prior merger between two other affluent medical systems, Northwestern and Cadence, was strategically important as NorthShore and Advocate attempt to gain approval for the merger from the Federal Trade Commission and Illinois regulators.  While these issues are important to the ways of health care business these days, how they will affect health care delivery remains to be seen.

In most ways, I suspect the merger of NorthShore and Advocate to become "Advocate NorthShore Health Partners" reflects a reality - the two systems will function as they have in most areas except for contract negotiations with insurers at first.  A huge geographic footprint of metro Chicago is consumed by these two organizations. To that end, the administrators savvy in these skills will be uniquely positioned to retain their jobs, but since both organizations will be culling redundancy to save costs, middle management will feel the first effects if this "partnership" consummates.  This will serve both health systems well and "cut costs," but I suspect that little of this cost savings will seen by patients.

Electronic Medical Records

NorthShore University HealthSystem uses EPIC Systems for it's entire electronic medical record system solution - both in and outpatient - while Advocate uses Cerner's Millennium EMR system for its inpatient EMR, Allscripts for its employed-physician group outpatient EMR, and eClinicalWorks for the EMR of it's "physician partners."  Bruce Smith, Chief Information Officer at Advocate previously explained the rationale for their three-EMR system this way:
"… it gives our independent physicians the option of staying independent. They select if they use the software [and] they work with the vendor. If they choose to leave Advocate Physician Partners, they can do so and take the data with them. It remains under their control, as opposed to the Medical Group, in which everything is in one shared database."
While this solution worked for a while, the complexities of maintaining three systems makes the Cerner/Allscripts/eClinicalWorks solution at Advocate vulnerable to EPIC Systems' unified EMR solution.   It is also interesting to note that the latest 2014 Medscape EMR Report tabbed nationwide EPIC penetration at 23% to Cerner's 9%.  NorthShore University Healthsystem was the metro Chicago's first EPIC client and while its 4 hospitals are a relative minority compared to Advocate's more geographically diverse 12-hospital system, its seamless outpatient and inpatient integration of EMR platform may threaten Cerner and Allscripts control of Advocate's EMR solution. While I suspect change may not come immediately, if a move to consolidate EMR systems occurs, both doctors and patients in one of the systems may seen some dramatic changes going forward as a result.

Physicians

For employed physicians of each system, the effects of this union will be minimal.  But for those who are independent, if an EMR system switch is required, many more will find themselves joining a system because of prohibitive costs to make such a change.  There will also be renewed efforts to consolidate payment models for physicians system wide if these large health systems unite.   As Medicare and Medicaid payments are restricted by CMS in the future, pressure to control expenses for such a large system will be inevitable.  Advocate is employing a "budgeted payment model" compared to a "fee-for-service model," so doctors will be instrumental at working along side the health care system to achieve cost savings while attempting to maintain care quality - not always an easy thing to achieve. Also, in-system referral of patients will be encouraged, if not eventually tacitly mandated, but one advantage to such a large system is that more resources are available.  Whether the affluent patient population of NorthShore's population will want to utilize those resources remains to be seen. But it is interesting to consider the possibilities that might arise as colleagues from one system can unite with colleagues from another health system to provide care.

For individual physicians joining such a large system, the opportunity for a wide range of practice environments exists, but the wide geographic spread of this system makes the possibility of having to practice in multiple locations (especially for specialists who are increasingly viewed as "proceduralists") a larger reality.  Also, geographically-stipulated non-compete clauses in employment contracts will be a concern since the newly-formed "partnership" might mean the physician would have to relocate to another city if they wanted to change practice environments.  This is a growing concern for doctors who want to practice in Chicago as health systems consolidate.  While this concern might not mean much to the average patient, it might be affect recruitment of specialized physician talent to the Chicago Metro area.

Staffing

For most nurses and technicians, I suspect the effects of consolidation of these two systems will be minimal.  More likely, the combined assets of these two large health systems might facilitate some improvements in staffing as the patient population served by these two systems swell.  But both systems are plagued by the needs for wide geographic coverage of hospitals.  And as competition for trained technical staff continues between large health systems, turnover is likely to be higher in systems that require greater amounts of entropy as staff are shared between hospitals or employees might make a change to a hospital closer to their home, impacting some centers more than others.

Patients

For most patients, the implications of such a mega-merger will be minimal at first.  But the current trend of rising out-of-pocket health care costs for patients does not seem to be abating.  Mergers are business decisions, not patient care decisions, and the people most likely to benefit from "cost savings" and "efficiencies" (as defined in the press releases of this merger) are more likely the systems themselves.  But eventually, these rising out-of-pocket costs swill push a demand more transparency of procedural pricing - first with expensive diagnostic tests (like CT/MRI), then with medical procedures.  And while health systems will need to compete with each other, their larger monopoly will keep prices artificially high since competitors will be few.  

Patients will also see their doctor staring at computer screens more than ever as EMRs change and incentives for data entry are tied to physician compensation even more in the new managed care environment ahead.  Senior doctors' pushback on these requirements will be tolerated for a while as health care systems wait for them to retire, but younger tech-savvy physicians will consider this form of health care their new norm.

Healthcare.gov problems and rising penalties for those without insurance will kick in in 2015 - how these issues will affect such a large health care system remains to be seen.

Summary 

So we'll see how this works and how many of my predictions come true in the years ahead.  One thing's for certain, health care in Chicago, just as in so many other regions of the country, has forever changed to fewer health care delivery options for both physicians and patients.

-Wes

Thursday, September 11, 2014

The Big Flail

After you've written on a blog for a long time, you begin to ask yourself why.  Oh sure, there are the great opportunities for a single person to make a point, to act as a tiny tugboat trying to push a corporate mothership in a slightly different direction, but you begin to realize that there are very few times that actually happens. You try to provide a voice to issues that are often unheard, then realize that voice is only occasionally appreciated but more often duly noted, then ignored.  This is the nature of internet and quite frankly, medicine now - it is a world of competing interests.  On one side you have the patients, doing a messy job of getting sick, and corporate health care systems - either government, private, for-profit or non-profit - doing their very best to make sure their illness is neat and tidy, easy to control, perfectly understood, and quantifiable.  To this end, each has their own agendas that must be served, be it another regulation, value-added improvement, or a profit motive to secure the bottom line. 

This idea came to me yesterday in clinic.  Increasingly, very microsecond of my day, my week, my weekend has now been efficiently parsed into tiny computerized scheduling chunks.  It doesn't matter where I work, because like The Cloud, location doesn't matter - schedulers and administrative handlers can reach me, be it by beeper, computer, Outlook email, EPIC email, desk phone or my personal iPhone. There are so many places to check for messages that when I don't respond, the person trying to reach me just moves up the chain of communication options.  Eventually there's no down time, no time to think, there are few places to go where there is quiet any longer. It's become life by a thousand interruptions - a Big Flail.

Increasingly, there's a push to do away with beepers and move telecommunications in medicine to my personal iPhone.  But I an resisting this because I need to set a boundary between work and my personal life - if for nothing else but self preservation.  We are told this is being done in the name of "security" and "non-secure beeper messages" but I think it's because people don't want to wait.  They need their answer now. I really wonder what the evidenced based data on beeper message hacking is in health care and if more patients were helped or hurt by beeper data breeches.  There's a better idea, they say: consolidate.  It's more "efficient."  I know, I'm such a Luddite. But to whom do I respond when that head administrator calls on my iPhone as I'm  examining a patient?  How to I separate a Twitter message from an ER message? Does the act of looking at my phone when I'm with a patient engender trust or an appearance of distraction?

It's hard to argue with "security" when someone creates a new medical policy.  We all want to be secure.  We all want to know that our most private and personal  medical information is protected from prying eyes.  But quite frankly (and this is very politically incorrect to say) real information security in medicine is a joke.  After all, people's lives are perfectly encoded on a computer now and eight different billers, coders, insurance company trolls or hospital marketers can delve into that database of information and find specifics about a patient or group of patients with simply the click of a button.  Phishing schemes make a mockery of our passwords.  Seriously, who are we fooling? Let's be honest: paper charts housed in a known location behind a locked door were MUCH more secure. 

Hurry up.  Click here, click there, "Excuse me," "Can I have a moment of your time?", "There's a the 7 am meeting tomorrow," "What was that Ms. Jones?", "Yes, I'll try to make it," "Did you try it unipolar?", "Yes, I'll check my inbasket,""You left your addendum open,""They're calling for the cardioversion,""Should we add him in?", "I have to take my board review course, can you take call?,"The ER's calling,""Can you check her pacer, too, when you see her?", "Did you sign the EKG?"

Doctors need some quiet, down time, some time to think, to pay attention. We need to create our own boundaries between our personal and professional lives that are respected.  We need to think we can get away, to regroup, have some quiet time for ourselves or with a patient, even for a moment.  And if that means that some of us want to separate work from home by the use of a beeper instead of an iPhone, so be it. 

Otherwise, our personal lives will become a Big Flail, too.

-Wes
 

Monday, September 08, 2014

Another MacGyver Moment in Pacemaker Implantation

Installing a permanent pacemaker or defibrillator has become commonplace event in cardiology these days.  These devices implanted in a patient are comprised of two main parts: the lead(s) and the pulse generator.  After installing the leads in the heart and connecting them to the pulse generator, the lead and pulse generator assembly are then placed beneath the skin in a small subcutaneous (or in rarer cases, submuscular) "pocket" that is created surgically.  Considerable care is taken to cauterize bleeding vessels when the pocket is created.  To facilitate visualization of these occasional bleeding vessels deep within the created pocket, I prefer to use a surgical headlamp to direct the light deep within the pocket cavity rather than relying on a conventional overhead surgical light.  I have found that headlamps have helped me limit my incidence of post-operative pocket hematoma development.

So as things have had it, I seem to have a knack for attracting every eighty- or ninety-plus year old who needs an emergency pacemaker on the weekend when I'm on call, and this past weekend was no exception.

So the team was assembled and the pacemaker implantation equipment readied.  They knew I liked a headlamp, so they dug deep into the recesses of their inventory to pull out their only headlamp that appeared to be from a bygone surgical era.  Being pressed for time, I couldn't argue and had to make due, but knew that this headlamp might not be very reliable, especially as I saw how the headlamp's fiberoptic cord was secured to the light source that generated about as much light as a few well-lit candles by a cumbersome spring-loaded Rube Goldberg contraption.  As I placed the headlamp on my head, and tightened the plastic strap that housed the headlamp to my head, I needed a backup plan in case the light failed.

Would I have to use the overhead light and make do, or might there be another way? 

I needed another MacGyver Moment.

That's when my on-call staff team came up with a brilliant, simplified idea:




iPhone to the rescue!


-Wes

(PS:  This device is experimental and has not been approved by the FDA.  Use this device at your own risk.    If you experience headaches, nausea, difficulty with concentration, or an erection lasting for longer than four hours, discontinue use of this device and contact your doctor immediately.  I have no commercial interest in this device.  Also, since the headlamp still worked this weekend, no workaround was needed for the patient, but something tells me we might be getting a new headlamp soon.)


Friday, September 05, 2014

Cybernetic Medicine

Cybernetics, the scientific study of control and communication in the animal and the machine, used to be the stuff of science fiction.  Today, thanks to a Faustian bargain between corporations, regulators, and politicians, it is defining medicine.

Every day, the exponential explosion of data entry and regulatory requirements doctors endure boggles the mind, all in the name of "health care." 

Feedback is critical to field of cybernetics.  And when Medicare's straps have you by the balls, you comply.

No longer is it good enough to learn a diagnosis or procedure code, doctors must attend online courses to learn how to use a new "calculator" to determine a more proper code.  After all, there will soon be over 70,000 of them.  Each more specific than the other, each more ridiculous.   There are five data-entry fields to click on that calculator, each another tiny, yet time-consuming decision to be made, just to determine a code.  No doubt teams of clever twenty-something computer programmers are overjoyed with their coding calculator and the way it pops up automatically on our screen when needed, then disappears.  So pretty.  So cool.  See how easy they've made it to complete that regulatory requirement?

And this does not begin to address the increasingly algorithmically-driven electronic medical record and procedures envisioned in the years ahead. As if all things can and must be perfectly defined and quantified in medicine.  No mistakes.  No judgment needed.  No need to type. Just close your eyes, click a few buttons, and follow the pathway.  Stop thinking. Just do it. Enter the data. Resistance is futile.

After all, it's about the money...

... and perfect physician cyborgs.

Feel that strap tightening?

-Wes













Friday, August 22, 2014

Where To Teach?

As I begin another year teaching EKG's to our new residents, I find I am increasingly asking myself "Where to teach?"

I do not mean to imply a geographic sense to the word "where" (although this is difficult, too, as residents move from hospital to hospital in large health care systems like ours as they change rotations), but rather as more of a "level." What level do I teach our residents the art of EKG reading? Do I keep it rudimentary or do I teach it at the level of a good cardiology fellow? Are we striving for excellence or striving for adequacy in EKG interpretation? Said another way: do I teach at a Dubin's level of EKG interpretation or a Marriott's?

This is not an easy decision for those engaged in teaching medical students and residents.

Every year I am evaluated by the residents for my instruction, and every year I get good marks. But an e-mail received from our program director made me concerned, because a criticism they had heard from the residents was that my instruction was too advanced. (This was a first for me despite using similar core lecture materials year to year).

Which led me to wonder, is my curriculum too advanced for our newer residents or are medical students not receiving instruction on EKGs in medical schools before residency? Or has is the art of EKG interpretation evolving to simply reading the computer-generated interpretation at the top of the tracing? Should residents just be taught basic ACLS-level tracings or the more subtle findings of hypothermia and hypercalcemia?

I wonder why there's such a difference now, why there is a draw to spoon-feed our residents rather than to teach them basic principles upon which to grow their understanding. Perhaps residents are flooded. Perhaps they are scared. Or (more likely) perhaps we need to do a better job leading by example. Perhaps, as one fellow of mine said, our attendings in medical schools are so hurried to get back to clinic that they never do chalk-talks or EKG reading with residents any more. Maybe the pressures to make medicine more efficient is robbing from education.

Whatever it is, there is a change.

I'm sure I'm not the only teacher who's encountered the same difficulty knowing where to teach now. But I continue to believe that our youngest doctors can rise to any challenge they are given as long as they have enough time, so don't expect it to be any easier from now on, but maybe just a bit slower.

My time, after all, is unlimited. (* cough *)

-Wes

Friday, August 15, 2014

To the ABIM: What Real Life-long Learning Should Look Like

He left a little early to stop by the cath lab to see his patient before her procedure.  Cordial "Hello's" and "Good mornings" and "Any last questions?" were mentioned before she signed her consent.  The team was working feverishly to prepare her for her procedure.  "Have you met the anesthesiologist yet?" was next, and almost on cue, the anesthesiologist arrived and took over for a bit.

He hurried upstairs to the conference room.  There, was an all-too-fattening array of welcoming donuts and bagels, a coffee and hot water dispenser, and a few remaining empty cups. This was the stuff of breakfast on more hurried days.  Still, a small cup of coffee was welcomed and poured quickly. Another nurse had arrived with him and he asked, "Can I pour you one?"  She accepted and they quickly made their way into the conference room after signing the attendance sheet.  They didn't want to miss the start of the conference for that was sometimes the best part of the conference.

In a stroke of genius, the organizers of the Cath Conference quickly review the news of the week, both locally, nationally, and medical.  They even show wild things colleagues did the week before outside of conference, like flyboarding or a shot of a colleague holding a huge striped bass they caught the weekend before with their 8 year-old daughter.  Complaints about the design of the restrospective trial reviewing digoxin's use for atrial fibrillation, sodium's uncertain consumption recommendations this week were met with rolled eyes, and the possibility of transcaval retrograde transaortic valve replacement in patients with no other access was discussed, with a quick aside of direct translumbar aortic punctures and even direct left atrial punctures being performed by surgeons in earlier times.    In short, they shared the other side of themselves together, the reality of science, their humanness.

Then they shared cases.

The cases are not always pretty.  Some were tough cases, wonderful cases, cases no one had seen before.  They discuss the complicated social situations that bring even more complicated dynamics to the case.  They discuss the errors and the complications.  Importantly, they all understand this is a legally protected conference - a morbidity and mortality conference, if you will -  a place where there are frank discussions about the right way to treat things and the wrong way, but a place that is supportive to those who have struggled, and incredibly helpful to those who still struggle with many challenges.  Administration hears about the problems doctors had with the lab equipment or staff or whatever - professionally.

And it's the most popular conference in our hospital.  People of all ages and technical backgrounds are welcomed.  Old and young, cath lab staff, nurses, quality personnel, research staff, administrators, guest speakers, cardiologists and surgeons.  Everyone, that is, except industry or pharmaceutical folks.  This is, after all, the work of health care, not marketing.

At the end, they greeted, however briefly.  A quick question is asked.  A consult requested.  A research form signed.  Then off they went on their ways for another week to do their jobs.

This is lifelong learning as it should be: cordial, professional, collaborative, fulfilling, timely, up to date, and self-generated.  And it happens because it has to, not because it's directed by a centralized bureaucratic money-making organization who claims they know what's best for doctors and what's best for society.

When doctors, nurses, technologists and health care teams learn this way it's sustainable for a lifetime for one simple reason:

... because it's enjoyed.

-Wes

Tuesday, August 12, 2014

Data Plan Health Care Shows Promise

CHICAGO - Citing mounting health care costs, electronic note bloat, and concerns with the quality and quality of Big Data, IBM, Apple, and EPIC Systems recently announced a new initiative to totally revamp US health care by offering health care services by data plan. The health care initiative was recently discovered in a little known section of the Patient Protection and Affordable Care Act (ACA) that changed portions of the U.S. Tax Code.

Under the new system, the brainchild of prominent Chicago physician-turned-health care entrepreneur Henry Throckmorton, MD, patients will purchase an initial 250 megabytes of data space on the EMR for all their health needs for $250 per month.  “It’s cheaper than most current cell phone service," Throckmorton explained. "When patients exceed their data allotment, health care ceases until patients purchase an additional data storage plan." Expansion data plans come in Bronze (250 M Bytes), Silver (500 Mbytes), Gold (5 G Byte), and Platinum (10 GB) storage increments.

Rollover plans for family members are also offered for those nearing the end of life.

“Health care systems that promise to limit the use of macros, dot phrases and cut-and-paste tactices have a real competetive advantage over competitors insensitive to the patient's data needs!” Throckmorton explained. "This system finally puts health care incentives in the right place.”

But Roger Wilco, spokesperson for America’s Health Insurance Plans (AHIP), the national trade association representing the health insurance industry, seemed less enthusiastic. "This is preposterous! Who do these flowery internet types think they are? Don't they realize there are advantages to more middle men in health care? How are we supposed to get our cut of the money?"

Dr. I.P. Knightly of Urocare Health System in Beaverton, New York, seemed less concerned about the middlemen and appreciated the improvements he's seen in patient care:  “Because I document everything on the EMR, including phone calls, results and work schedules, patient are less likely to call so I get a good night’s sleep!”

Nursing and medical students seem torn, however. While some see benefits to shorter notes, some like Tim Allen, MD, a hard-working fourth-year medical student from Roanoke, VA, sees other challenges “I’m still trying to understand ortho notes that no longer contain the critical information fields like the patient’s full name, VIP status, research status, and a complete review of systems. How's a guy supposed to understand what ‘Silt @ t/s/s/sp/dp’ means?”

Market analyst Rebecca Solomon of Lock, Stock and Barrel Equity Partners noted "Apple, IBM and EPIC are quickly gaining market share from more conventional insurance policies. The concept has also resonated with the Department of Health and Human Services because of the cost savings seen from fewer data-hungry imaging studies being ordered."

Mobile partnerships with AT&T, Verizon, and T-mobile are planned in the next fiscal year.

*  *  * 
 -Wes

P.S.: If you thought this press release might be real, even for a second, consider why.

Maintenance of Certification: Beauty Is in the Eyes of the Beholder

This must-read paper from Drs Centor, Fleming and Moyer was recently published in the Annals of Internal Medicine. While it does not pertain to specialists, it serves as a level-headed rebuttal to the positive perspective of the Maintenance of Certification program (MOC) developed and marketed by the American Board of Internal Medicine and the American Board of Medical Specialties:
"There are no facts, only interpretations."
—Friedrich Nietzsche

In this issue, Baron and Johnson (1) describe the history of and rationale for the creation of the American Board of Internal Medicine (ABIM) and recent changes in maintenance of certification (MOC). They focus on setting standards and identifying “good doctors” who meet those standards. By implication, those who do not participate or are unsuccessful in achieving recertification are substandard. Although the ABIM is clearly proud of the MOC process that it has developed, many internists find it a source of great distress.

We suggest considering a basic observation in cognitive psychology, the affect heuristic, as a construct to help understand the disconnect between the ABIM's and internists' views of MOC (2–3). According to this heuristic, when we like a thing or an idea, we overestimate the benefits and underestimate the risks or unintended consequences. If we dislike something, we underestimate the benefits and overestimate the risks.

Those invested in developing the MOC process seem to highlight potential benefits and minimize possible unintended consequences. We have deep concerns that this well-intended policy will, indeed, cause negative consequences for physicians and society.

Over the past several months, we have heard from many internists about the MOC process. These physicians have a wide variety of training and experience and include well-trained, insightful, and skilled internists who share a commitment to maintaining high standards of professional performance. Yet, their concerns over the new demands that the MOC process entails are palpable. Their focus is on the potential unintended consequences, and they are struggling to acknowledge the potential benefits. When these physicians talk with us about MOC, frustration and dismay about the process dominate the conversations.

Internists feel increasing pressure from many directions. Time is an entity that none of us can recoup, and internists appropriately raise concerns about growing time pressures on all fronts (4). They are experiencing increasing administrative burdens that limit their ability to provide the type of patient care that they want to deliver.

These burdens include issues related to usability and interoperability of electronic health records, complex documentation requirements, growing requirements for prior authorization of the tests and treatments that they prescribe, and a payment system that does not recognize the time and effort that they spend on telephone or e-mail communication. The new MOC requirements add to this burden by being time-consuming and costly and having unclear benefits on patient care. Added to these concerns is a high-stakes, secure recertification examination whose first-time failure rate has increased from 10% to 22% over the past 5 years.

Although most first-time recertifying examinees who fail eventually pass the examination, they suffer distress and additional cost to retake it. Internists, like all physicians, want to bring their best, evidence-based practice to every patient every day. They want to test their knowledge and better their practices in a formative way to improve patient care and outcomes.

We worry that the ABIM may focus too much on metrics, administrative processes, and finding the “substandard doctors” who theoretically place the public at risk and too little on the design and implementation of a process that encourages ongoing education and professional development. The implication is that MOC will allow for better policing of “bad” internists rather than helping us all be “better” internists. We believe that the ABIM's stated accountability to the profession, which accompanies its accountability to the public, should lead to better recognition of dissatisfaction among its diplomates and a more collaborative approach with internal medicine specialty and subspecialty societies to address this dissatisfaction.

Unfortunately, the new MOC process has become the straw that broke the camel's back in many internists' minds. They dislike each part of the process but seem most angry about the practice improvement modules and secure examination. They see the first as “busy work” and the second as lacking relevance to their personal practice and to how medicine is currently practiced. The present structure of the summative secure examination of the ABIM does not provide specific feedback to facilitate this process let alone reflect the current state of practice, namely, collaboration in patient care and real-time engagement of evidence-based resources.

Any physician evaluation process should consider the practical wisdom, knowledge, and skill necessary to be a good practicing physician and test how those attributes are actually used in patient care. Fostering the development of phronesis (practical wisdom) in physicians through the effective and safe use of knowledge and skill in the clinical moment allows us to fulfill the covenant we have with patients and the contract we have with society.

Our internist colleagues tell us that they embrace the importance of remaining current, but they do not believe that the current MOC process helps them achieve that goal. As currently implemented, MOC involves substantial time, and internists believe that time supersedes more educationally sound activities. Current learning theory supports the use of testing to guide further learning and the provision of educational tools to address knowledge weaknesses.

Testing for knowledge alone does not determine how skilled and effective an internist is at the bedside, in history-taking, and in performing a targeted physical examination. Would it not be better and more practical to have a testing process that assesses the ability to gather and interpret information and that encompasses the entire clinical encounter? Can the MOC process as it stands truly evaluate our ability to deliver patient-centered care?

Too many internists view “professional self-regulation” as currently conceived by the ABIM to be a nonproductive and often punitive experience. All too often, they see regulatory bodies as depleting money, time, and joy from their professional lives. Further, many do not believe that burdensome processes being forced on them will benefit their patients or their professional lives. Thus, it should be no surprise that internists focus on the direct and indirect costs of MOC rather than on the potential benefits that are the focus of the current commentary of the ABIM leaders.

We recognize the ABIM's good intent and the substantive challenges of developing an effective assessment process that ensures a corps of good internists. Unfortunately, too many internists find some aspects of the current process lacking at a time when concerns about the ramifications of this high-stakes professional endeavor are increasing.
While these authors' polite critique of the ABIM's method of assessing fellow physicians makes excellent points, we should still question the relevance of such a system for specialitist, especially for those who gain clinical and surgical experience over time. Furthermore, the MOC requirement that requires the performance of research on physicians using unscientifically validated patient surveys fails to afford doctors the most basic research protections created after the unintended consequences of similar well-meaning government research programs came to light. To ignore these additional shortcomings of the ABIM's MOC process should not be tolerated by any practicing member of our profession.

-Wes

Reference: Centor RM, Fleming DA,and Moyer, DV. "Maintenance of Certification: Beauty Is in the Eyes of the Beholder" from Ann Intern Med. 2014;161(3):226-227. doi:10.7326/M14-1014

The Tradeoffs of Obamacare

A few from above, from Saurabh Jha, MD (Twitter: @roguerad):
The biggest trade-off is between a constitutional republic, with all its checks and balances, and a centrally-planned healthcare.  The two are fundamentally incompatible.  The future will yield many more convulsions.  Many more Halbigs.

The optimism surrounding the ACA, summed up by President Obama's promise "if you like your doctor, you can keep your doctor," gave many the impression, myself included, that healthcare reform can be Pareto optimal; a win-win for all.

Regrettably, trade-offs are a fact of life.  Which means there are winners and there are losers.  This is not unusual.  But by not acknowledging the trade-offs we have created resentment in the losers, and widened the partisan chasm.
Read the whole thing.

-Wes