Sunday, February 9, 2014

Health Care Culture Wars

There have been a number of developments in the past week that I wanted to comment on, but I kept finding myself thinking about two op-eds I read recently.  Each, in its own way, discusses the impact of culture in the health care system on our health care.  In brief – our culture of medicine may actually be adversely impacting our health.

The first was a piece by third year medical student Ilana Yurkiewicz entitled Why Rude Doctors Make Bad Doctors.  You should read the whole piece, but a couple of her thoughts really hit home to me.  Ms. Yurkiewicz makes a point of saying that ill-mannered physicians are in the minority, but, even so, their behavior adds up: she cites a study from the UCLA School of Medicine that found 50% of medical students across the U.S. experience some sort of mistreatment, such as being bullied.  She points out another study that found 17% of nurses and physicians could name a specific adverse patient outcome that occurred as a result of disrespectful behavior.

Ms. Yurkiewicz warns that communication in health care settings suffers as people worry about intimidation, fear of confrontation, or retaliation, so potential errors or warning signs may not get pointed out. 

Here’s one of her important insights: “Many in medicine actively protect the culture of disrespect because they hold a fundamentally flawed idea: that harshness creates competence” (italics added).  

As Ms. Yurkiewicz goes on to say, “bad cultures lead to bad outcomes.”

In addition to ending the culture that tolerates bullying by medical professionals, Ms. Yurkiewicz argues that the culture puts too much of a premium on saving face, which “…creates doctors who value looking like they know what they’re doing at all times more than actually doing what is best.” 

Strong stuff.  It is perhaps no coincidence that our archetype physician has gone from the kind, gentle, all knowing Marcus Welby, who was happy to make house calls, to the even more brilliant but pathologically irascible and insensitive Dr. House, who only sees patients in the hospital.

The second op-ed, which comes from a very different perspective, was by We Are Giving Ourselves Cancer


We are silently irradiating ourselves to death” (italics added).

In addition to the simple overuse of scans, Ms. Redberg and Ms. Smith-Bindman mention the lack of standards about dosage, which they say can be 50 times more at one hospital than another.  Studies have confirmed the variability across institutions and even within the same institution.  

The common thread I find in these two very different pieces is the can-do, almost cowboy culture of “we can do it, so we will do it, and don’t tell me any different.” 

I find signs of this everywhere I look.  A few days ago HHS released rules allowing patients direct access to their lab results, which begs the question – why weren’t they available before?  If it was that the results were deemed too complicated for patients to understand, why wasn’t more effort made earlier to make them more consumer friendly?

Or take my personal favorite – colonoscopies.  They bring in lots of cash for GI docs, but the prep is universally reviled by patients and the procedure isn’t much fun either.  Turns out maybe they don’t need to be this bad – the FDA has just approved a pill-sized camera that patients simply swallow.  Granted, this took some advances in technology, but virtual colonoscopies have been around for several years, so why haven’t they become more the “gold standard”?  And why can’t the prep be easier – or at least less distasteful – for patients?  A consumer market, driven by patient preferences, would have addressed this long ago.

Frankly, too much of what goes on in medicine looks like it is more about protecting income or turf than about protecting patients. 

There are fights going on between physicians and their medical boards about how to demonstrate ongoing competence.  Board certification has gone from lifetime to 10 years and is moving in some specialties to 2-5 years, but not all physicians want to have to prove they know what they are doing – why not?  In another battle, anesthesiologists don’t want nurse anesthetists horning in on their territory, although they admit they don’t have proof that patient outcomes suffer (and, in fact, nurse anesthetists can claim the care is the same). 

Heck, there has been a battle going on for years about the release of Medicare Physician Payment data.  Advocates for the release have pointed out the potential for detecting fraud and overutilization and improving patient safety, while the AMA has raised physician privacy issues.  Really?  Physician privacy concerns outweigh patient safety or defrauding Medicare?  It would appear that the battle for the release has been won, but I’m not sure the war is over. 

The best example of all, though, may be medical education.  Perhaps someone could explain to me, with a straight face, why we still have allopathic (M.D.) and osteopathic (D.O.) branches of medicine, each with its own set of schools, residency programs, hospitals, licensing and oversight – not to mention chiropractic or alternative medicine.  It’s been over a hundred years after the Flexner Report and we still haven’t figured out how to take the best from each approach in terms of what works best for patients and how to best train people to deliver that care?     

As Ms. Yurkiewicz neatly concludes about our medical education process, “…we also can’t ignore a system that takes loads of formerly ‘nice’ people and churns out jaded, bitter, and gruff ones.”  Amen, although I like to believe that plenty of physicians somehow still manage to stay “nice” despite the process.

I could go on and on, but perhaps the reader will take my point.

Just when I start to get too discouraged, signs of positive culture change do pop-up.  CVS just announced they will no longer sell tobacco products, deciding they truly are in the health care business and forgoing $2b in annual revenue as a result.  They’ve already made a big bet in retail clinics, as have several of their pharmacy competitors. 

Volumes have been written about retail clinics’ potential; even hospitals are getting into the game (we’ll have to see what kind of retail experience they can deliver).  A truly retail perspective should be better at putting patients first.   

Still, even the much vaunted retail clinics haven’t severely dented more traditional practices of medicine, due in large part to the usual suspects – regulatory and reimbursement barriers.  Its distant cousin telehealth faces much the same problems, and, as a result, is having its most success in places where there aren’t many good alternatives, such as in rural areas.  Those are the underlying kinds of culture issues that are proving very hard to shake.

The culture problem really crystallized for me a couple years ago when Dr. Michael Joyner of the Mayo Clinic raised the question of whether physicians should treat lack of exercise as a medical condition.  That signaled to me that we’ve officially tipped too far from thinking about health to relying on medicine, and signified abdicating our own responsibility for taking care of our own health to the medical professionals.  They certainly should be part of our health team – just not in charge of that team.   It’s our body, our health, and we should be in charge.

At the end of the day, it is us – the patients, the supposed consumers – who allow the culture to exist.  Every time we don’t ask physicians questions or don’t demand better explanations, we allow it.  Every time we get a pill or an extra test instead of taking time to evaluate risks and risk factors, we allow it.  Every time we accept overbooking, confusing bills, inconvenient hours, or inadequate time with our health care professionals, we allow it.  And, of course, every extra pound, every missed exercise, and every missed fruit and vegetable serving, we allow it. 

Maybe we need fewer doctors like House and more patients with the attitude Howard Beale had in Network, where he famously declared “I’m mad as hell and I’m not going to take this anymore!”  We need more of that attitude to win the health care culture wars.

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