Doctor, It's You, Not Me

We tout the physician-patient relationship as the cornerstone of our health care system, but it turns out it may not be particularly solid after all.  A recent survey by Vitals found that 70% of patients have a somewhat tenuous relationship with their physician.

Fifty-four percent described their relationship as "good enough for the moment," while 14% said "I'm not really into him/her," and 4% complained their physician was "cold and emotionless."  The remaining 30% claimed their relationship with their physician was "the one and only" (it should be noted that Vitals released the results around Valentine's Day).  Half of patients are already stepping out, using alternative sources of care like retail clinics.

Non-clinical factors are leading sources of complaints: lack of professionalism from the physician's staff (57%), difficulty getting an appointment (47%), long wait for the doctor (45%), and the condition of the doctor's office (41%).

Honestly, it's amazing that only half have gone elsewhere.

In-network status was the leading reason for choosing a physician (63%), far surpassing even location (37%).  Factors ostensibly related to quality trail: bedside manner (34%), education/credentials (30%), years of experience (18%), and patient reviews (16%).  I've said before that the approach of using provider networks is not only outdated but also contrary to patients' best interests.  Is in-network status really how we want people to choose their physician?

And we wonder why the physician/patient relationship is fraying, or why patient engagement is a problem.

It's interesting how health care is attacking patient engagement.  A recent report on patient engagement from Chilmark Research looked at the various technological options providers could, but usually don't, use in improving engagement.  For example, staying connected with patients between and after visits through patient portals, apps, or telemedicine.  That's all good stuff, and needs to be part of any solution, but such tools support but don't drive engagement, or relationships.

A perspective from Dr. Thpmas Lee in NEJM  was perhaps closer to targeting the problem.  Dr. Lee wants to reduce patient suffering, in all its many forms -- not just physical but also emotional suffering, such as through thoughtless interactions.  He urges providers to think more from the patient's perspective.  It sounds an awful lot like primum non nocere -- first, do harm -- that is supposed to be one of the guiding principles of medicine.

Still, reducing patient suffering seems somewhat of a necessary but not sufficient goal.  It won't sustain a relationship, and our goals for patient health should be more than "less suffering."

Many physicians, such as those involved in PCMH or ACOs, are using health coaches to try to stay connected with patients.  Health coaches are often nurses, sometimes might be physician assistants or nurse practitioners, but almost never are physicians themselves.  They are a good idea, but they sort of delegate the physician-patient relationship to the health coach.

Again, we should be aiming higher.

Many physicians complain that EHRs are adversely impacting their relationships with patients.  This has caused, among other things, a boom in the medical scribe industry, which some physicians feel allows them to interact with patients more directly.  Only in health care would anyone think having a third person present to take notes during an intimate encounter like an exam might help a relationship.

Opponents of scribes -- and you can include me in that number -- believe that they merely mask the EHR usability issues, instead of addressing them.  Researchers from UC San Diego have developed a "lab-in-a-box" to help do the latter.  It uses sensors and software to track physicians-patient interactions while using EHRs.  The lead researcher, Nadir Weibel, noted:

"With the heavy demand that current medical records put on the physician, doctors look at the screen instead of looking at their patients.  Important clues such as facial expression, and direct eye-contact between patient and physician are therefore lost."

Really, do we need sensors to identify what hampers physicians from connecting better with patients?  It strikes me that if the physician-patient relationship was paramount to physicians, then we wouldn't just now be scratching at the surface of how the EHRs impact that relationship.  Physicians have neither articulated well what makes the relationships work, nor demanded that EHRs support them better.  EHRs vendors should be falling all over themselves to differentiate themselves on how they can help improve patient interactions.

More on the right track, I think, is a tool called SHARE-IT, developed by researchers from McMasters University.  The concept isn't revolutionary at all; it simply allows physicians to present clinical information to patients in an interactive format at point-of-care.  As Thomas Agoritsas, one of the research fellows involved in its development, said:

"The process should be more about the discussion you have with your doctor and about enhancing the conversation, not overwhelming patients with too much information. It's less about showing the evidence than showing it in a way that it becomes a discussion."

Now we're getting somewhere.

Of course, the success of a such a tool depends on the physician taking the time to have that interactive discussion, rather than delegating it to a nurse or telling the patient to look at it later and let them know if they have any questions.  Sad to say, but it is hard to see that happening as often as it should.  Patients are lucky to get fifteen minutes with physicians, as physicians feel increasingly pressured to meet patient (revenue) quotas.

That, my friends, is why we have a physician-patient relationship problem.

We've gotten muddled about what we want from physicians.  They're trained to diagnose and to treat, and somehow the latter has become transactional: prescribe a pill, perform a procedure, refer to some other specialist.  Those are not the kinds of interactions that foster relationships, yet they are what consume physicians' time and drive our payment mechanisms.

With about half of us suffering from one or more chronic conditions, and as much as three-fourths of spending associated with chronic conditions, helping patients manage those conditions is one of the most important roles for physicians, especially for the rapidly vanishing primary care physicians.  They should be teachers (or coaches, mentors, whatever we want to call them) who help people make better lifestyle and other health choices on an ongoing basis, rather than being tasked with maximizing patient transactions episodically.  We need fewer transactions and more conversations.
 
The traits that make physicians great at diagnosis are not the same as those that make them great surgeons, and neither ensures they can help teach patients how to live healthier lives.  We lump all those skills together into what we ask of physicians, and that's a mistake.

Famed physician leader William Osler once said: "The good physician treats the disease, the great physician treats the patient who has the disease."  If we truly want better patient health, we need stronger physician/patient relationships, and so we need to figure out how to help more physicians become great.

How the Mighty Haven't Fallen

I recently read an article that speculated on how even the mighty Google could fade into irrelevance faster than we might think.  It made me wonder why that kind of change doesn't seem to happen in health care.

The Google article, by Farhad Manjoo in The Wall Street Journal, cited one-time technology leaders like Wang and DEC (for those of you with long memories), and pointed out that other long-time powerhouses such as Hewlett Packard and even Microsoft are furiously trying to reestablish themselves after decades of (relative) decline.  Most companies would love to have Microsoft's product position, revenue, and cash, but in 2015 most people would probably bet on Apple over Microsoft.  Manjoo quotes tech analyst Ben Thompson, who believes Google will lose out on brand advertising, which will go to companies that can create "immersive experiences" for consumers, engaging them for long periods of time.

Manhoo thinks Facebook is well-positioned to take advantage of the advertising shift, I'm thinking Twitch, but either way, it illustrates how even dominant market leaders in technology can get usurped almost overnight, the way Google did to 1990's search leaders like Inkatomi, Excite, AltaVisa, or Yahoo.  There's already a new DARPA-developed search engine called Memex which some say can do things Google search can't.  It is currently being used primarily for law enforcement activities (e.g., combating human trafficking), but perhaps in ten years we'll all be Memexing things on the Web instead of Googling them.

Then there's health care.

Just out of curiosity, I looked at share of spending by type of service in the National Health Expenditures, from 1960 to 2013.  Here's what I found:

Pretty astounding, isn't it?  For all our many clinical and technological advances, the same three health sectors that dominated health care spending in 1960 still command virtually the same shares in 2013 -- over 60% of our overall spending.  They've "lost" less than 2% of share to other types of spending during those decades.  

It hasn't all been smooth sailing, of course.  Hospital spending reached almost 40% of the total in the early 1980s (pre-DRG!), dipped below 30% in the early years of the 21st century, and has rebounded in this decade.  The physician share has been steadier -- a peak of around 22% in the early 2000's, a low of 18.3% in 1978, but mostly stayed around 20%.  Prescription drugs spending, on the other hand, got to as low as 4.5% of the total in 1981 and 1982, reached a peak of 10.4% in 2006, and now seems to be on a slow decline, despite various ominous warnings about the impact of expensive drugs.  But, all in all, the composition of Big 3 of the medical-industrial complex remains unchanged over a very long time.

It's as if the Big 3 U.S. auto manufacturers still maintained their 1960 dominance today, or the 3 TV broadcast networks still had their pre-cable/Internet share of viewers.  Both trios still have hefty market shares, still play key roles in their respective industries, but are nowhere near their historical dominance.  New competitors emerged to give consumers more options, and took away significant shares of those markets.  

Unlike what has happened in health care.  

To be fair, it is apples and oranges to contrast loss of market share for a single company with market share for a category of spending within a sector, but I think the point is illustrative.  I could look at share of, say, advertising spending for search engines in 1960 versus now but -- oh, that's right -- the search engine industry didn't even exist in 1960.  In most other parts of the economy, change comes so rapidly the past doesn't much resemble the present, but in health care that's not the case.

Hospitals, physicians, pharmaceuticals, and the health care industry generally have certainly evolved significantly in the past 50+ years, but it is more incremental evolution than the kind of "punctured equilibrium" Steve Jay Gould and others posit that result in rapid changes that overthrow species.  You'd think that the many crises our health care system has faced over the years would have offered opportunities for that kind of unexpected change, yet here we are, with a health care system that a time traveler from 1960 would easily recognize..

I don't have anything against hospitals, doctors, or prescription drugs, at least not in principle.  It just doesn't feel like progress that we're not coming up with radically new care and delivery options that don't rely on them.  

For example, IBM is trying to convince the FDA that it shouldn't regulate Watson, its "cognitive system" that it has used in a variety of health care and other contexts, in the same way it regulates medical devices.  I'm not holding my breath for the FDA to open things up.  I don't think the FDA has quite caught up with the concept of medical software (which could also include a number of apps), and I suspect the health care establishment is not going to be too supportive of allowing more latitude for such approaches.  Look at the ongoing battle about how to regulate telemedicine, despite overwhelming patient interest.  

Unlike most markets, health care isn't really driven by consumer demand.  A couple years ago, JAMA published a survey of physicians, in which  they blamed rising costs on pretty much everyone else but themselves, more than half even blaming patients.  A new study has cast doubt on the view that patient demand is driving unnecessary spending.  Looking at cancer patients, the authors found that only 1% of patients asked for clinically inappropriate care.  The saddest thing for me from the study was that only 8.7% of patient encounters included a patient demand.  We're a long, long way from informed patients taking responsibility for their own care, or their own health.

Having control over what constitutes the "practice of medicine" is certainly an effective way of forestalling new kinds of competitors.  That control has been placed in the hands of the providers practicing care, ostensibly to safeguard patients' interests,. but it's getting harder and harder to believe those interests are primary.  It seems more like protecting turf.  Our convoluted system of medical education similarly seems both old-fashioned and needlessly parochial.  If we don't address these kinds of self-serving mechanisms, the 2065 health care system might not look that much different than 2015's.  

A couple months ago I wrote a post that raised the question of whether, in a world where microbiome treatments, gene therapy, even nanobots may emerge as prevailing types of treatment, we'll even need physicians, at least in the same way we do now.  I received a number of comments that were aghast at the notion that we might not always need physicians to deliver our care.  I believe it is this kind of thinking that has allowed the Big 3 of health care to retain their dominance.  

If we can't even imagine a health care system that doesn't solely rely on the traditional sources of care, we'll certainly never achieve one.

Let My Data Go

I've been thinking about health care data a lot lately.

Now, I'm no data maven, no informatics guru.  But the data breach at Anthem, which could impact as many as 80 million customers, was such big news that I suspect a lot of people -- not just Anthem customers -- are suddenly worrying about their own health care data.  That is, if they weren't already freaked out by similar breaches within the past year at companies like Home Depot (60 million), Target (70 million), even Chase (76 million).  And, of course, the sophisticated hack of Sony last fall help elevate cyberpiracy into a bipartisan, international concern.

It's pretty scary.

Even worse, experts fear the attack is just the start of similar attacks on other health care organizations.  When your credit card information is stolen, your card issuer will typically cover any losses, and give you a new card.  You can buy identity theft protection.  However, you can't get new health care information.  Once that's stolen, you are irrevocably exposed.  With more and more health care information digital, it is a ripe target. 

Anthem was no doubt vulnerable to the hacking in any event -- it is suspected that that an administrator's credentials were used to gain access, as was true with the Sony hack -- but it didn't help that the Anthem data wasn't encrypted.  Many health care organizations might complain about HIPAA burdens, but encryption of the data isn't, as it turns out, one of its many requirements, something that lawmakers are already rethinking.  .
People much smarter than me talk about things like firewalls, de-identification, and encryption, but I'm beginning to wonder if it is all for naught.  Just before the Anthem breach, Science had a special issue The End of Privacy.  Among the many worrisome articles, researchers in one showed how few data points were needed to identify specific individuals.  It turns out that as few as four random pieces of credit card data allowed the researchers to identify 90% of the card users.  If data from Facebook, Twitter, or health care organizations, were included, it might be even easier.

I'm beginning to wonder if we're thinking about health care data wrong.

In what I'll characterize as our very 1950's approach to health care data, each provider (and administrators, such as health plans) has his/her/their own data about each patient, with the result that data about any patient is typically held by many providers and other organizations,  We've spent massive amounts of federal and private dollars to get records digital and to try to connect them, but ONC admits that only 15% of eligible professional have attested to the Stage 2 requirements.  And Stage 2 is by no means the desired end point.

I've written before about our dismaying lack of interoperability, but a recent paper by Niam Yaraghi presents some interesting thoughts on perhaps a better way.  Instead of HIEs -- health information exchanges -- trying to connect all that data while perpetually needing government handouts, Dr. Yaraghi thinks they should be in the data analytics and real time data services businesses.  He believes this provides more robust and value-added business models that will facilitate the kind of interoperability we're looking for.

I think Dr. Yaraghi is on the right track, but with perhaps the wrong industry.  Frankly, I'm not sure that HIEs, with their health care background and health care mentality, are at all the right organizations to be in these sophisticated data businesses.

One way to think of the problem is that there are two different health care systems.  The first is the physical one where things happen to people: they get sick, they get examined, they take a pill, they get a procedure, etc.  Then there is the meta-system, if you will -- the data about all those things that happen.  Those two systems have always been intertwined, but perhaps it is time to untwine them.  

In the new approach, patients and their providers would get data as needed for care, and generate data by their actions, but would not be the ones holding onto the data.  Data vendors would be.  Providers might have to pay to get value-added suggestions to deliver more effective care, but they might also get paid for data they generate, and any net increase in spending would hopefully be more than covered by better performance under value-based payment structures.

Companies like Google, Facebook, and Amazon are rumored to be interested in health care, and managing its data seems to me to be a lot better fit than, say, more fitness monitors.  They're very good at managing massive batches of data, and they pride themselves on being able to use that data to target ads.  Maybe that's what health care needs.

Some people may recoil at the notion that their health care data would be used to drive ads.  I think that is an old-fashioned view.  After all, I doubt there is much in my medical records that Google can't already ferret out through my online activity.  Same for Facebook.  If they could use my health care data to target ads for health care products, services, and/or providers that might help me improve my health or help me manage it more cost-effectively, why wouldn't I want to see those?  Is my hospital or surgeon going to tell me I might get a better outcome, for less, someplace else?  I don't think so, but Amazon or Google might.

Keep in mind that having a data company use our data to drive ads is not the same as actually sharing that individual data with the advertisers.  I'm not sure I'd have any less actual confidentiality than I expect now, and at least my data can be put to better use.  

You might even call it "Meaningful Use."

Our current approach of "protecting" our data in its multiple silos has led a system in which costs are opaque yet wildly varying (e.g., the GAO's recent report), where we don't do a good job either tracking outcomes or using what data there is to improve them, and in which it is widely agreed that we have too much unnecessary care.   As Dr. David Lee Scher wrote in a recent post: "Yet the millions of bits of discrete data amassed every minute in healthcare are warehoused in a contextual vacuum."  The silos don't work.

Dr. Scher believes increased analytics can drive some major changes, but I'd argue that cannot be achieved with our current proprietary stance towards health care data.  

Yes, I'm sure Google or other data companies can be hacked too, but if it comes to whom I think is more likely to be able to safeguard against such unwanted intrusions, I trust them more than my doctor, my hospital, or my health plan.  

Thicker silos aren't the answer.  Make health data a commodity, so that providers can focus on what they do best -- delivering care -- and so that businesses can compete on deriving value from that data.

The Doctor Won't See You Now

The recent outbreak of measles in the U.S., which is widely believed to be to have started in Disneyland, has produced at least one surprising result: doctors "firing" patients who refuse to get vaccinated.

This could get interesting.

The physician who has been the center of much of the reporting is Dr. Charles Goodman, a California pediatrician.  Dr. Goodman has told parents that they either vaccinate their children or find another physician, out of concern for the health of the rest of his patients.  As he told CBS News, "I have to weigh the risk of a kid in my office getting measles and potentially dying versus the rights of those parents to not immunize when I thought most of them were making that choice based on bad information."

The reluctance to get children vaccinated is usually associated with the MMR (mumps-measles-rubella) vaccine, which skeptics have linked to autism.  Experts, such as at the CDC, refute these claims.  Frank Bruni, in a New York Times op-ed, associates the lower vaccination rates not with poverty -- as might normally be expected -- but with affluence, citing a Hollywood Reporter article that found very low rates in neighborhood like Santa Monica and Beverly Hills.

The AMA Code of Ethics does list patient non-compliance -- failure to follow physician treatment recommendations -- as a reason for terminating the physician-patient relationship.  Purposeful failure to follow established vaccination recommendations would seem to fall into this category, but once that door is open, I wonder how wide it swings.

After all, last year an article in Medscape proclaimed "an epidemic of non-compliance."  It noted a 2011 Consumer Reports survey of primary care doctors which found that patients not following their advice was the physicians' top complaint.  The article went on to note a variety of statistics about patient failure to take medications as prescribed, adversely impacting their health, adding costs to treat them (some $290 billion), and increasing mortality rates (some 125,000 excess deaths per year).  A study in the Annuals of Internal Medicine found that almost 1-in-3 didn't even fill new prescriptions.

Is any of that grounds for being fired?

I was struck by something else Dr. Goodman said:  "That's why I took the stance, believe your doctor, listen to your doctor, not the Internet, or go somewhere else."  He was no doubt referring to the anti-vaccine diatribes available on the Internet, but the horse is out of barn about patients using the Internet to research their conditions and possible treatments.  The Pew Foundation found that 72% of Internet users looked for health information online, and that was back in 2012.

A lot of patients are going to get fired if that happens whenever they show up with information that happens to disagree with the physician's belief system.  Vaccines may appear to be a relatively clear-cut case, but not all information that a physician doesn't agree with is automatically wrong.  As Aaron Carroll and Austin Frakt pointed out recently, many therapies not only benefit fewer people than we might think but many also cause harm to some patients.

Dr. Victor Montori of the Mayo Clinic asserted that non-compliance isn't necessarily the patient's "fault."  Sometimes, he believes, the treatment plan wasn't simply right for that patient.  As he said: "Healthcare right now is all about itself. Healthcare right now is about how do we get bigger, more market share."  In his opinion, we won't get the best health care system until we start shrinking it.

Sometimes not doing what your doctor recommends is a good idea.

And, of course, how many of us have been told by their doctors to lose some weight, eat better, and get more exercise?  Doctors are now starting to actually give prescriptions for exercise, spurred by the Exercise is Medicine initiative of the American College of Sports Medicine.   I'll bet we're even worse about filling those prescriptions than we are about our prescription medicines.

Our persistent failures to take better care of ourselves could have resulted in many of us getting kicked out of our physician's practice.  

The fact that we haven't seen a rash of patients getting fired by their physicians may be viewed as a testament to the power of the patient-physician relationship.  Or, more cynically, as testament to the power of fee-for-service medicine.  But those days may be waning.

HHS Secretary Sylvia Matthews just announced an ambitious goal to move 50% of Medicare payments to value-based mechanisms by 2018, rewarding providers for quality rather than quantity.  And her goal is not just for Medicare; her hope is that other public and private payors follow suit.  A large coalition of providers and payors has already signed on.

The AMA is not quite on board.  AMA Executive Director James Madara admits that: "In many areas of patient care, we do not yet have high-quality outcome measures with enough specificity to drive improvement."  You'd think that an organization supposedly overseeing the professional efforts of its members and concerned with patients' health would be more concerned about that, but, of course, it's more about the money.

So when doctors' incomes become challenged by poor patient outcomes, it will be very tempting for physicians to start winnowing out non-compliant patients.  That's not entirely unfair; I wouldn't want to be held accountable for patients who refuse to follow instructions that would help them maintain their health either.

However, we're in an era, or soon to be in an era, where it will be very feasible for physicians to monitor in real-time whether we're taking our meds, getting our exercise, sleeping enough, and so on.  Big Brother may not be the government, but rather our physician.  We've just ended decades of angst about losing or not being able to obtain health coverage due to health status (assuming ACA isn't overturned or repealed, anyway), but there's nothing stopping our physicians from penalizing us for our bad health habits even more than those health plans used to be able to do.

Still, the line at which such winnowing is appropriate is murky.  Doing so out of concern for the rest of the patients' health is one thing; having a different (yet hopefully informed) opinion about a proposed treatment is something very different.  I have these mental images of the Seinfeld episode where Elaine is unable to escape the notation in her medical record labeling her "difficult," causing her to search further and further for a doctor who will see her.  And that was in an era of paper charts; imagine how our vaunted inter-connected EHRs would facilitate such "blackballing."

The one thing that seems clear to me is that physicians shouldn't kick out patients for their own financial gain.  They probably won't, for the most part anyway.  But there's no shortage of data about physicians performing what would appear to be quite unnecessary services strictly for their own gain (e.g., a recent New York Times article about snowbirds), so I wouldn't rule it out.

Well-meaning as he may be, Dr. Goodman may have helped start something that we're all going to regret.