We Know We Are Doing Bad Medicine… But…. Said the Doctor…

There is a summary write-up of a discussion between doctors on MedScape. This is not an article (or video since it contains the video of three doctors’ discussion in addition to the transcript) for public viewing; one must be a published scientific article author to be able to view the original. In case you do have an article in the NIH database and have access, the link is provided. I do have access so I summarize here what the discussion is about for those who do not have access and, as before, I need to ask you to sit down before you read it. Some parts of the article are shocking.

The debate title is “The Pros and Cons of Patient Satisfaction Measures” and it is a Primary Care debate between three doctors: Bradley P. Fox, M.D., William R. Sonnenberg, M.D., and  Charles P Vega M.D. The discussion is dated July 8, 2014.

Apparently Dr. Sonnenberg made the suggestion that “patient satisfaction” should be used “as guide for physician evaluations and payment.” He presented a paper in the Keynote Physician, which is a paper of small circulation so he thought nothing of the ensuing consequence. Then later he gave a lecture in San Diego on Brochiolitis (children’s lung infection) and suggested that doctors “need to pin downs diagnosis” in patients because otherwise “parents will be taking their children to emergency wards or urgent care centers, where they will be given the obligatory prescription for azithromycin (common antibiotic), which seems to make everyone happy.”

This created what you may call chaos in the conference as ER doctors ran after Dr. Sonnenberg after his talk telling him that “Look, we know that what we are doing is wrong, that this is bad medicine. But our performance is judged largely by 2 parameters. First, do we get the patient door to door in 45 minutes? Second, do we keep the patient satisfied?

Wow! WOW! and WOW!

They know that they are practicing bad medicine! They know and admit it! Plus they also admit that medicine is all about money because they need to get the patient out the door–in case you don’t know, there is a time limit set by each emergency room for what it considers to be acceptable to pass before they must admit the patient to the hospital. Thus getting patients to not be admitted is goal number one over and above patient health! Goal number two is to make sure patients leave with a smile, even if they were given the wrong treatment.

What happened to ethics? To the Hippocratic Oath that states “Do No Harm!”?

The discussion continues about how administrators are leading what doctors do. There is really nothing new about this since we all know and have always known that doctors can only do what the administrators, who are not doctors, let them do. This not only leads to bad medicine but also can have dangerous consequences, as our recent discovery of superbugs suggests. Superbugs do not respond to any known antibiotics. The reason for these superbugs is precisely the over-prescription of antibiotics for cases where it is not only not needed but may actually cause harm. If doctors are judged by patient satisfaction and they are not happy, according to what these three doctors are talking about, the patients did not receive antibiotic treatment!

Thus we have a multitude of problems here, not the least of which is patient education–or lack thereof.

The three doctors go on discussing how increased patient satisfaction is actually associated with higher patient mortality rates–which would be understandable based on the antibiotics argument but not on any other measure. They also discuss the importance of patient satisfaction for “patient adherence” meaning that we stick with our doctors.

It nearly seems to me that three used-car sales reps are talking here! Is this real?

They continue: “Right now, the effect of patient satisfaction on income is about 3% of a primary care physician’s salary and 2% of a specialist’s salary. This is not a major chunk of a physician’s salary, or anywhere close.”

This is a very interesting discussion. Pretty soon I will feel like a bag of peanuts for sale. How much of my health really maters to doctors?

The discussion continues: “Physicians are generally a very competitive lot, and if you look at a survey and see that you are in the lower 10% or 20% of a given metric, you will try to do things to increase it.” The discussion does not detail how far doctors are willing to go to achieve to be in higher than the lower 20% of a given metric and it is not clear what the “metric” in this sentence refers to but whatever I try to refer to in terms of what physicians are for, it sounds bad, except in one case, in which patient health is a metric.

Unfortunately the questions of metric with respect to patient health has not come up anywhere in this discussion.

But there is another angle to being watched and judged by administrators. Dr. Sonnenberg said

Once I was dinged for something I believe is distinctly unfair. Years ago, a patient had an x-ray in the emergency ward; I received the result 3 days later. I called the patient promptly when the x-ray showed up on my desk. The patient yelled and screamed and gave me a bad report, and I ended up getting certified for 1 year instead of 2 years. It did not matter that what I did was logical, proper, and the best anyone could have done. They did not care; they saw the and dinged me for it anyway.

Thus even when a doctor does the right thing, the administrators’ rules are above and beyond what a doctor may seem to be the right action–even if that is the right action for the patient.

Dr. Fox was the only one who suggested the kind of measurement that included the terms “real-time or medically sensitive approach” for being included in a metric of deciding the quality of a physician.  A “medically sensitive approach” is still not “did we get the person healthy” approach but better than “was the patient out the door in 45 minutes?” for sure.

But then here is a not-so-funny statement for you:

One humorous anecdote I heard was that to get rid of the outliers, make sure you put down an abuse diagnosis in the coding. If you put down an abuse diagnosis — alcohol or drug abuse — those statistics are automatically excluded by Press Ganey. I have heard that this is a way to game the system…. (Dr. Sonnenberg.)

So the system is being gamed in medicine. Again, nothing new, only a confirmation of what we all already knew only it is odd to hear it from the mouth of a doctor. Isn’t it?

I am ashamed that I read this discussion but glad that I did as well for it proves what we all know: medicine today is in shambles because of incompetent administrators who look only at profits. There is nothing wrong with looking for profits if appropriate care is provided. But getting profits based on how fast the patient is kicked out of the office is not a profit center for a physician!

I am looking forward to your thoughts!

Angela

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About Angela A Stanton, Ph.D.

Angela A Stanton, PhD, is a Neuroeconomist focusing on chronic pain, electrolyte homeostasis, and genetics. She lives in Southern California. Her current research is focused on migraine cause, prevention and treatment without the use of medicines. As a forever migraineur from childhood, her discovery was helped by experimenting on herself. She found the cause of migraine to be at the ionic level, associated with disruption of the electrolyte homeostasis, resulting from genetic variations of all voltage gated channels that modulate electrolytes and voltage in the brain, insulin and glucose transporters, and several other related variants, such as the MTHFR variants of the B vitamin methylation process and many others. Migraineurs are glucose sensitive and should avoid eating carbs as much as possible. As a result of the success of the first edition of her book and new research and findings after treating over 4000 migraineurs world wide, all ages and both genders, she is now finishing the 2nd edition. The 2nd edition is the “holy grail” of migraines, incorporating all there is to know and also hypotheses. It includes an academic research section with suggestions for further research. The book is full of citations to authenticate the statements she makes to be followed up by those interested and to spark further research interest. It is a "Complete Guide". Due out in the summer of 2017. Dr. Stanton received her BSc at UCLA in Mathematics, MBA at UCR, MS in Management Science and Engineering at Stanford University, PhD in NeuroEconomics at Claremont Graduate University, and fMRI certification at Harvard University Medical School at the Martinos Center for Neuroimaging for experimenting with neurotransmitters on human volunteers. For relaxation Dr. Stanton paints and photographs. Follow her on Twitter at: @MigraineBook
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6 Responses to We Know We Are Doing Bad Medicine… But…. Said the Doctor…

  1. Reblogged this on SHERRI OF PALM SPRINGS and commented:
    This is a must read

    Liked by 1 person

  2. Hi Angela, wonderful blog..enlightening for so many… Hope for more as I re-blog my friend

    Liked by 1 person

  3. Roald Michel says:

    A little while ago I was following a discussion in a Li-group focusing on problems/challenges that psychologists/therapists had in their private practice. Most commentators came up with money issues and rarely with something related to working with their clients/patients.

    So it’s not only doctors. It can be the case with any profession! A doctor, psychologist, farmer, judge, garbage collector, banker, police officer, and what have you, all are human beings. They all can be criminals, ethical to the core, indifferent, altruistic, con artists, exploding from integrity, slime balls, greedy, cowards, competent, lazy, etc. And I don’t see this changing any time soon. Not even when you would succeed in changing your “systems” for the “better”. Instead, we need individuals who are NOT blindly following or trusting their (in this case) so called health providers, and to realize/acknowledge that the # 1 responsible for their health are they themselves! Ask questions, get info, check credentials, “look it up”, and THINK! Given we are living in the information age, this shouldn’t be too difficult. And if one is still too lazy to act like that, or doesn’t want to be in control? Well…….suffer, worship your sacred health professional to no end, and then…………rot in hell. But don’t complain eh, because it’s all your own stupid fault.

    Ultimately it comes down to what I’m promoting for a long time already: Get rid of the damned leadership worship. If there’s one thing education should focus on, it’s exactly THAT!

    Liked by 1 person

    • I totally agree Roald. That is why I want to start a patient advocacy group to teach them how to do it. I find that most are intimidated by the doctors and by the system and those of us who are not intimidated, we learn the ugliness behind, I posted this article to show precisely how incredibly the entire system deteriorated so completely that these three doctors dare to talk about lack of health care for the sake of health openly as if “business as normal” and no ethical problems here. I know I will make a dent in the medial system. I may not be able to turn the entire system around but I sure am getting a lot of attention from people/patients who one by one will change their approaches. If the changes must come from the bottom up, they will come from the bottom up. I just needed confirmation that indeed, that is where things can be changed. So I will work toward that. I started already some time ago with this blog and also with one on facebook. I now get many requests for help in how to communicate, what to take, how to self diagnose, etc. It takes a bit of learning for many–not everyone is as capable of being a self-started as you and I are. There are too many trusting people on this planet; they think people are good by nature. That is what they were taught. Now they need to learn the truth. It will take time.

      Liked by 1 person

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