Dawn of the planet of the value based

sunrise clark

It is the dawn of a new era.

Many cogs are now required to turn the wheels of our nation’s juggernaut health care industry. Physicians, historically the driving force in medicine, are not generally the “cog” type. This juxtaposition can have unhealthy consequences for all of us.

In his August Wall Street Journal article “Why Doctors Are Sick of Their Profession,” Dr. Sandeep Jauhar documented the pathology in our nation’s medical history. And while I agree with the good doctor’s diagnosis, I am not as comfortable with his treatment plan, which includes:

  1. “giving rewards for patient satisfaction”
  2. “replace the current fee-for-service system with payment methods such as bundled payment, in which doctors on a case are paid a lump sum to divide among themselves”
  3. “pay for performance, which offers incentives for good health outcomes.”

At first glance, Dr. Jauhar’s suggestions would appear to be reasonable measures. But employing such metrics may not sit well with our current physician workforce for a number of valid reasons.

In days past, the medical profession attracted highly intelligent practical dreamers in search of a career that allowed and rewarded unfettered blending of art and science; answering a “calling” that revered the heartfelt patient-physician relationship. If you were a “Renaissance man” or woman, crossing medicine’s threshold felt like coming home. Now in this modern medical renaissance, home is not necessarily where the heart is. Home is now inhabited by impostors masquerading as quality and value.

In days past, creativity and problem solving were vital to success in health care. Now strict adherence to guidelines, meeting quotas, and saving money for third party payers are paramount. Now the “rough spots” in the delivery line -physicians who view patients as individuals as opposed to populations – are being made smooth or else discarded.

Given a metric that determines their “bonus,” worker bees will instinctively aim for that mark. So if earning money to send their kids to college depends on getting a “five star” customer satisfaction rating, then expect health care professionals to make flashing a salesman’s smile the priority. Running a clinic on time will become more important than taking time to comfort that patient who’s problem unexpectedly deserves more attention than the automated schedule allowed…can’t risk upsetting twenty people for the sake of one, you know.

The story goes that Albert Einstein once wrote on his blackboard: Not everything that counts can be counted, and not everything that can be counted counts.

Regardless of the origin, this statement rings with truth. More than an observation, it is a challenge.

hand

I held a hand the other day. There was no procedure code for it. It did not satisfy any quality metric. Truth be told, it was probably more beneficial and more appreciated than the epidural injection that preceded it.

We are living in the dawn of the planet of the value based. Students now embarking upon their medical school journey will emerge light years away from where they began. When they graduate and step into the blinding sunlight of the real world, will they even recognize it?

Or, as in the climactic scene from Planet of the Apes – when Charlton Heston’s character realized man’s demise was his own doing – will they cry out…

You finally really did it!

You maniacs!

You blew it up!

 planet-of-the-apes-1968-movies-14704094-1920-811-which-was-the-best-planet-of-the-apes-a-look-across-time

 

I hope not.

I will do what I can.

But, then again, I am a rough spot.

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This Cathedral Won’t Build Itself

washmonwinter

It’s Sunday morning February 16, 2014 at the American Medical Association Candidate Workshop. I’m sitting in this Washington, D.C. conference room, listening to one-hundred ways I can get more politically involved, but hearing one-thousand reasons why it would be crazy for me…

And this popped into my mind.

 

Stones_

Breaking rocks?

In the closing days of my Master of Medical Management program at USC, Professor Dave Logan introduced to our class the concept of a default future, the future that will happen if nothing is done to change it. He then asked the class – 22 seasoned physicians – to describe what health care would look like in 10 years:

“Everything will be automated and impersonal.”

“You’ll have to wait two years to get a hip replacement.”

“It will be a two, no three tier system.”

“The doctor-patient relationship will be history.”

“Managers will run everything.”

“Doctors will be worker bees.”

“Patient care will suffer.”

“I will finally get to go home at 4:30, because everything will shut down.”

What struck me is that no one mentioned that doctors would be paid less money. This was the Marshall School of BUSINESS, yet none of these professionals put lower income at the top of their list of worries. Which is precisely why these physicians, all physicians, need to be leaders – not just managers, not just worker bees.

I have been a GLMS officer for the past three years, and at every board meeting it stared at me from the backside of my name placard – our mission statement. Only in the past few months have I really taken notice. It is so elegant:

Promote the science, art and profession of medicine.

Protect the integrity of the patient-physician relationship.

Advocate for the health and well-being of the community.

Unite physicians regardless of practice setting to achieve these ends.

Doesn’t this sum up why you and I became physicians? Isn’t this a stark contrast to the default futures predicted by my USC cohorts?

I remember very little about the blur that was my first week of medical school, but I will never forget the question that one of the PhD types posed to our class. He asked us to raise our hand if we went into medicine to save the world. Without hesitation almost every hand enthusiastically went up.

“Then you are in the wrong place,” he smugly blurted into his lavalier mike. “Go learn how to grow corn in the desert. Then you will save the world.”

crops on the desert

This made me think. Why did I want to be a doctor? Was it for the prestige? The respect? The money? The power? Or was it because I wanted to have a profession where I could touch the lives of others? Relieve the suffering of a single individual? Of a multitude?

It has been my privilege to be a physician now for more than twenty-eight years. And while I still can’t fully answer the question of why I wanted to become a doctor, I can definitely say why I want to wake up tomorrow and be a doctor. It is in that mission statement.

Some of you are in the whirlwind that is medical school, others are developing confidence to match the bravado that carries you during the early years in practice, some are grinding away against the current of the faceless third-party, and some are looking back and wondering if they should have tried to grow corn on sand.

There is a default future out there. Somehow, you know what it is. If you pause and think, you can even say it out loud so it seems more real. And it will come to pass, unless you make a decision to act – unless we make a decision to act.

I am asking you to unite with your partner, your mentor, your colleagues, your spouse, your patients and me. Together we can take the first steps to change the default future. It has to start somewhere. It can start here. Right now.

We have core values that we share, and when our strategy is in line with achieving the greater good, our choice of profession becomes a higher calling.

Communication is paramount. And we must communicate passionately and effectively. Connect with your colleagues via tweets and email (find me on Twitter @jamespmurphymd; my email is president@glms.org). Join a committee, attend the meetings, call legislators, write letters to the editor, join the GLMS Alliance with your spouse and look to GLMS for leadership development opportunities. As soon as possible, download the new GLMS mobile app and read the alerts, publications and notices.

Lead. Manage if you must, but you must lead.

Breaking rocks?

Dave Logan told us of a band of laborers sweating in the hot sun in some poverty-stricken Third World country. They were pinging away at rocks with small hammers, relentless, sweat pouring, dust choking. But amazingly they seemed happy despite the mind-numbing conditions. When one was asked how he could not be miserable in the mundane task of breaking rocks, he replied, “I’m not breaking rocks, sir. I am building a cathedral.”

oaxaca cathedral

Let’s make a new future.

Let’s build a cathedral.

Sincerely,
James Patrick Murphy, MD, MMM
President, Greater Louisville Medical Society

president@glms.org

Twitter  @jamespmurphymd

 

P.S. Have you heard about what happened during my installation speech at the GLMS Presidents’ Celebration? Watch the video here.

Note: This article was first published as the

Greater Louisville Medical Society President’s eVoice,

Louisville Medicine, June 2013

The way we were…

pat and adele at washington

Pat and Adele, Spring 1985