Saturday, January 31, 2015

Primary Care Is So Over

There are close to a quarter million primary care physicians in the U.S., more than any other individual specialty, and about half the total number of all specialists combined. Yet, somehow, primary care seems to lack the power and social influence necessary to chart its own professional course. As the availability and granularity of specialist physicians increased, the value proposition of a generalist primary care doctor seems to have become unclear to those who pay for medical services and to physicians as well. As a result, primary care medicine was forced to price itself lower than specialized medicine, and now it is being forced to compete with a variety of other business models. Primary care seems to be experiencing an identity crisis, unable to decide if it is the cornerstone of medicine, or an antiquated service whose time has passed.

What is primary care?

The primary care name itself can be understood in two very different ways, depending on how you translate the word primary. It could be seen as the first step one needs to take when engaging with the medical system, a step followed by secondary care, tertiary care, etc. This is the gatekeeping view, where primary care doctors apply their knowledge to direct patients to appropriate specialized resources, if necessary. Since there could be multiple specialized resources, and since medicine is very complex, the gatekeeper doctor is also tasked with follow up, coordination and general supervision. In the business world, this job is known as project management, and it is usually filled by workers that need not be expert at anything other than management of tasks and resources.

Another way to look at primary care is to assert that it is the central and predominant type of medical care, or the way most medical care is provided. In this model, the primary care physician is expected to treat and resolve all but the most unusual medical problems, which may from time to time require a consult with a specialized resource. A consult is not the same as a transfer of care. This type of practice requires that the primary care physician has more knowledge and more understanding of the patient than all transient specialists put together. And this type of super doctor cannot be either underpaid or easily replaced. Unfortunately, short of some old timers here and there, nobody practices primary care quite this way anymore.

There are many reasons why medicine developed into an essentially fragmented model of care. The often touted explosion in medical knowledge, beyond what one human can accumulate and apply, is probably not as instrumental here as money and power seem to be. There are only a handful of diseases that make life miserable for most people, and eventually kill us all, and data shows that most medical resources are spent on a tiny percentage of people at any given time. It is difficult to reconcile these realities with the assertion that we need hundreds of thousands of highly specialized resources, because no one doctor can master the intricacies of a few run of the mill diseases occurring over and over across the board, and seriously affecting only a minority of patients. This, by the way, should not be confused with the obvious need for having a great variety of specialized research in academic and industry settings.

Whatever else it might be, primary care is a $100 billion per year industry in complete disarray. In addition to its own revenues, primary care as it stands today, heavily influences the flow of revenues in all other health care sectors. This should explain rather nicely why so many businesses are trying to be part of it, trying to reform it, reinvent it, flip it, control it, or just replace it. What practically all these innovations have in common is a tacit agreement to adopt the lighter definition of what primary care consists of, for the very simple reason of reducing barriers to entry into this potentially lucrative market.

Keeping People Healthy

In today’s complex environment, individuals cannot be trusted to care for themselves or their children, and rightfully so. The survival and prosperity of our society is predicated on passive consumption of massive quantities of goods and services. Our electronic way of life is designed based on the timeless axiom of “don’t make me think”, and an extra click of a button is considered undue burden on average consumers. We are expected to ingest billions of Big Macs to keep the economy chugging, and go through trillions of disposable trinkets sold on the Internet to keep WWIII from erupting. Even getting the news every morning has been replaced with news “feeds” to save you the long walk down the driveway to pick up the old newspaper. And turning pages, even on the Internet, is too much of an imposition. What makes us excellent consumers is also rendering us unfit to be trusted with our own health.

In this age of patient empowerment and freedom from paternalistic physicians, it seems that primary care doctors are being put in charge of keeping us healthy. It only seems that way though, because nobody needs a doctor’s education and expertise, not to mention expense, to figure out what every good grandma, and every single one of us, knows already. Besides, going to see a doctor does not fit with our tried and true, instantly gratifying, passive consumption paradigm. In our new way of so called life, primary care becomes an electronic assistant that uses, and is used by, every consumer, every day. Note that the modern term “primary care provider” is specifically geared to this low level function. Nobody uses the term cardiology provider, or surgery provider, or even pediatrics provider, to refer to a medical doctor. Primary care is different.
  • Primary care monitors your food intake and level of exercise, reminding you to eat your veggies (or no desert) and take your constitutional regularly
  • Primary care reminds you, or schedules for you, health screenings and preventive care services as recommended by your government
  • Primary care monitors your vital signs and lets you know if normal parameters are exceeded
  • Primary care answers your questions if you feel under the weather, or just concerned that you might be
  • Primary care treats minor illness and injuries, such as mosquito bites and nail fungus
  • Primary care is available 24x7 from the comfort of your iPhone, or in extreme cases next to the bakery counter at your favorite discount store
  • Primary care is provided by Siri and augmented by certified technicians with impeccable customer service credentials
If you have a sudden urge to kick me in the shins right now, remember that primary care is not your profession. You are credentialed in Family Medicine, Internal Medicine or Pediatric Medicine, keyword here being Medicine. Yes, you may be providing some of these services for some of your patients, mostly for free, but is this really what you want to do all day, every day? Yes, having people come see you when they are healthy, better equips you to care for them when they are sick, but this seems a luxury few can afford today. The new primary care has as much to do with practicing medicine, as fixing traffic tickets has to do with practicing law. It is a piece of your old practice that has been successfully carved out by competing businesses that can and will be providing these, and many more, services to your patients. And if you’re not careful, specialists will take whatever is left on your plate.

Healing the Sick

When primary care was defined by Barbara Starfield as high quality, compassionate, comprehensive general medicine, it was an honor to be called a primary care physician. Today, the term is becoming essentially oxymoronic. Physicians, contemplating the plucking of low hanging fruit from their scope of practice, are usually concerned with being forced to juggle a schedule full of complex patients, with no cognitive respite throughout the day. This, however, is highly unlikely. If you subtract the healthy and easy patients from your schedule, they are not going to be magically replaced by an equal number of very sick individuals. Instead of 25 to 30 spurts of quick encounters, you are more likely to experience 12 to 15 long visits per day. Is that so bad?

It is very bad if your pay rate stays the same. It is spectacularly good if it doubles and triples. Whereas primary care physicians of the past are trapped in high-volume hamster wheel races, the new family docs, internists and pediatricians will be providing real value to their patients. Since the pundits are screaming from every rooftop that we should be transitioning from volume to value, this seems like a perfect arrangement for all stakeholders. Value, of course, needs to be valued, so paying, say, $300 for a doctor visit (not to be confused with primary care) sounds pretty respectable to me.

Corner drugstores are full of medicines and gadgets that used to be exclusively available from doctors. There is nothing new in transitioning tests and therapies into the hands of the lay public. You don’t have a microscope and a rabbit in your office, do you? Quit worrying about nurses and retail stores and the Internet stealing your lunch. You didn’t go to medical school to coach poor people on their sinful lifestyles and their need to be righteous and deserving of charity. You wanted to heal the sick, so have at it. If you want to fight for something, don’t fight for volume. Fight for value. Your value.

Tuesday, January 20, 2015

Artificial Intelligence

Did you know that the Ford Motor Company which created the first mass produced horseless carriage in 1908 is one of the largest manufacturers of automobiles a century later? Did you notice how cars today look almost the same as the Model T? They are all made of metal, have four wheels, a steering wheel, a dashboard, a windshield, two rows of seats and an engine. Closer inspection reveals that all newer car manufacturers make cars that look and feel just like the cars made by the Ford Motor Company. And they all drive on roads and use wheels, wheels, the hottest disruptive innovation of the Neolithic era. Truly disruptive innovation, unlike its short lived destructive cousins, stretches across millennia of useful applications.

Strangely enough, beds and tables and chairs, and the houses they furnish, look basically the same as those used by Louis XIV. Bread loaves and wine look the same too, and so do fishes. Another thing that hasn’t changed much from the beginning of time is the fertility of our collective imagination. At one time we imagined cherubs floating on clouds and magical beings who control the world and every single life within it. Entire industries sprung around that innovation, industries whose thought-leaders ruled the world in the name and on behalf of our imaginary hopes and mostly fears. For a while there, we decided that imagination is a personal thing and it should be separated from the mundane tangibles of our earthly affairs. That didn’t last long.

What separates us from the hapless creatures we are now killing by the bushel is the capacity and need to believe in something greater than ourselves, something that transcends our mortality and provides us with a purpose external to our own existence. First it was the certain belief in an omnipotent, and incomprehensible to mere mortals, intelligent design of the world we live in. Now it is the arrogant belief in our ability to create our future creator, an artificial intelligence to supersede our own, and to shape the world in ways beyond the wildest dreams of avarice and the trembling terrors of perdition’s flames. The age old puzzle of whether God can make a rock so big and heavy that even He cannot lift it, seems about to be resolved.

Suffering today, being beaten, tortured, starved and killed, is just fine, because after that comes your own personal Garden of Eden. Being unemployed, unemployable and living on meager handouts with no hope for a better future for you or your children, is perfectly fine, because after that comes “the eradication of disease and poverty”. Well, it is not “unfathomable” that it comes, and that’s pretty good, so go ahead and fathom amongst yourselves. And be afraid, very afraid, because unless you give us more money to study how we should go about doing the right thing, some really scary scenarios, such as having Gov. Schwarzenegger chase you in the middle of the night, are also fathomable. When? Sooner than you think, if you are still thinking, otherwise let’s say next Tuesday.

Stating that we are on the verge of creating artificial intelligence superior to the human brain, when we can't even make artificial chickens at this point, sounds a bit specious, doesn’t it? But that is not preventing us from incessantly talking and writing about it in order to generate the tried and true mixture of hopes for salvation, at an unspecified time in the future, with immediate and actionable fears of doing wrong today. We have magnificent prophets and we already have the heretics lined up as well. Did you ever wonder why some prophets had their litanies included in definitive compilations of bibles, while others were literally and figuratively burned at the stake? It may be helpful to look behind the curtains at those who anointed the prophets then and those who are anointing them now, because they are one and the same.

The job of prophets has always been to strip commoners of their ability to make independent decisions. Today’s prophets of disruptive innovation are showing us the road to becoming Roman patricians spending our entire lives sprawled on fainting couches while being fanned and fed gorgeous grapes by beautiful machines. The first thing we must do is to offload decision making to the precursor of the slave-savant machine of the future, so it can learn and practice the art and science of pleasuring us. Letting your GPS decide how to get from point A to point B is one example, and letting Google decide what you should read is another, although the latter may soon become obsolete, since enjoying grapes on your couch does not require any reading. Letting your “phone” decide when you should stand and when you should sit, when to eat and what to eat, and when you feel and how you feel is the next step in our evolution towards a perfect union between amino acids and silicon compounds.  

Perhaps nothing illustrates our glorious path to heaven on earth better than health care, and befittingly so, since health is life, hence health care is life care, is everything. The old definition of health care included mostly restorative medical activities to one’s health, but as the value of people keeps declining in an overpopulated global economy, and the costs of repairs are increasing, a more expansive, machine oriented, definition seems in order. People, you see, are essentially carbon-based machines, like say cars, the only analogy simpleminded voters seem to comprehend. To reduce your lifetime expenses on your car, and to enjoy a reliable vehicle for the duration, you need to have all the maintenance done on schedule (e.g. oil changes, tire rotation, filters, belts, etc.), drive carefully and obey the law, use the car sparingly, without too much starting and stopping, and you should wash and wax regularly, and generally keep it nice and clean inside and out.

You get the recommended preventive care for your model, all the screenings and tests, so any early signs of malfunction can be addressed, and you swallow all the recommended additives to make operations smooth and well lubricated, without undue stress to any of your parts, especially the feeble brain part. You refrain from reckless activities, and keep your mind and body clean on the inside and on the outside. The prophets, or futurists, as they prefer to be addressed today, are guiding us to all sorts of little silicon parts that we can incorporate in ourselves on the incremental road to transferring the limited intelligence functionality of biological creatures to superior artificial components. This simple process of artificial evolution towards a brighter future does not seem to come naturally to most people. These things never do. This is precisely why piety and obedience need to be enforced by cannons and laws, and here and there a few weaklings or outright skeptics must be made examples of what people should fear most.

Google is now making self-driving cars and in the future it will be making self-driving people. Whereas the self-driving Google cars look the same as those made by the Ford Motors Company, the futuristic self-driving Google people will look indistinguishable from the Neolithic geniuses who invented the wheel. And just like the Google cars are not really driving themselves, the Google people won’t either. Google is driving the cars and Google will be driving the people, and Google is driven by people. As it always has been and as it always shall be, a handful of megalomaniacal people will be driving masses of other people into hopeless existence, although, this time around, hopelessness should come with grape-dispensing machines and free happy pills.

Artificial intelligence is not autonomous machine intelligence. Artificial intelligence is not the fictional story of cyborgs roaming the earth. It is the story of the Wizard of Oz, the story of Stalin and Maoist reeducation, the story of Torquemada and the Dark Ages, the story of Egyptian Pharaohs and high priests clad in jewels accepting offerings from starving barefooted men while overseeing ritual sacrifices. It is the story of a cosmically inconsequential power trip that may set us back millennia instead of just centuries. At times like this, we should keep in mind that the true innovations driving humanity, and all cyclical prophecies of bliss and gloom along the way, were invented by men who were just slightly removed from apes.

Tuesday, January 6, 2015

Why Physicians Must Unionize

If F. A. Hayek were alive today, he would support the revival of labor unions in general and professional labor unions in particular. Towards the end of the Second World War, Hayek wrote a book warning us all that allowing governments to engage in extensive central planning of economic activities is nothing more than a road to serfdom for humanity. F.A. Hayek was not an Ayn Rand sociopath, and he included in his vision reasonable government regulation of markets, strong safety nets, and something that looks awfully similar to the avant-garde “guaranteed basic income” discussed nowadays in some European countries. Unfortunately for us, and kudos to Prof. Hayek, seventy years after the publication of his book, we are well on our way to universal indentured servitude.

Ordinary Citizens

In September 2014, Martin Gilens and Benjamin Page, two Princeton researchers, published the results of a longitudinal study on policy decisions in the U.S. from 1981 to 2002. After crunching enormous amounts of data, Gilens and Page conclude that “economic elites and organized groups representing business interests have substantial independent impacts on U.S. government policy, while average citizens and mass-based interest groups have little or no independent influence”. In spite of enjoying all the trappings of democracy (e.g. freedom of speech, widespread franchise), we seem to live in a “democracy by coincidence, in which ordinary citizens get what they want from government only when they happen to agree with elites or interest groups that are really calling the shots”.

Perhaps that’s how it always was, and certainly that’s how it is now, but at several points in our history government enacted policies in stark contrast to the interests of both economic elites and business interests. Labor laws were just such an occurrence. Labor unions in their various formats could be viewed as the tool by which the interests of average citizens, the “revolt from below”, were channeled into mass-based interest groups that were powerful enough to counteract the interests of economic elites and their business groups, at least for a while. When big business managed to weaken the early unions during the 1920s, we got ourselves a Great Recession. In the midst of our self-inflicted misery, unions came back roaring to take on big businesses and the government they thoroughly controlled. Most workplace protections and gains in workers’ wages date to that era. Eventually though, big business prevailed. The Taft-Harley Act (or the “slave-labor bill”, as Harry Truman referred to it) was enacted in 1947, and it all went downhill from there to this day.


Physicians in the U.S. belong to the economic elites, as defined by Gilens and Page. Theoretically speaking, the profession should have been able to influence government policies to its advantage, and arguably that was the case for most of the twentieth century. In the 21st century, we are witnessing the industrialization of medicine, and although physicians are still handsomely compensated for their labor, a marked deterioration in their working conditions is gradually occurring. Whereas the industrial revolutions decimated the numbers of master craftsmen who owned their own tools (means of production) and increased the number of journeymen (workers for hire), the industrialization of medicine is decimating the ranks of physicians who own medical facilities, while swelling the ranks of employed doctors.

The master craftsmen of two hundred years ago were driven out of business, and down into wage labor, because they could not compete with industrialized manufacturing. Independent physicians today are driven into employment solely by government policies, since industrial medicine is neither cheaper, nor better than the cottage industry it replaces. Medicine is not really undergoing a revolution as much as a hostile takeover by big business, with full government support. Once a critical mass of employed physicians is reached, and independent practice is no longer viewed as a viable option, chances are that the wages of physicians will more closely align with the wages of every other labor sector. This is therefore the very last opportunity for doctors to leverage their economic elite status and find a way to pair it with an equally powerful interest group, i.e. a Union.

When unions were strong, America prospered. When unions were crushed, neutered or fell victim to their own internal corruption, American economy barely sputtered along. Big business propaganda notwithstanding, unions are not about socialism, communism or collectivism. The sole purpose of unions in a capitalist economy is to counterbalance the excessive influence of economic elites and business interest groups, allowing ordinary citizens to get what they want from time to time. Unions are there to preserve democracy and keep us off that cursed road to serfdom. Even if you are a hardcore free-market conservative, sincerely believing that organized labor is evil, you must understand that often times it takes a lesser evil to combat the greater evil. Discussing, analyzing, lamenting, advocating or pontificating, is no longer sufficient.

A Physicians Union

A physicians union would be very different than the labor unions of the twentieth century. A physicians union would be a true innovation. To be effective, a physicians union would need to include in its folds both employed and independent doctors. Thus, a physicians union cannot be a traditional labor union. Both employed physicians’ salaries and independent doctors’ revenues are driven by the same factors, and although regulatory actions burden independents to larger extents, all are adversely affected by government policies. As long as there is no excess supply of physicians, the alignment of interests between independents and salaried docs, far exceeds any real or perceived conflicts.

The same cannot be said about medical specialties, but a truly powerful physicians union will need to include all specialists as well. If the original Medicare fee setting process drove an enormous wedge between primary care and specialists, the new value-based payment schemes are well positioned to amplify and exacerbate conflicts across all specialties. It is therefore imperative for a physicians union to resolve these conflicts and find a way to work together, or in other words, get over it, because the exact order in which you go down is less important than the fact that eventually everybody will be taken down.

And then there’s politics, but I have faith that intelligent and educated people understand by now that the sole difference between progressive and conservative agendas, is a personal preference to have your serfdom managed either through a government intermediary, or directly by the business overlords. There are also legal issues to ferret out and negotiate. But by far the toughest barrier to creating such union consists of the physicians themselves. Unlike the miners or the railroad workers who build the labor unions in this country, physicians don’t live in squalor, and they don’t put their lives on the line every day for a pittance. As a group, physicians are largely conservative and not given to activism. And this is precisely why an American physicians union can become the most formidable social innovation of our times.

Together We Stand

Did you know that on January 12th, 2,600 mental health workers and 700 other workers at Kaiser Permanente in California will be launching a strike to protest the inadequacy of mental health care at Kaiser? They won’t accomplish much, if anything. There is no coverage in the media, no buzz, no controversy, no lengthy exposés, no debate and no threats from the White House. What do you think would be the reaction if 17,000 physicians employed by Kaiser would walk out at the same time? And what would happen if several hundred thousand members of the Physicians Union of America would walk out as well? I bet mental health services at Kaiser, and everywhere else, would be the talk of the nation, and somehow the funds to hire and pay decent wages to mental health professionals would miraculously materialize.

Imagine a professional union fighting for the freedom of its individual members to exercise professional judgment for the sole benefit of individual citizens. Imagine a medical union fighting to provide the best care to ordinary citizens, free from the whims of the political and business classes. Now close your eyes and imagine the shock and awe created by a union of the best, the brightest, the most successful, most educated, most trusted, most ethical and most irreplaceable group of citizens, standing up and unequivocally stating that central planning has gone too far and has reached levels of immorality that are beyond what a free society can peacefully tolerate.  Then imagine that such union has the power to shut down every hospital, every medical facility and every practice, in every city, every town and every hamlet across the land, bringing the medical industrial complex to a grinding halt.  And now, open your eyes and make a wish...

Thursday, January 1, 2015

What’s to Become of Primary Care? Or, Something to Do with Computers

You may not be ready to admit it even to yourself, but you know it’s changing. Permanently. Some say it’s for the better. Others say it’s for the worse. Most don’t really care much one way or the other. After all, health care has been evolving and changing over thousands of years, and the experts best positioned to evaluate the health care turmoil of our times are yet to be born. Those of us who are now in the eye of the storm have an understandable tendency to analyze high velocity changes, such as the number of uninsured or the number of hospital mergers, but the slower and more permanent changes are unfolding deep below the surface. Perhaps the most enduring alteration to what we call health care is the diminishment of medicine as a whole, and the fading importance of its practitioners, starting with the outer edges of primary care.

The “Looming” Primary Care Physician Shortage

We’ve been experiencing a “looming” primary care doctor shortage for several decades now, and so far it somehow failed to progress beyond the looming stage. The Affordable Care Act (ACA) is adding millions of previously uninsured citizens to the already swollen ranks of health care consumers, which is bound to exacerbate the shortage of primary care physicians, particularly as we move from sick care to health care, which is mostly to be provided by primary care facilities. As the public is wringing its hands in fear and apprehension, several solutions to this life-threatening shortage are being proposed and proactively implemented. The first and foremost solution is to allow non-physicians to provide primary care, whether in care teams with a physician figurehead in the corner office, or in retail settings at the grocery store. The second and longer term solution is the institution of remote medical care, provided by a mixture of outsourced physicians, non-physicians and algorithmic self-service apps.

The primary care shortage narrative is now as well established as death and taxes. Our constant inability to address this shortage is also immutable, and it has been so for all the decades we could have used to train more primary care doctors. Whether by design or by happenstance, we are now working hard to reduce demand, and perceived need, for actual doctors in primary care, and at the same time, we are working equally hard, if not harder, to increase the soothing volume of cheap and inconsequential services which are considered part of primary care. Ironically, it took many decades of random and often times planned decisions, made largely by the medical establishment to create this apparent discrepancy, and the pattern continues to this day.

Primary Care is Like Jiffy Lube

How often do you hear conservative doctors, still fighting the good old fight of 1965, stating that if your car insurance were to pay for oil changes, it would also cost a fortune? Insurance, you see, should be reserved for catastrophic events, and everything else should be paid with cash by each individual. And if the individual has no cash, then how many grocery stores would give you food (which is also lifesaving) if you had no money to pay for it? These positions are practically impossible to debate, particularly since personal charity is always the answer to opposing arguments. Oil changes and basic food are indeed planned and fully expected expenditures that each responsible person should budget for, and so are routine and non-catastrophic medical needs. But guess what else all these things appear to have in common? They are simple, undifferentiated, commoditized goods and services that anyone can provide, and many people can provide for themselves.

If primary care is to medicine what Jiffy Lube is to the automotive industry, we don’t need physicians to deliver primary care. Period. Even more astonishing is that this seems to be the main argument put forward by the direct primary care (DPC) movement. Previously known as concierge medicine, i.e. extra quality for more money, DPC makes the straightforward argument that good primary care is a cheap commodity made expensive by inordinate layers of insurance and bureaucratic regulation. For $60 a month or so, you can have all the primary care you can eat, if you pay directly to whoever employs your doctor, or if your purchasers (i.e. insurer or employer) do the same thing on your behalf, which renders direct primary care anything but direct, but that’s another story altogether. Strangely enough, I don’t see too many dermatologists stepping all over each other to convince us that what they do is worth very little money.

Divide and Conquer

Prof. George Weisz wrote a book titled “Divide and Conquer: A Comparative History of Medical Specialization”. I am not sure who was conquering what, but the slow current that will eventually wipe physicians out, as a profession, has its origins in the formally organized specialization of medicine.  Among the many theories and scientific justifications for the inevitability of specialization, Dr. Carl August Wunderlich observed as early as 1841 that “Now a specialty is a necessary condition for everybody who wants to become rich and famous rapidly”. The quest for fame and fortune, which has been our engine of advancement, has the localized consequence of turning each step forward into a giant zero sum game. For some physicians to become rich and famous, many others had to accept less wealth and lower status in society. And after kicking and screaming for a while, they all did.

In the beginning, a specialized physician was one who voluntarily chose to “restrict” or “limit” his practice to certain portions of general practice. In due course, general practice became involuntarily restricted to whatever specialists chose not to do. The scientific and largely elitist arguments of the nineteen century were used iteratively over time in increasingly contrived contexts, culminating with the late twentieth century expulsion of general practitioners from hospital care.  Hospitals today, although very different than hospitals in the nineteen century, are still the mechanism by which wealth and fame are accumulated in medicine. Agreeing to stay out of the cathedrals of medicine, pretty much sealed the fate of primary care.

Public Health

What is then left for primary care to do? I am certain this question is offensive to physicians practicing primary care. After all, it’s not just medicine that changed over the last couple of centuries. Disease itself was changed as a result. Today we have scores of people living with multiple chronic conditions, each one fatal on its own merit until not too long ago, and the generalist doctor is best positioned to manage the whole sick person. Some primary care physicians are still treading in specialist and hospitalist territories without apology and doing a great job at that too. However, the insidious slow current underneath it all, is not only continuing its menacing advance, but it is accelerating, because when physicians as a profession ceded control to specialists, they also invited into the tent other more powerful interests seeking their own riches and fame.

In the olden days physicians chose to specialize after they invented something, or became enthralled with new technologies or a certain group of diseases. Specialization allowed physicians to gain expertise using complex instruments and provided access to larger populations of people afflicted with whatever they were trying to study and improve. Scientific discovery in medicine followed the same pattern as in all other fields where groundbreaking research required an obsessively narrow focus. Excelling at one particular thing, as opposed to being adequate at everything, brought financial and personal rewards. This paradigm is being broken now by a brand new instrument – the computer, and by a brand new group of diseases – being alive. 

Just like the invention of the ophthalmoscope created the formal specialty of ophthalmology, the application of computers to medicine is creating the spanking new specialty of informatics, with one huge difference. Whereas the old specialization by organ, disease or instrument, was designed to narrow practice focus to subsets of patients, and small parts of each patient, informatics aims to expand its scope of practice to include every living person. Informatics is essentially the use of computers to practice an expansive and aggressive version of public health, which includes preventive, curative and research medicine. And thus, general practice on a much grander scale is resurrected, because old King Solomon was right and “that which has been is that which will be, and that which has been done is that which will be done”.

Something to do with Computers

That slow subterranean current that is changing medicine is the same one that changed and will continue to change everything we do into an industry. Nourishment became the food industry. Moving from place to place morphed into the travel industry, including automotive and aviation in its folds. Swapping is now the retail industry, and guarding one’s offspring and possessions became the defense industry. Some of these changes took thousands of years to complete, while others were executed seemingly overnight. Medicine is now engaged in its much delayed transformation to a healthcare (one word) industry.

The main difference between industries and the decentralized processes they replaced is that industries have captains, gurus, thought leaders and regulators, who rarely if ever interact with the masses serviced by the industry, i.e. consumers. The direct providers of industrial services are mostly laypeople, themselves consumers, rewarded with tokens they can use to cross-consume other industrial services. Fame and riches are reserved for the small but potent and irreplaceable captain class – the planners, the organizers and the administrators of industrial efficiency and productivity.

The stethoscope improved on a doctor’s ear, so he can more closely listen to a patient’s heart or lungs. The ophthalmoscope improved the vision of a specialist physician, so he can better see inside the eyes of each patient. The computer is improving the brains of all physicians, so they can treat entire populations without having to see, hear or touch any patients. Physicians specializing (or generalizing) in informatics are the captains of the emerging healthcare industry. The primacy of the general practitioner of old is finally being restored to the supremacy of the physician informaticist of new.

If the illustrious Dr. Wunderlich were to take the temperature of medicine today, he would indubitably observe that modern physicians, who want to become rich and famous rapidly, should find something to do with computers.

Monday, December 8, 2014

JASON: The Great American Experiment

The distinguished JASON group of anonymous scientists and academics that provides consulting services to the U.S. government on matters of defense science and technology, just published a sequel to the 2013 best seller, “A Robust Health Data Infrastructure”. The new report is titled “Data for Individual Health”, and it has two purposes. The first and foremost purpose is to backtrack on the searing criticism leveled at government efforts to promote health information technology, which evoked much angst and indignation earlier this year. The second purpose is to expound upon the exact nature of personal data required to feed the robust infrastructure laid out in the first JASON report, complete with illustrations and examples of breakthrough benefits to humanity, such as helping city planners design bicycle paths. Yes, bicycle paths. And if you didn’t know that the number one health care problem in this country is the layout of bicycle paths, then you are a Luddite, and luckily your generation will soon be dead.

After dutifully observing that only a tiny percentage of Americans use medical services of any kind, JASON is informing us that the government agencies that funded its work “specifically” asked the group “to address how to bridge, on the national scale, to a system focused on health of individuals rather than care of individuals” [italics in the original]. It seems that the overdetermined triple aim of health care reform, better health for populations, better care for individuals, at lower per capita costs, is finally being reformulated into a solvable optimization problem by removing the unprofitable constraints on caring for the sick.

As was the case with the previous JASON report, the group was briefed by a diverse array of researchers and technology experts, including the great new hope of health, our most beloved, innovative, tax evading, and slave labor supported, Apple Inc. The content of briefing sessions is not available to mere mortals, but one in particular is rather enlightening in its title: “Disrupting the Status Quo: Putting Healthy People First”. Never since the dawn of medicine, from Hippocrates, to Florence Nightingale, to Mother Teresa and today’s Doctors Without Borders, have we experienced greater disruption in the status quo.

Similar to the first JASON report, the second offering is chockfull of technical recommendations for the “collection, assimilation, and exchange” of quantifiable “data streams” emanating from living things, whether in traditional medical surroundings or as people go about living their healthy lives. There is nothing earth shattering in the JASON findings or recommendations, but some finer points may be worth mentioning anyway.

Phenotypes - After providing us with a crash course in genomic sequencing and the workings of RNA and other protein molecules in the first report, JASON argued that the “biomedical research community will be a major consumer of data from an interoperable health data infrastructure”, hence the government “should solicit input from the biomedical research community to ensure that the health data infrastructure meets the needs of researchers”. In the second installment, JASON is reiterating its obviously very strong interest in genotype-phenotype relationships and their assimilation into the IT system they are recommending we build. Luckily, some of the JASON briefers happened to hail from academic centers renowned for grant funded genomic research in general, and efforts to “develop algorithms and methods to convert EHR data into meaningful phenotypes” in particular.

In Vivo - I have to admit that compared to run of the mill interoperability papers, which deal with unconscious patients in the ER, or people irritated by having to fill out paper forms, the JASON report is much more interesting. Here is another supercool futuristic development that we absolutely must consider when creating an IT infrastructure to collect data for health related research, which is essentially the main concern of the JASON group. It seems that the Defense Advanced Research Projects Agency (DARPA) is working on in vivo nanoplatforms. Something about “ultra-small scaffolds inserted directly into the body” and “fluorescent nanospheres that are functionalized to detect biomarkers of interest”. The purpose seems to be “continuous physiological monitoring for the warfighter”. We do of course want to support our troops, so these cute little nanites must also be part of our robust health data infrastructure.

FHIR - In this report JASON is taking an unequivocal stand behind a new HL7 standard for clinical information exchange, the Fast Healthcare Interoperability Resources (FHIR), which is actually pretty neat, and has been in development for approximately three years. FHIR is envisioned as a replacement for the C-CDA, which replaced the CCD, which replaced the CCR, which replaced an array of HL7 2.x messages. JASON is recommending that government “policies should make it advantageous for one or more leading EHR vendors to be the first to propose such standards”. Lo and behold, two days after the JASON report was published, a group of leading vendors and institutions, several of which briefed JASON, and some who are helping the government implement JASON’s recommendation, launched the Argonaut Project for precisely this “advantageous” purpose.

FDA - For some reason the JASON report is engaging in a lengthy and strangely passionate litigation of the 23andMe (a DNA analysis service) tiff with the Food and Drug Administration (FDA) from a year or so ago, concluding with a recommendation that the FDA should take a “more nuanced approach” to its regulation of apps that could be construed as “practicing medicine”. The FDA regulatory authority over medical software has been in the crosshairs of corporate lobbyists (tech, pharma, telecom, etc.) for a couple of years now, with a variety of bipartisan deregulation bills introduced, or almost introduced, unsuccessfully in Congress. Coincidentally, two days after the publication of the JASON report, Senators Bennet (D-CO) and Hatch (R-UT) introduced the MEDTECH Act, the most serious attempt so far to restrain the FDA’s regulatory abilities.  

Non-profits – JASON is recommending that non-profit organizations, either those that are disease specific or general in nature, “should be encouraged to assess their goals with respect to health data streams, and to provide “stamps of approval” for applications (apps) and other consumer tools”. In other words non-profit organizations should leverage the trust of their communities to monetize their members’ health data. JASON also recommends that private foundations should help the government by creating cash prizes to entice entire communities into participation in data wellness games. This is brilliant thinking, which leads me to hypothesize that at least one of the JASON members must be a Nobel laureate in marketing.

In this era of “transparency”, where every dollar from every pharmaceutical company or government agency, paid to every doctor and hospital, comes under relentless public scrutiny, why should JASON be exempt? Shouldn’t the JASON reports be accompanied by full disclosures of conflict of interest, both for JASON members and the various briefers whose pet projects populate every page of every report? Where is the media when a group of secretive researchers and private corporations are steering almost 20% of our economy towards endeavors immediately beneficial first and foremost to themselves?

When you read the JASON reports back to back, you are left with the impression that the group’s overarching goal is to create an international distributed repository of genetic materials tied to individual, environmental, behavioral and disease specific manifestations for all people on this planet. There is no doubt in my mind that a structure of this type and magnitude can facilitate an infinite number of perhaps beneficial research projects, and maybe even an IPO here and there. But if taxpayers are expected to fund the infrastructure for such expansive research, shouldn’t they be asked, or at the very least clearly informed?

And why rob the President of the United States of a legacy-defining “We choose to go to the moon” speech? It could go something like this: My fellow Americans, by 2025 every American will have his or her DNA collected and catalogued, and by 2025 every movement and every breath of every American man woman and child will be associated with their genomic sample, launching the grandest experiment in the history of mankind. From the ashes of the Great American Experiment, we will bring you more than freedom, more than liberty and more than a futile pursuit of happiness. We will bring you, Health. Download it for free from iTunes today.

In 1802, Thomas Jefferson wrote in a letter to David Hall: “We have no interests nor passions different from those of our fellow citizens. We have the same object: the success of representative government. Nor are we acting for ourselves alone, but for the whole human race. The event of our experiment is to show whether man can be trusted with self-government. The eyes of suffering humanity are fixed on us with anxiety as their only hope, and on such a theatre, for such a cause, we must suppress all smaller passions and local considerations.” Whatever.

Monday, November 24, 2014

Teachable Moments: Be Thankful for Gruber

So there is this guy from MIT or Harvard, or some other place where they teach our leaders how to lead, and his name is Jonathan Gruber. Mr. Gruber, it seems, was hired to consult with the Obama administration during the time the Affordable Care Act (ACA) was created because of his extensive expertise in designing the Massachusetts health care system. In recent weeks, people who don’t particularly like our President, and his Obamacare health insurance reform, began floating video snippets of Mr. Gruber publicly discussing the stupidity of the American electorate and the purposeful lack of transparency that in his learned opinion enabled the enactment of the ACA.

The rightwing conservative media savored their “I told you so” moment with great gusto. The leftwing media immediately rose to the occasion reiterating the litany of Obamacare benefits, which should not be forgotten just because this one guy said that we are all idiots. Mr. Gruber himself expressed “regret” for his “off the cuff” remarks. Perhaps they don’t teach linguistics at MIT, but “off the cuff” is not a synonym for erroneous. David Axelrod declared on Twitter that Mr. Gruber is the one who is stupid and the White House assured us that nobody there shares Mr. Gruber’s opinions. Some Congressional leaders, seemingly afflicted by the Iran-Contra syndrome, couldn’t remember who Mr. Gruber was, while others decided to bring Mr. Gruber in for questioning. Reality TV doesn’t get much better than this.

But what if Mr. Gruber is right? What if we are stupid? Not each and single one of us, and not all day, every day, but every two years or so when we come together to form the American electorate. Here is a dirty little public secret: many of us share Mr. Gruber’s opinion, albeit in a more eclectic format, and many of us have no problem publicly broadcasting our views. Liberals believe conservatives are too stupid to understand that Medicare is a Government run program, too stupid to understand scientific concepts, and stupid enough to go to war over imaginary threats. Conservatives believe liberals are too stupid to understand the Constitution, too stupid to grasp the basic concepts of freedom & liberty, and stupid enough to hand over our democracy to a fascist communist Islamic emperor on a platinum fundraising event platter.

Perhaps instead of gleefully watching the Gruber spectacle, we would be better served by trying to figure out why our collective actions look stupid when viewed from the elevated vistas of our rarefied intelligentsia. Using health care reform as an example, although there are many more equally instructive subjects, here are a couple of recent teachable moments that could explain our tarnished image.

California Proposition 45

On November 4th, California voters “soundly rejected” a proposition “that would have halted excessive health care insurance rates”. It seems that California voters like paying excessive prices for their health insurance, and if you like your excessive prices, you should be able to keep them. Alternatively, one could be tempted to surmise that California voters are too stupid to understand what they are voting for. Earlier this year, Californians expressed massive support for Proposition 45. Between then and Election Day a $43 million media blitz, financed mostly by insurance companies, descended upon California to convince voters that allowing health insurance corporations to steal their money, unencumbered by public regulations, is a good thing. It worked.

It may be worth mentioning that the non-profit Kaiser Permanente poured almost $15 million of its tax exempt revenues into defeating Proposition 45. Back in 2009, while the Affordable Care Act was being shaped, President Obama held out Kaiser Permanente as “one of the models of high-quality, cost-efficient care” that “would have solved our problems”, based on the experience of his grandmother in Hawaii. We may need to broaden the usage of epithets beyond the plebeian electorate.

But the one thing that breaks my heart in the Proposition 45 surreal, yet typical, chain of events is that almost without exception, California medical associations chose to align with and actively support the insurance industry. The same insurance industry that is treating doctors like commodities, firing them from networks at will, and is routinely robbing them of professional autonomy. TV commercials featuring real physicians, sporting white coats and stethoscopes, abusing their trusted relationships, reciting outlandish prophecies that no one can verify, littered the public airwaves in California this fall. Practically every organization whose members are paid with health care dollars threw its support behind this willfully deceptive campaign to defraud the people of California.

Insider Trading

Back at the start of 2013, the Centers for Medicare and Medicaid Services (CMS) indicated that payments to Medicare Advantage plans are “likely to decline by 2.3 percent in 2014”. On April 1st of 2013, CMS reversed its decision and released final Medicare Advantage rates for 2014 that showed an increase in payments following a “change in methodology”. Turns out that a Congressional staffer provided information to a lobbyist, who passed it on to an analyst, triggering a buying spree of health insurance stocks prior to the CMS announcement and lots of rich people got richer. The New York Times dutifully published an article in its business section outlining the insider trading investigation recently initiated by the Securities and Exchange Commission for this event.

Leaving this particular outrage aside, one might wonder about the nature of this “change in methodology” that triggered an increase in Medicare Advantage payments. Did the CMS revise its calculations? Did the original figures contain arithmetic errors? As it turns out, this is not about math. An email from the lobbyist to the analyst indicates that rates were changed because “a deal has been hatched to increase Medicare Advantage rates in order to smooth the confirmation of Marilyn Tavenner as the new head of Medicare”.

Unlike her predecessor, Dr. Donald Berwick, who is a staunch liberal with a long record of public statements to that effect, Ms. Tavenner was an uncontroversial appointee, with no political (or any other) damning baggage, and as such enjoyed the support of large swaths of the industry, as well as powerful Republican officials, such as Sen. Chuck Grassley and Rep. Eric Cantor. But that was hardly enough. It seems that today in America, the lawfully elected President of the United States, and the lawfully elected Congress, in order to perform the most mundane functions of their respective offices, must first grease the palms of health insurance companies. And the saddest part is that neither The New York Times, nor any other media outlet, thought this to be newsworthy.

Other Grubers

Mr. Gruber is just the latest public figure to express regret for being caught. Back in 2012, Gov. Romney had to stage a tortured apology for calling half the country irresponsible bums. Last year, the powerful Director of National Intelligence James Clapper, apologized for blatantly and intentionally lying to Congress about covert surveillance of most Americans. Just a few days ago, Uber’s CEO Travis Kalanick, staged a ridiculous Twitter apology for explicit threats to unfriendly journalists made by another Uber executive behind closed doors. Facebook apologized for experimenting on its users and Google constantly apologizes for snooping around without permission. We now have an entitled class that regrets only the inconvenience of having its business and opinions exposed, and subsequently used by their opponents in the power games played by the rich and famous.

Mr. Gruber rightfully did not apologize for his remarks, because they were authentic and truthful as most “off the cuff” utterances are. From the vantage point of our elected government and its diverse assortment of greedy consultants, the American electorate must indeed look pretty stupid. And from the higher perches of billionaires and corporate interests, both American voters, and their seemingly elected officials, must appear as the sheer embodiment of laughable stupidity. Instead of reflexively shooting the unsavory messenger, perhaps we should thank him for the heads up, look at ourselves in the mirrors held by great power and great wealth, and take stock of what we have become as a nation. We can do this, precisely because in spite of acting like a bunch of idiots lately, we are not, and never have been, stupid.

Tuesday, November 18, 2014

Quick Medicine

By the time the next decade rolls in there will be no paper charts. There will probably still be paper floating around in various capacities, but there will be no one charting on paper. The term “charting” itself may become obsolete, like yonder or popinjay. The term EHR, which is what replaces the paper chart, won’t last either because it doesn’t roll easily off the tongue like say, email instead of letter or missive. EHRs don’t do anything else easily, so chances are EHRs themselves won’t last much longer, relatively speaking. Sooner or later, the national spotlight will shift to something other than health care, and other electronic critters will emerge from the shadows.  What will they be? What should they be? Those could be two very different answers.

What Should Be

Have you noticed how people advocating for EHRs use the word quickly in practically every sentence? Mega EHR allows you to quickly document XYZ, and Super EHR can quickly gather all historical data and display it in a summary dashboard which allows you to quickly assess the status of the patient. You can quickly send prescriptions to pharmacies, quickly order a bunch of tests, and quickly print out (the horror!) education materials. Your staff can quickly schedule patients, quickly answer questions, quickly verify eligibility and quickly drop claims. Your patients can quickly get answers, quickly schedule visits and quickly have their concerns resolved.

Of course, most of these things are aspirational at this point, but the language is indicative of the thought process behind EHR design: hurry up and get it over with. Time is money and quickly disposing of each patient is absolutely imperative in a high functioning health system. You could argue that there is nothing wrong with speeding up, or even eliminating, administrative tasks, and you would be right. But is reviewing historical information on a patient and documenting today’s encounter an administrative task? When reviewing histories is compressed into briefly glancing at a bunch of sparklines like they have for the stock market, it may seem like you are engaging in an administrative task. Buried somewhere deep in the dark chart though, there may be a note you made about Mary’s difficulties to navigate the front porch stairs last year.

Why did you make that old note? It’s not required for billing. It’s not demanded by insurers. What made you type that in? Do you usually make notes about irrelevant things that you fully expect to never see again? When you used paper charts, you had to flip through many pages to gather the information you can now quickly glean from your infographic patient dashboard. And while you were paging back and forth through that chart, chances are you would have stumbled upon that little note that seemed important enough for you to scribble down last year. And maybe you would discover other little notes too.

Is reading a book the same as reading the SparkNotes? Oh, you will pass the test either way, and may even get better scores with the SparkNotes version, but is it the same? Is reading this: “Ultimately, he is unable to bear the psychic consequences of his atrocities”, the same as reading this: “Tomorrow, and tomorrow, and tomorrow, /Creeps in this petty pace from day to day, /To the last syllable of recorded time; /And all our yesterdays have lighted fools /The way to dusty death. Out, out, brief candle! /Life's but a walking shadow, a poor player, /That struts and frets his hour upon the stage, /And then is heard no more. It is a tale /Told by an idiot, full of sound and fury, /Signifying nothing.”? Which version leaves you better equipped to address the story at hand, and the story-teller himself as a whole person? And which version makes you, the reader, feel more like a whole person?

Whatever else the EHR of the future might do, it should quit trying to quantify, summarize, highlight and decontextualize the soul out of the medical record. Disposing of patients quickly should not be our goal. Other than being demeaning and dehumanizing for all involved, seeing patients quickly is the root of all our health care woes. In an environment increasingly hostile to human interaction, EHRs should ferociously fight to create more time for patients to spend with their doctors. EHRs should automate the business of medicine and eventually the science of medicine, while protecting the art of medicine. And by art, I don’t mean compassion and advocacy. I mean the application of professional judgment, without which the science is incomplete and will always be incomplete, regardless of how many genes we can map or how many bots we can implant in ourselves.

Assuming that the business of health care will be marching along the glorious path currently laid out by our betters, the EHR of the future should endeavor to become a silent background processing machine. Natural language processing should be the first and foremost feature to be implemented to perfection. The EHR should parse and extract useful information from doctor-patient interactions to maximize physician reimbursement by maximizing claim values (yep, I just said that), and by scouring all opportunities to obtain incentives and bonuses from the overlords, and automatically applying for all, without user intervention. Not an easy task, but IBM Watson could drop out of medical school and take this on.

The flip side of maximizing revenue is to cut overhead. No practice needs a scheduler. Let patients schedule themselves online or on the phone. Let them check in and let them room themselves (think about those little restaurant gizmos that beep when your table is ready). Let them take their own vitals and answer all those preliminary questions on their own. For the outliers, the frail and the elderly, one medical assistant can cover these tasks for bigger practices. It doesn’t sound much like an EHR because it isn’t.

What else costs money, but has practically nothing to do with medicine? All the school notes, the back to work notes, the disability forms, trade forms and all other forms, authorizations, pre-authorizations, eligibility checks, statements and everything in between, can be delegated to computerized self-service. Get the medical records online and let patients have at it. Make it user friendly like all other trivial consumer facing apps that have absolutely no bearing on enterprise technologies. Make them colorful and fun. Show pictures, animations and ads. Put them on the iPhone. Monetize the heck out of everything, and remove this purely administrative burden from the practice.

And then comes a moment when restraint needs to be religiously exercised. Stay the heck away from the exam room. Let people say whatever they want to say. Let doctors ask whatever they want to ask. Forget about boxes, no matter how useful they look. Forget about structure too, because Watson will be taking care of that. Don’t make documentation easy, because taking notes is not just about documentation. It is mostly about the background thought process that makes one decide what to note and what to discard. Remember, the way you would use different styles of handwriting and text of different sizes or boldness, and how you added critical notes in the margins, or big pointy arrows? Actively taking notes helps you synthesize information, internalize, memorize and understand the narrative (programmers, think back to your college days).

If EHRs want to be helpful, let them be secretaries. Arrange the notes in a way conducive to better information retrieval. Don’t summarize and don’t impose your (or your machine’s) notions of what is or is not important. Collate and bind everything into a patient book. Remember that this is a reference book and the user can read at a 30th grade level. It is not a cookbook and it is certainly not a picture book. Add a table of contents. Use the computer to make it dynamic. Make it easy to flip pages in an electronic context. Make the fonts nice and large, and do learn from beautifully maintained old paper charts. Go out and look at some before they are extinct. You can’t improve that which you don’t know.

What Will Be

Of course none of the above is going to materialize in a meaningful way, except maybe the infantilized consumer facing EHR. Health care is going retail and health care will care about its customers precisely as much as Walmart and Amazon do. And health care will care for its employees as much as Walmart and Amazon do. When providers are all transitioned to having their employer paid for value, EHRs will become very easy to use. A few big buttons, at the bottom of pages prefilled with stereotypes and sprinkled with colored sparklines, should quickly do the job (i.e. Order, Refer, or Deny). There will be nothing for you to document and nothing for the patient to convey because the system already knows everything there is to know. Eventually, it will dispense with the buttons altogether, and your job will be to quickly explain to your customer why the system did what it did. And you will never have to use a computer ever again. Mission quickly accomplished.