On the surface, two Wall Street Journal articles painted a gloomy and depressing picture of US healthcare, now and beyond.
That wasn’t my take. I felt a rush of optimism. Let me explain.
In, ObamaCare’s Lost Tribe: Doctors, deputy WSJ editor, Daniel Henninger wrote about the (forgotten) plight of doctors in the Affordable Care Act. He critiqued the mainstream media coverage of the Supreme Court decision because it left out mention of “the one group we should make sure has time to focus on what’s in front of them: doctors treating patients.”
Mr. Henninger went on to highlight the unintended consequences of certain pay-for-performance measures. He cited, perhaps, not completely accurately, arguments of Dr. Christine Cassel, an influential doctor in the measured-directives movement. Dr. Cassel and colleague, Dr. Sachin Jain, recently wrote a stirring essay in JAMA that emphasized the importance of choosing performance measures that enhance–not suppress–doctors’ motivation. They conclude:
To reach sustainable quality goals, however, close attention must be given to whether and how these initiatives motivate physicians and not turn physicians into pawns working only toward specific measurable outcomes, losing the complex problem-solving and diagnostic capabilities essential to their role in quality of patient care, and diminish their sense of professional responsibility by making it a market commodity.
It could not be more timely and appropriate to warn about the consequences of well-meaning healthcare incentives. Yes, on the surface, and in a fantasy world where EMR systems functioning like Apple products, it’s a great idea to collect data that could sort out and reward quality care. All good doctors that I know desire a system that rewards good doctoring. Human nature drives good students to want to see their report card. We’d love it if our skills determined referrals. It’s critical that doctors be skillfully measured and motivated.
The problem of course is an old one: do the current grades reflect performance? Does compliance with checklists (which often mandate measuring biomarkers that may not be important) and the number of bullet-points on a letter to the referring doctor reflect how well you listened, synthesized the findings and shared a medical decision with the patient? Or…might compliance with many of today’s measurements actually impair quality care? Can we discover a quality measures that actually measure what matters most–judgment and mastery of the obvious?
Here’s a certainty: as humans, doctors will respond to incentives. If incented to click, we will click; if incented to doctor, we will doctor.
An optimistic take
We are talking.
Real world consequences of our current healthcare delivery are becoming part of the conversation. This is good. In the news on ACA, the lack of attention to the contact points of care–patient and doctor together–have been striking. For too long, media has looked away and said, oh well, let the medical people deal with the forms and the computers and the quality measures. It’s not that bad out there; doctors are okay. But that’s not the case in the real world. Just yesterday, a smart young doctor called me because she was upset.
My patients aren’t all the same. This stupid EMR tries to make all patients with coronary artery disease the same. This is terrible. (Ed note: She was using one of the leading EMR systems.)
To smooth the now bumpy contact points of healthcare delivery, we need the help of an informed and engaged people. Patients will have to decide whether they want their doctor pecking at a computer and mindlessly measuring biomarkers. Since nearly everyone will use healthcare, it seems obvious that all of us should have a say in how best to incentivize quality care. Doctors can’t change policy; people will have to. But how can the public participate without information? This is why it’s encouraging to see mainstream media publishing the conversation. (It’s like voting–how does one participate without information?)
The second WSJ article
In the Crushing Cost of Care, journalists Janet Adamy and Tom McGinty chronicle the pain, suffering and enormously high cost of care of patients entombed in ICUs. They detailed the tragic struggle of one poor soul and his family. After a heart transplant, the patient suffered multiple severe complications; the therapy of each extracted high costs–both in dollars and in human suffering. Particularly anguishing was the moral distress of the nursing staff, who wanted the patient’s pain relieved but also felt the pressure of the family who wanted their son awake enough to participate in rehab. (For the record, no such pain medicine exists.) Ultimately, despite the fact that the transplanted heart worked well, the patient died slowly and painfully from complications of being so ill in the first place.
Though this important essay nicely captured the difficulty in finding happy solutions in these cases, what wasn’t emphasized enough is the commonness of this tragedy. Nearly every ICU that I have ever walked into—a fair number—harbor these cases. No data here, but I’d guess that this tragic drama plays out in most hospitals every day. These cases pull at your heart. You want, even root for, the patient to survive and triumph. But at what cost in suffering? In the WSJ case, the family capitulated to comfort care minutes before death. Ideally, there would be a crystal ball to help tell everyone when enough is enough. Without that crystal ball though, caregivers must find the strength to present the truth, and to kindly and skillfully confront our limits.
We are also starting to talk about mortality.
I’ve been witness to the tragedy of “do everything” for almost two decades of medical practice. One doctor interacting with one patient and one family can’t move the needle. That’s why it feels good to see mainstream media help spread the important message–of the limits and consequences of life-prolonging care.
It needs be said, no check that, it needs to be understood as truth: that although we can do a lot, the fury of modern Medicine is neither painless nor free.
Don’t even start with death panel talk. The “Crushing Cost of Care” highlighted the importance of honest and frank conversations about the limits and sometimes, downright harm of “doing everything.” These common and tragic stories deserve more notice. Then, perhaps, a normal part of the doctor-patient conversation would include talking about a patient’s goal for their care. Will a day come when it’s normal–a quality measure even–to at least consider as an option, care that emphasizes the quality and comfort of life, not just its quantity? In scant enlightened enclaves, these conversations happen, but they are far from normal in the real world. In the real world, too often the default to ‘do everything’ inflicts unnecessary suffering.
Many are afraid to die. This is normal because life is good. But we also should fear ‘do everything’ Medicine.
So yes, I am hopeful and cautiously optimistic that mainstream media can help start and foster these important conversations.
An informed and engaged public will surely help us improve the care we deliver.
John Mandrola is a cardiologist who blogs at Dr John M.