Rebutting a physician’s plea to declare independence

Writing in the Wall Street Journal, Daniel F. Craviotto Jr. an orthopedist, made a plea to physicians to declare independence from third parties and emancipate themselves from servitude to payers, mandates and electronic health records (EHR).

As rants go, this was a first class rant. But its effect was that of a Charles de Gaulle’s whisper to Vichy France rather than a Churchillian oratory at the finest hour.

The article went viral (it has been tweeted nearly 3,000 times), though with little virulence. And it is not WSJ’s paywall to blame.

The author might have assumed that most the health care community in general and physicians in particular wish to be free from regulations. I have serious doubts that this assumption is correct in the aggregate. The relationship between regulators and physicians is more complex and symbiotic than it first appears.

Some physicians believe in bureaucracy. Rationalism will march us out of our health care wilderness. This belief in scientific managerialism, faith in technocracy, is the new theism. The rationale of the new theists is that regulations fail not because they are inherently useless but because there are so few of them, and even fewer that are actually smart.

Like the first religions started with polytheism, the new believers want more agencies, more alphabet soups, more gods.

This type of reasoning can empirically neither be proven nor disproven. Hence, the comparison to religion is apt. It is like the argument made by neo-Keynesian economists: Stimulus failed because it was too small. How do we know it was too small? Because it failed.

This circular reasoning is immortal and akin to an infinite set; one can always impute upon it the promise of success if only one added just a little more.

Convinced of their own virtue and the vice of others, many physicians crave more regulations. They hope that in the next round will emerge the regulatory Thor wielding his nuanced hammer on evil Medicare serpents and fraudsters. Instead we receive the leviathanic, uncoordinated Moby Dick that throws Queequeg out with Ahab and splashes a lot of salt water in the process.

Some meet any criticism of third party players, coding and regulatory waste with a false dichotomy: “So now you want to abolish insurance and Medicare, what’s your alternative?” or, “You are against ICD-10, so should we descend in to anarcho-capitalism and send poor kids to workhouses?”

This line of thinking reminds me of the willful scarcity of cerebral activity that allows some to interpret in any government intervention a short step to national socialism. The phenotype is the same. The polarity is merely reversed.

The rest of us, those who can see the vast zone between a dysfunctional electronic health record and zero government, are merely quibbling about the price, not the principle.

And quibble we must.

We should question the marginal utility of regulations, the evidence base from which they arise, the unintended consequences of their complexity, their opportunity costs and the waste of tax payer’s money for rules that do not improve outcomes.

Outcomes, remember outcomes? We hold a new drug or device to this metric, why not a regulatory decree that is both perennially alive and permanently fossilized?

And so the author of the rant has a point.

An inordinate time of physicians is spent on non-clinical work such as coding, billing and compliance. This has been estimated to be as high as 80% (I am waiting for the regulated shape-shifter to say this is clinical work, really). One recognizes that non-clinical work is unavoidable to an extent, and in saying that 80% is too high I hope the binary minds of some do not infer that I think it should be zero percent. But if 80% is not too high how about 90%? 99%? 99.5%? Is there no limit?

If physicians spend more time in activities that allow them to be measured than the activity for which the measurements are sought, this is a sign of dysfunction. The clinical horse is being grounded by the regulatory cart.

And this has consequences for patient care. Physicians rarely make eye contact with patients these days staring, instead, at the vast dark matter of their EHR wondering how many words it takes to say the patient has a common cold.

As Nietzsche warned, well sort of, “If you gaze into the EHR, the EHR also gazes in to you. Beware physicians, lest you become an electronic health record.”

We are living an epidemic of documentation of such utter clinical irrelevance that one struggles to comprehend. And yet some demand even more rules, more codes and more metrics as more granularity is desired and imperfection of information even less tolerated.

To paraphrase Churchill, “Never was so little owed by so few to so many.” Never was so little achieved by so many. A giant bureaucratic sledgehammer is being wielded against a nut it repeatedly fails to crack.

Craviotto’s declaration of independence is misplaced. To rue government involvement in health care within the safety of a guild, protected from the vicissitudes of the market and competition with Rajeev from Bangalore is a tad rich and rather like the famous ungrateful climber who was carried on the back of sherpas to within a canter of the summit of Everest.

He should, instead, have appealed to our sanity and common sense, the only weapons we have to tame the bipartisan regulatory Goliath.

Saurabh Jha is a radiologist and can be reached on Twitter @RogueRad

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  • Steven Reidbord MD

    Ah, the age-old question: whether to reform “the system” from within, versus to opt out. Wherever this arises in life, it’s usually presented as a mutually exclusive choice. Often it’s not. *Of course* physicians should have a seat at the table, quibbling with other stakeholders over regulatory minutia. The devil, after all, is in the details. And regulatory oversight, whether public or private, isn’t going away. If you can’t beat them, join them.

    Meanwhile, some doctors, the infantrymen in Dr. Craviotto’s analogy, ponder voting with our feet. Will we march under the flag of commanders who order us to shine our boots in the midst of battle? Yes, many of us will, grumbling the whole way about armchair generals who don’t know (or apparently care) what’s it’s like in the trenches. Others of us choose “direct care” practices or other opt-outs.

    Some argue the latter is a limited or short-term solution; it wins the battle but not the war. Many patients cannot afford even routine medical care, let alone expensive procedures. A system, not individual doctors, will need to address this. So yes, physicians need to shape that system. At the same time, a number of us will do our part to maintain or improve patient care on our own, while a better system takes shape.

    • Arby

      Agreed. I like the idea of opting out for two reasons. One, so physicians and patients have freedom of choice, and two, because if this catches on, the powers that be can’t ignore that their policies are failures. Of course, it could end badly with them outlawing private pay entirely. One never knows in these cases.

      Still I realize not everyone can or will opt out. In that case, they’ll have to fight the battle from the inside. And, I hope that they don’t turn to the dark side if given the opportunity to be administrators.


    Concerning the VA – the “clinicians” (meaning physicians I think) ARE in control at the VA as far as being primary clinicians. PAs and NPs are in subservient roles. It is recently that the VA has proposed allowing NPs to practice independently within the system to help with the load. From the state of things with the physicians in the primary clinician role, this move would do nothing but help.

    • doc99

      Better funding would help more.

      From Kevin Pho, MD

      … In a Wall Street Journal column, William A. Galston notes, “Roughly 42% — $66 billion — of the VA’s budget is subject to annual appropriations,” and that, “the Congressional Budget Office’s latest budget projections showed that between 2013 and 2024, discretionary spending — defense and nondefense — is scheduled to fall from 7.2% of GDP to 5.1%, the lowest share since at least 1962.”

      This is at a time when the VA health system will be stretched even further as more troops from Iraq and Afghanistan return home.

      The Cato Institute’s Michael Tanner seconds that:

      Enrollment in VA services has increased by 13% from 2007 to 2012. Despite a 76% increase in expenditures ($24 billion) over that period, the program still suffers from chronic budget problems. In fact, the Congressional Budget Office estimates that it would require as much as a 75% increase in inflation-adjusted funding for the VA to treat all veterans.

      The government has a track record of underfunding their single-payer health models.

  • Saurabh Jha

    ” If the Sherpa carried the climber part of the way to Everest’s summit, the climber is now carrying the Sherpa!”
    Thanks for reading. I love that line! Because it brings to imagination something that would be considered so outrageous by Sherpas, and when thought of in the same way, evokes incredulity as to how on earth did we arrive here.

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