Medicine is like blackjack: Physicians need to count cards


In the game of blackjack, players will attempt to increase their odds of winning by using the frowned upon method of counting cards. The basic principle is to add or subtract points to the cards dealt under the belief that the cards remaining in the deck are more or less likely to give the player a winning hand. Not a guarantee, of course, just trying to tip the odds in the players’ favor.

Over the past several years, it has sadly become more clear that providers’ survival will depend on a similar strategy. The last straw is currently being thrown on providers’ back in the form of reimbursements tied to nebulous quality measures. Those of us who have been in practice for many years have discovered that outcomes are more often then not dependent on factors over which we have little control.

How then do we count the cards to tip the odds in our favor? The answer: The simple realization that the more complex the problem, the more likely there will be a poor outcome. The more complex medical issues tend to occur in those patients who are the most uncooperative, cause you the most stress, take up most of your time, have the most comorbidities, most litigious, and least likely to have adequate insurance. Add to this the added new burden of these patients being the most likely to give you poor quality marks and you have a recipe for disaster.

Nowhere are these issues more obvious then the emergency room. Among the numerous issued involve in taking ER call, how many so-called quality surveys ask patients how long they had to wait to see their physician, not taking into account the fact that the physician may be responding to an emergency? Fortunately for providers, there is one card we can play, the fact that the more common problems tend to be the simple ones.  It is far less stressful, and now more lucrative, to deal with ten simple wrist fractures in children, even if all of these children have Medicaid, than one uninsured drunk with an open tibia fracture at 3 a.m.

Also, the more common a problem, the more experience and comfort you have in dealing with it. In other words, although patients with complex problems may be only 5% of your patient population, they take 30% of your time, cause 40% of your stress, be 50% of your litigation risk, and be 60% of your uninsured population. At the same time they actually may cause us to lose money in the form of poor reimbursement and time lost for other patients: especially with reimbursement tied to poor quality marks. Is it any wonder we no longer wish to deal with that 5%?

I recently read another in a long list of studies trying to explain why more complex patients are being transferred to tertiary care hospitals when it is felt they could be treated locally. The conclusion always seems to be that more studies are needed. Really?

Although it will be frowned upon,  providers’ survival now depends on counting the cards correctly.

Thomas D. Guastavino is a physician.

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