Although I am now working part time, I still get my academy’s monthly newsletter. I pretty much ignore the ads and any clinical studies that do not directly affect the work I am doing now, but I still find myself drawn to stories with a political bent. Namely, those stories that reflect the latest health reform controversy. The vast majority of these stories do not mention anything really new, just a rehashing of old problems, and only mentioning them because that particular problem has now moved up in the queue. I find myself having the same reaction that I have had for the past 20 years, anger that my academy has badly mishandled how these problems were approached, taking a “this is coming, it’s time to prepare” attitude, blindly accepting the conclusions of others. Clearly, this has not worked.
The first time I really took some interest in medical politics was with Hillarycare in 1993. Putting in 80-hour weeks and trying to raise three children, I had time for little else. I never fully understood what the plan entailed so like most physicians I try to rely on what my academy was saying. They did not offer much on clarification but instead took the “this is coming, it’s time to prepare” (TICITTP) approach. I remember my academy offering access to TICTTP resources. But in reality, there was not much to be done so I — and a lot of my colleagues — did nothing. Then, when Hillarycare failed there was barely a mention by my academy. That was when I first thought, what would have happened if I took the academy’s advice and prepared?
Flash forward to the late 90s — the next “crisis.” This was the era of private capitation (or decapitation, depending on your point of view). Private insurers were going to offer to a group of physicians “X” amount of dollars to provide all the care for “Y” number of patients for “Z” amount of time. A mad scramble then ensued where different medical groups tried to position themselves to be in the best negotiating position. It’s kind of like throwing red meat at a bunch of hungry dogs then taking credit for the fight. Our area was no exception. A group of local positions put together a multi-specialty group that offered us to join but the contract was so bad we turned it down. My academies reaction was TICITTP. That left us in an awful position, but we felt we had no choice. Then when private capitation failed we asked ourselves what would have happened if we had joined the multi-specialty group? However, my main criticism was reserved for my academy, offering no critical analysis or question as to whether this was a workable concept, just TICITTP, and causing me to look at everything my academy said with a critical eye.
I was hoping that my academy would have learned a lesson from this, but no. Here is a list of the subsequent “crises” and my academy’s reaction, all variations of TICITTP.
1. “To Err is Human” report. No critical analysis, just a blind acceptance of the results and a plea to physicians to “reduce errors.” Continued failure to demand a clear distinction between a true medical error and a complication.
2. Pain management. Acceptance of the new pain guidelines (including a lot of ads for Oxycontin) and an admittance that we physicians were “unnecessarily keeping our patients in pain.”
3. Pharma reps. A declaration that accepting any “gifts” from pharma reps was “questionably ethical.”
4. Anonymous patient satisfaction scores. An offering of access to resources and courses on how to improve scores, including plants in the lobby and valet parking. No mention of how patient satisfaction could be detrimental.
5. EHR. Full-blown TICITTP without question, ads from EHR companies, and advice on how to get “meaningful use” money as quickly as possible. Then more TICITTP for the replacement EHR systems after the first ones failed.
6. Quality based care. Another full-blown TICITTP. Period.
7. ACA. Some question was to whether or not it would work — which came as a shock — but mostly still TICITTP.
8. MOC. A continuous vain attempt to prove to the world physicians are competent. Oddly, this is the one area where physicians seem to have gone into full revolt.
9. Tort reform. Continued lip service.
After our experience with private capitation, we learned our lesson and did not follow TICITTP (especially EHR), and we did better than a lot of our colleagues who did. Ironically, now that many TICITTP points have turned out to be disasters, my academy is again doing TICITTP only this time taking almost the exact opposite stance.
This did not add to my confidence.
We are now on the threshold of the biggest change, full-blown single payer. It remains to be seen whether our academies will take the initiative and demand a seat at the negotiating table as the details are hammered out or will it be just more TICITTP.
I am not hopeful.
Thomas D. Guastavino is an orthopedic surgeon.
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