What’s On Your Doctor’s Mind?
And what does it mean for the future of medicine?
Medicine is changing fast, especially right here in Massachusetts. As the rest of the nation continues to debate universal healthcare, we’re already six years into our own experiment. It’s been a great success: Today 98 percent of our residents are insured. But to contain the costs associated with the program, state legislators recently passed a controversial law altering the way medicine is practiced here. And that’s just one of the many ways in which the ground is shifting under the feet of our physicians, forcing them to ask a lot of hard questions. The answers to those questions, 12 of which we explore below, reveal a lot about the kind of healthcare you and your family will receive in the years ahead.
Top Docs Survey
Click on a question to find out how Boston’s best doctors answered the questions posed here. Also, check out all of our Top Docs 2012 coverage, including a searchable database of 645 doctors in more than 50 specialties.
1. Am I a fool for becoming a general practitioner?
2. What if I could have fewer patients?
3. Should I tell my patients what I would do in their place?
4. How do I say I’m sorry?
5. Should I worry about what it costs?
6. Am I burned out?
7. Do I need a robot?
8. What can I do to make patients follow my instructions?
9. Can I trust the drug companies?
10. Are med students learning enough?
11. Should I treat only healthy patients?
12. Should I e-mail with my patients?
Primary-care physicians make about half as much per hour as brain surgeons and cancer radiologists, and substantially less than doctors in most other specialties.
That and the other indignities of being a general practitioner (GP)—lack of respect from fellow physicians, insane patient loads—have given med students second thoughts about the field. The evidence is startling: According to Joseph W. Gravel Jr., the president of the Massachusetts Academy of Family Physicians, only 20 to 25 percent of today’s medical students choose primary care—about half the number needed to replace GPs who are retiring.
But change is coming. Under recently passed legislation, the state will begin encouraging private insurers—and requiring Medicaid and state-employee-benefits providers—to form teams of physicians, managed by GPs, that will focus on keeping patients healthy rather that treating illness. General practitioners will not only be able to see all of their patients’ prescriptions and treatments, they’ll also be given the freedom to experiment with unconventional kinds of treatment and prevention, such as buying high-filter vacuum cleaners for asthma patients or removing high-pile carpeting from the home of a senior who is at risk for falls.
Gravel is excited about what’s to come. “I tell residents, there’s no better time to be going into primary care,” he says.
A few years ago, the hustle of modern medicine nearly drove primary-care physician Kate Isselbacher to quit. “I was thinking of giving up medicine entirely, because the joy was lost for me,” she says. “With reimbursements from insurance companies dropping, you have to see more patients just to stay afloat. It was like an assembly line, and that was not what I envisioned.”
Today, the average primary-care doctor has about 2,300 patients, with an average of just 15 minutes for each appointment. That’s not what most doctors feel they signed up for, and many are having thoughts just like Isselbacher’s. Rather than drop out, though, Isselbacher decided to simply drop the parts of the job she didn’t like, and begin looking for a way to practice that would be less driven by the need to see so many patients for so little time.
She found her answer in what’s known as concierge medicine, which, for an annual fee (typically between $1,500 and $3,500), provides patients with 24/7 access to their primary-care physicians. The fee guarantees them same- or next-day appointments but doesn’t cover the cost of the appointments themselves.
More and more doctors are starting to go this route. A year ago, John Szymanski, an internist practicing at the North Shore Physicians Group, joined MDVIP, a concierge-medicine service. He says the switch netted him exactly what he wanted: more time with fewer patients. “When I was seeing 22 patients a day, I was always behind. I found myself constantly looking at my watch,” he says. “Now the only time I look at my watch is to time a patient’s pulse.”
There’s no easy answer to this one. Patients desperately want their doctors to tell them what to do when faced with a difficult decision. But the fact is, doctors themselves often don’t agree on what’s right.
Last year Pamela Hartzband and her husband, Jerome Groopman, both physicians at Beth Israel Deaconess Medical Center, addressed this issue in Your Medical Mind. According to Hartzband, a lot of medical advice, even when it’s based on research and experience, has a “subjective core” to it.
Whenever a patient asks Hartzband, “What would you do if you were in my shoes?” she always mentions that different doctors weigh risks and benefits differently. Even she and her husband, she tells them, are known to disagree about what a patient should do. Hartzband, an endocrinologist, is more cautious, while Groopman, a writer and researcher, is action-oriented. Speaking to a patient with, say, a possible thyroid nodule, she’s likely to say, “What I’d do is probably watch and wait in your situation. But what my husband would do is take it out yesterday.”
So what’s the best course? To offer personal advice, Groopman suggests, but also to be aware of your personal inclinations and make them clear. “You want to help guide the patient,” he says, “but you don’t want to fall into the trap of superimposing your own value judgments on the patient.”
For decades, the fear of malpractice lawsuits has kept doctors on edge, forcing them to practice “defensive medicine,” says Alan C. Woodward, past president of the Massachusetts Medical Society (MMS). “They have been told, once something goes wrong, do not communicate with the patient or the family, which can breed a culture of secrecy, blame, denial, and finger-pointing that thwarts patient-safety improvement.”
In 1986 Massachusetts became the first state with a so-called apology law, which enables doctors to say they’re sorry without their words becoming admissions of guilt in malpractice suits. Thirty-five other states have since followed suit. Over time, though, the MMS has realized that a simple apology is only the first step in what should be a series of corrective actions in the case of a mistake.
This summer the organization drafted a plan, “Disclose, Apologize, and Offer,” that would enable doctors to tell patients when they’ve made mistakes, offer an apology, and have the hospital then determine if financial compensation is appropriate. This means that in those instances when things do go wrong, as they occasionally will, physicians will not just say, “I’m sorry,” but will also be able to offer corrective action—which can help both doctors and patients avoid unpleasant malpractice suits.
The plan became law this summer, and now hospitals here are beginning to implement programs to provide peer support for doctors who want to own up to their mistakes. “It is a change in mindset,” says Kenneth Sands, who is running such a pilot program at Beth Israel Deaconess Medical Center. “But I think for most clinicians, this feels like a relief.”
The United States spends more per capita on healthcare than any other country. Massachusetts spends more than any other state, and Boston spends more than any other city in the state. In other words, we’re sitting at ground zero in the crisis of healthcare costs.
There’s no single factor that explains why costs in Massachusetts have increased by more than 50 percent in the past decade (to $9,278 per capita), but waste and inefficiency are near the top. To address the problem, this past August the governor signed the Massachusetts Health Care Cost Containment Law, an ambitious attempt to save the state $200 billion over the next 15 years.
This fall, the Institute of Medicine, a research organization, released a study showing that Americans spend $750 billion each year on unnecessary, ineffective, and, in some cases, harmful medical treatments. That’s 30 percent of annual healthcare spending. The most infuriating part is that neither doctors nor patients know what the services actually cost.
All this talk about money can get pretty uncomfortable—debating it when a patient’s care is at stake can seem to violate the goals of a healthcare system. But doctors are beginning to acknowledge that cost discussions are important. Neel Shah, a resident at Brigham and Women’s and founder of the educational nonprofit Costs of Care, is finding they don’t have to be so fraught, either. “There’s lots of examples where doing what’s best for the patient in front of you is also good for society,” he says. Among them: generic drugs, clear end-of-life instructions, and more-efficient testing.
The state’s new healthcare law addresses some of these issues, in part by making the costs of tests and procedures much more available to doctors. But Shah says that’s only a first step. Doctors have to get used to the idea of discussing fees with their patients. “The number one reason why doctors don’t bring up cost is because they’re not comfortable,” he says. “It doesn’t make much sense.”
The study, published this past August in The Archives of Internal Medicine, was a bombshell.
The Mayo Clinic surveyed 7,288 physicians and found that nearly half of them had experienced at least one of the three major symptoms of burnout: emotional exhaustion (38 percent), depersonalization (29 percent), and a low sense of accomplishment (12 percent).
“They lose the joy,” explains John Fromson, a physician and an associate director of psychiatry at Massachusetts General Hospital. Fromson, who specializes in treating doctor burnout, says the reasons for such high levels are legion. The pressure to see more patients in less time affects all doctors, as does the strain of having every decision scrutinized by business-oriented third parties. Student-debt loads averaging $130,000 can weigh heavily on young doctors, and with retirement ages on the rise, older physicians can feel like there’s no relief in sight. To compound matters, the culture among doctors discourages them from seeking outside help.
Fortunately, physicians and hospital administrators are beginning to recognize the problem. Beth Israel Deaconess, Children’s Hospital, and Brigham and Women’s have all now instituted their own easily accessible clinician-support programs to address burnout before it becomes a potentially serious problem.
As doctors look for ways to save money and improve the efficiency of their practices, some forward-looking physicians, like Bob Nguyen, a urologist at Children’s Hospital, are turning to robotic assistants that can go home with their patients.
Earlier this year, Nguyen launched an experiment to see what kinds of cost savings he might net by “hiring” five robotic assistants, which he sent home with his surgical patients to observe their recoveries. Through screens in his robots’ heads, Nguyen was able to video chat with his patients and watch them doing basic tasks.
He discovered that his patients were suddenly starting to look forward to “seeing the doctor.” As he had hoped, the robots save money by allowing him to check in on patients without billing them for hospital time, and more important, 93 percent of his patients said the robots were a good substitute for the doctor himself. Robots, it turned out, got patients more involved in their own care.
The robot revolution isn’t exclusive to pediatrics. Other studies have found, for instance, that some stroke victims actually prefer robot therapists to humans.
A doctor’s responsibility has traditionally ended when a patient goes home. Part of the reason has been simple logistics. As Kristin Remus, a general practitioner at Beth Israel Deaconess Medical Center, explains, “All I can do is recommend things. I can’t make people exercise. I can’t make them lose weight and have a healthier diet.” Without supervision and reminders, patients can make mistakes that land them back in the hospital.
This past October, as part of the Affordable Care Act, the Centers for Medicare and Medicaid Services (CMS) began withholding reimbursement money—up to one percent—from hospitals nationwide where patients were readmitted within 30 days.
Of the 307 hospitals docked the maximum amount, three—Beth Israel Deaconess, Boston Medical Center, and Tufts Medical Center—are here in Boston. Of those, the BI had the highest readmission rates: 22.9 percent for heart attacks, 27.6 percent for heart failure, and 21.6 percent for pneumonia, in each case three points above the national average.
Now the hospital is experimenting with ways to curb mistakes that patients make at home. Last year, Remus and some of her colleagues took part in a trial that aimed to greatly extend a doctor’s reach. Using a computer-based healthcare interface called OpenNotes, the primary-care physician Tom Delbanco and the nurse Jan Walker, both at Beth Israel Deaconess, coordinated a nationwide pilot program to give patients at-home access to everything their doctors wrote in their files. As a result, between 77 and 87 percent of patients reported feeling more in control of their care, and did much better at things like adhering to complicated prescription-drug regimens.
“Our fantasy for the future,” Delbanco says, “is that patients may well countersign notes. Or maybe even write part of the notes. In a way, the notes become a contract between the doctor and the patient.” That’s not quite as motivating or reassuring as having a live-in doctor, but it might be the next best thing.
This year, the pharmaceutical giant GlaxoSmithKlein paid $3 billion to the federal government for promoting drugs for unapproved uses, and for failing to report safety data to the Federal Drug Administration. It was the largest single civil settlement in history, and it was part of a trend. Since 2009, according to research in the New England Journal of Medicine, drug companies have paid $11 billion in similar penalties.
Doctors, in turn, have reacted by treating Big Pharma–sponsored research warily. But until this fall, we didn’t know just how warily. In September, Aaron Kesselheim, a physician in the Division of Pharmacoepidemiology and Pharmacoeconomics at Brigham and Women’s, published a study in The New England Journal of Medicine that found that drug-company sponsorship made physicians half as likely to prescribe a drug—no matter how rigorous and well designed the study.
“That’s a rational response to this track record,” Kesselheim says. “On the other hand, it’s also not sufficient just to say that because something is funded by the drug company, I should immediately dismiss it.” Without industry-backed research on statins, for example, doctors might not have all the tools they now use to treat high cholesterol. Increasingly, according to Kesselheim, there’s simply no way for doctors to ignore drug-company-funded trials, because, for better or worse, Big Pharma is underwriting an ever greater percentage of clinical research.
So what can the drug companies do to begin rebuilding the trust of doctors? Kesselheim says a good start would be registering their study protocol with a national database, and releasing raw data.
It used to be that medical residents routinely worked 30-hour shifts and 100-hour weeks. A kind of boot-camp ethos prevailed: Only total immersion could produce doctors who were truly ready to serve on medicine’s front lines. But the hours took their toll: Residents made mistakes in care, crashed their cars on the way home, and snapped at patients in need of emotional support.
So in 2003, in response to mounting pressure from the Accreditation Council for Graduate Medical Education, hospital duty for residents was capped at 80 hours per week. And in 2011 the state followed the Institute of Medicine’s recommendation to restrict single workdays to no more than 16 hours (down from 24).
Some doctors and trainees think the pendulum has now swung too far, limiting what residents can learn.
“There was a period of exploitation,” says Ammar Sarwar, a radiology resident at Beth Israel Deaconess. He’s glad that’s over, but Sarwar also thinks medical education has been harmed.
With a 16-hour shift limit, three different residents might wind up in charge of a single patient’s care. That’s a problem, because it increases the chance that important information isn’t shared during patient handoff. It also limits the residents’ ability to connect with patients.
However, Russell Phillips, the director of the Center for Primary Care at Harvard Medical School, argues that the handoff is precisely what trainees need to learn. Medicine is moving toward a team-care model, he says, and doctors need to learn to do it better—even if, like their predecessors, they have to learn on the fly.
There was much ado earlier this year when Helen Carter, a primary-care physician in Worcester, announced she would no longer accept new patients who weighed more than 200 pounds. Carter said she wanted to treat only patients who were dedicated to their own health, and, somewhat bizarrely, also claimed she wanted to avoid injuries to her staff. A public backlash quickly followed.
Carter’s story underscores an important point: Doctors have always had the right to refuse new patients. And under the new healthcare law, they might start exercising it a great deal more.
One of the marquee components of the new law is a reimbursement method called global payments: Doctors receive a predetermined fee per patient that is based upon the severity of the patient’s illness.
Until now, doctors have billed per service performed, which, some have argued, actually created a perverse incentive for them to conduct procedures and tests that weren’t medically necessary: The more they conducted, the more they earned.
The new law is designed to turn things around by creating a financial incentive for physicians to keep their patients well. If doctors don’t use up the money designated for a patient’s care, they get to keep it.
Not everybody likes this idea. Critics say that it can’t account for the complexity of some cases, especially when it comes to patients without support networks at home. Under the new system, according to Michael Grodin, a professor of health law, bioethics, and human rights at Boston University Medical School, doctors will be tempted to stack their rolls with healthy patients in order to maximize their pay-to-effort ratio.
In other words, healthcare decisions could increasingly become business decisions. And when that happens, Grodin says, “the sick and the poor always lose.”
Everybody’s had the experience, and it’s infuriating. You’ve got a simple question for your doctor, something she can answer in a one-line email after five seconds of thought. But that channel of communication is off-limits to you, so instead you have to call the main office, leave a message with the receptionist, and wait for a call back. Worse still, in some cases, you need to schedule an appointment, take time away from work, and go see your doctor in person.
To be fair, doctors need to preserve boundaries, and they have legitimate reasons to worry about being barraged with after-hours questions and demands. But George Abraham, an independent primary-care physician in Worcester, thinks it’s time for doctors to embrace electronic messaging as a tool for communicating with patients. His office uses an encrypted website where patients can log in and send secure messages. He likes the flexibility of being able to answer patients’ questions when it’s convenient for him, and his patients appreciate having direct access.
In Abraham’s experience, most people use electronic messaging judiciously. And if anyone writes more than a few sentences, he politely asks them to come in and see him.
Check out all of our Top Docs 2012 coverage, including a searchable database of 645 doctors in more than 50 specialties.
Correction, 12/10/2012, 8 p.m. : In the section “Should I worry about what it costs?” Neel Shah’s title has been revised. Shah is a resident at Brigham and Women’s, not an attending physician. We regret the error.