Thursday, February 27, 2014

Japanese housing, Doctors, and what happens when you dispose of something valuable

There was a very interesting Freakonomics podcast I listened to today, discussing the Japanese housing market.

In Japan, it is fairly routine for houses to have a half-life of 30 years, and when a house is purchased, the owner often demolishes the old home and builds a new one.  There are some historical reasons for this (e.g., many homes needed to be rebuilt after bombings in World War 2, high frequency of earthquakes), but regardless of the reason, Japan is unique in that homes are treated as a disposable property.  Therefore, unlike the United States or other wealthy nations, Japanese homes depreciate in value after they are built.

This leads to a huge drag on the economy, and has contributed to economic stagnation in Japan over the past 20 years.  The economics of this are pretty simple- when you take something that has a high intrinsic value, but treat it like it is disposable, you are wasting money.  The money that is being spent rebuilding perfectly fine homes is NOT being used elsewhere.  There is an opportunity-cost loss.

This is not true in the United States, and it is something we do better than Japan.  When people buy a home in the United States, they maintain it.  They go to Home Depot and improve it.  The home gains in value.  They realize it would be frankly insane to bulldoze something worth a million dollars or more.

Japan was able to do fine when companies like Toyota were thriving, but they were doing so in SPITE of their cavalier attitude to disposing of homes, and once the rest of economy was stagnating, those losses were hard to recover.

Bottom line: it is not in a society's best interest to treat something of real intrinsic value as disposable.

This reminds me of a consulting problem one of my MBA friends was telling me about, working for the United States Army.  He was consulted to figure to calculate "how much is one infantry man overseas worth?"  This was important for overseas missions, because the support costs for a soldier are very expensive- building bases, you need things like cooks, child care for families, gas to ship everyone and their equipment overseas, etc.  I think it worked out to about $1 million per infantryman, which was a sufficient justification for the Army.  If something is worth $1 million, it's worth spending money to build an appropriate support structure.

So .... listening to this podcast, and thinking about the question about infantryman, it made me think "how much is a physician worth?"

It's very clear to me that the societal trend is "not very much."  That's a mistake we are currently making in the United States, treating physicians like disposable resources, similar to the way Japan treats homes, and it's a very expensive mistake.  Some examples to that come to mind:

1. Valuing MBAs more than MDs.  If you look at the leadership of most hospital organizations, they have MBAs in the leadership positions, and they give the main decision-making capacity to the MBAs.  I love MBAs, and they have their role, but when non-physicians make health care decisions, they tend to neglect important patient care issues.  I'd be ok with, and support, perhaps a 60%:40% split in MD-to-MBA leadership in health care.  I don't know what the actual numbers are, but I'd guess that the current split if probably closer to 95% MBAs or other administrators, and a very small amount of MD influence.

Same things are true for most national health care panels.  For things like the Affordable Care Act, physician input in minimal.  There may be a token physician on a panel of 15 people, but most of the decision-making capacity goes to people representing pharma, the hospital administrators, electronic health records, or policy makers.

2. Treating MDs as employee worker bees, rather than as valued talent.  A colleague of mine relayed a story where the head physician of a large physician group was mediating a conflict between one his best physicians and their practice administrator, and the head physician commented that the practice administrator was the "person who did the most for the practice."  The physician predictably left the practice, and the head physician did not realize how offensive it was to de-value the work being done by the physicians in the group.  He viewed the administrator as the person who "got stuff done", and the physicians were merely the worker bees churning out widgets.  As a patient, do you want to be cared for by an organization who views you as a widget?  Unfortunately, these stories are common.

Similarly, one of my physician colleagues belongs to a Rotary organization, and has noted how it's a wonderful opportunity for thought leaders to gather, which gives them an opportunity to think about big picture issues, develop a vision, and implement tactics as their businesses evolve.  He noted that there are thought leaders from most industries other than medicine, but not that many physicians, and in particular very few employed physicians.   The physicians who belong are private-practice owners, so they are coming in the capacity as business owners, rather than as physicians per se.

Do you see what is happening?

In industries other than medicine, it is recognized that the people with the most education and the most experience also bring value to their organizations when they are given the freedom to think about the big picture, mingle with like-minded colleagues, and develop as human beings.

Current forces in place, however, are treating physicians like interchangeable parts, whose role is mainly to push buttons.  I don't mean that metaphorically- physicians are literally being paid to push buttons.  There are requirements from CMS (the Centers for Medicare and Medicaid Services, which is the Voldemort behind all negative changes in healthcare) that physicians need to push buttons that verify they are using their Electronic Health Record in a "meaningful way."  These are called "Meaningful Use" requirements.

It's time consuming, exhausting, and soul sucking.

My colleague Brian White has put it well- "Medicine, in its purest form, is a closed door with a patient and doctor talking to one another."  Anything that gets in the way ..... well, it gets in the way.

So, how much is a doctor worth?
I don't know.  I'd like to think that we have value, in many ways, comparable to that of an infantryman, which is $1 million.  It may actually be much higher ....

As a thought experiment- take someone you knew growing up who was in the top 5% of your high school class.  Have them go to a good college, and have them spend 4 years in a hard major, with challenging elective classes, working hard enough to get a GPA of 3.6 or higher, and using their discretionary time volunteering, doing research, and studying for the MCAT.

Then have them spend ANOTHER four years taking harder classes, in a pool of similarly competitive people, with their entire lives dedicated to medical school.  Add in the cost of not earning any money (.... and keep in mind these were very good students, so they'd typically get good jobs out of college), not saving for retirement, and all the opportunity cost associated with them not entering the work force.  Add in the cost to their social life- delaying marriage, having kids.  THEN add in about $200,000 of debt, assuming they don't already have debt from college.

Then add in ANOTHER 3-6 years of residency training.  Factor in another 3-6 years of opportunity cost loss in delay in entering the work force, the societal cost in having a very smart and talented subset of people delaying family/kids/planting roots, and the interest on the $200,000 of debt they are not yet able to pay off.  Take into account the opportunity cost loss that, had they gone into a field other than medicine, this is when they would have been rising through the ranks, getting promoted, and developing professionally.

Then add in ANOTHER year of fellowship training for the most talented and ambitious subset of these physicians.

At this point- how much value does that person have?  One way to think about it- a schoolteacher, nurse, and physical therapist all have lots of value, right?  At this point, you have a training time that is equal to all three of those professions combined, except that you are starting with a group that had a more stringent set of baseline requirements as an entry point.

All of that .... and that's before they even start their career.

So, it wise to treat that as a disposable commodity?  What is the cost to society when, for example, a physician decides to retire early because they are frustrated with compliance with CMS?  What is the cost to an organization when a physician walks way from their practice because they feel undervalued?  What is the cost to you as a patient when someone chooses a career in finance instead of medicine?

The United States simply can't afford the cost of treating physicians the way the Japanese treat homes.  Physicians have value, and systems built on undervaluing things with true intrinsic value cannot sustain the opportunity-cost loss in the long term.  It's like taking a beautiful 12-year-old home and bulldozing it because you want a new layout.  It's better to focus on upkeep, improvements, and appreciating what you have.

In search of a better way:
We here at Lake Washington Sports & Spine think that there is a better way.  All of the societal forces that are in place that devalue the importance of a physician- that's simply not the way we do business.

Everything we do here is built from our vision- "helping our patients be the best possible version of themselves every day, using the musculoskeletal system as a guide."

Why do we keep our billing and coding person Natalie in house?  Because it provides a better experience for the patient.

Why do provide information about exercise on our blog?  Because it provides a better experience for the patient.

We value our physicians, not just because we are the owners, but because we believe that if we value EVERYONE on the team, it allows us to provide a better experience for the patient.

Meet the Team: Natalie Straub

Q. What is your title at Lake Washington Sports & Spine?

A.  Billing and Coding Coordinator

Q. What is that exactly?

A.  I review each claim coded by the physicians to ensure they are coded correctly and also edit them when it is necessary.  I submit the claims to the insurance companies and follow up when a claim is denied.  I also am responsible for patient billing including answering any questions, setting up payment plans and working to ensure all accounts are paid by insurance and patients to meet a zero balance due.

Q. Many patients ask questions about co-insurance versus a copayment. What is the difference?

A.  A Copay is a payment made by a patient at the time of service that covers most general office visit consultations (ie: NO procedures done in office).  Coinsurance is your share of the costs of a health care service NOT covered under a Copay (ie: an Ultrasound, an injection, basically anything that is NOT a general visit consultation).  Also remember, some insurance plans do not have copays at all therefore all types of visits (consultations, procedures) fall under coinsurance only.

For example:  Patient “Bob” has Premera.  He does not have a copay listed on his insurance card so we do not collect any copay.  His Premera policy has a $500 deductible that the patient is responsible to meet before they pay 80% of the claim charges (so basically, Bob has to pay the first $500 of his medical expenses himself before his insurance pays anything).  Let’s say Bob already met that deductible and since Premera will only pay 80%, that leaves 20% coinsurance Bob’s responsibility.   

Q. What are examples of things that patients need to address before their visit to make sure that their claims are paid appropriately?

A.  If going through a health insurance (Regence, Premera, Aetna, ect) please make sure you check your benefits in advance and understand if you will owe a copay that day or coinsurance once your claim processes.  If going through an accident/injury claim, make sure you provide us with all claim information including the name of the company we are billing, claim number, claim manager or adjuster name/phone number and the date of injury.  Also, you need to have all chart notes from other treating providers faxed to us before scheduling your appointment.

Q. Do you have tips for patients so that they can better understand their coverage and benefits?

A. Contact the customer service phone number located on your insurance card and provide them with the name of the physician you’re seeing here.  If they are unable to locate that physician in their network, give the practice name and/or our billing name Emerald City Sports and Spine Medicine with our NPI (National Provider Identifier) which you can contact the office for.  Ask your insurance rep if we are in-network or contracted and to see what your benefits are for your appointment.

Q. From a patient perspective, how does it improve the quality of the patient experience that you are actually in office, as opposed to off-site?

A. I can immediately access all needed documents not scanned into patient charts and also can communicate directly with the medical assistants and physicians to resolve any billing issues rather than waiting for an email or call back.  Also, if a patient needs to drop off information needed to process their claim they can do so in office with me versus again an email or phone call.

Q. What are the characteristics of the ideal patients for Lake Washington Sports & Spine?

A.  Some characteristics include:

•Ready to make a positive change to become the best version of themselves

•Take responsibility for their care and do so by showing up on time to their appointments and paying their bills on time

•Trust in the staff here to do what’s in the patients best interest; following the physicians advice in clinical care and knowing we will do everything we can to get their claims processed through their insurance.

Q. In addition your role as a Billing and Coding specialists, you often serve as an unofficial "Ambassador of Good Cheer," accompanying patients on their visits and provide feedback on patient communication. What are things that you have learned from those experiences, and how does that translate to better care?

A. I have learned that some patients look for “counseling” rather than a clinic evaluation which I feel hinders the patients care.  I’ve learned it’s important to be empathetic to patients but to also steer them towards specific questions and actions that really focus on getting the patient better.  The physicians have many people to see in one day and if all they get with a patient is 15 minutes, it’s very important to utilize those 15 minutes by staying focused on “what can we do as team to get you better faster!”

Q. Do you feel like your perspectives are valued by Dr. Chimes and Dr. Hyman? How does that translate to a better patient experience?

A. Yes.  When the physicians value my thoughts and knowledge it allows me to do what I do BEST.  It allows me to bypass long conversations of why we should or shouldn’t do something and instead get claims processed and paid and work with patient’s to get their accounts to a zero balance.

Q. Are there common questions or topics that patients should bring to your attention sooner?

A. Whenever there’s a change in insurance, let me know ASAP!  It’s very helpful to know when a member id has changed, when an insurance has switched, when a new accident/injury claim has been opened...basically anything that changes how your bills will be processed I need to know BEFORE your appointment to give you my best service available.

Wednesday, February 19, 2014

A very nice review a patient shared with us, on yelp

5.0 star rating
I want to thank Dr. Chimes and LWSS for the very positive experience that I had recently.

I have been dealing with chronic abdominal pain since 2001. In 2001, I had a series of tests that included X-rays, Ultrasound scan, CT scan, MRI, and Bone scan. While it was comforting that none of these diagnostic tests revealed anything really bad like a tumor or cancer, there was also nothing revealed to explain the pain I was having. In the intervening years, some of these tests were repeated in an ongoing attempt to diagnose the problem.

I saw Dr. Chimes for the first time in December, 2013 based on the recommendation of a physical therapist who I have great confidence in. In the initial consultation that included an extensive review of the history of my case, Dr. Chimes recommended another Ultrasound scan which he personally would perform at LWSS. In this test, he discovered what appeared to be a tear in the abdominal wall in the area of my pain. During the procedure, he also consulted with his partner, Dr. Hyman, to review the test and seek his opinion. Based on this diagnosis, a CT scan with contrast was ordered. This test confirmed the abdominal tear and provided further detail and clarity on the condition.

After many years of frustration, I now believe the source of the pain has been revealed and I am consulting with a surgeon to understand possible options to deal with the condition.

Feel free to share the experience that I had with anyone who might find it of value.

Howard Fitz

Blog post about the dangers of following guidelines

This is an interesting link to the downsides of following "evidence-based" guidelines

a few thoughts:
- guidelines are based on consensus, not evidence
- as this case shows, people who are on these guideline panels often have financial conflict of interest
- always be wary, as a consumer, when you hear the word "quality".  Often the word quality is used when they really mean cost containment
- to that end, guidelines often use research, as the cliche goes, the same way a blind man uses a light pole- for support of a previous supposition (usually not paying for something), rather than for enlightenment

Lifestyle Change- the "Secret Weapon" for great health outcomes

I saw a patient today who impressed the heck out of me, and he gave me permission to tell his story.  I'll call him Fred for the purposes of his story, to protect his anonymity.

Fred's a middle-aged, high functioning executive, referred to me because of numbness in his hands and feet.  On examination, I picked up some findings concerning for compression coming from his neck.

I also expressed to him my concerns that he was undergoing some of the lifestyle changes I see in some of my most wonderful patients, where they are feeling health consequences from the complexity of their lives.  Fred is what I would consider "hyper-competent"- he's very smart and thoughtful, charismatic, a great people manager, and just gets stuff done.  As a consequence of his hyper-competence, he has the "reward" of getting more and more stuff to do, which does give him emotional satisfaction, as well as more money.

But it comes with a cost.  As we reviewed some of the symptoms I see in patients with too much complexity, some patterns emerged.

First, he has sympathetic overdrive.  The sympathetic nervous system is part of the autonomic nervous systems that handles the "fight or flight response", and Fred is always primed and ready for action.  Some negative consequences:
- heart arrhythmia
- resting heart rate over 80
- difficulty "shutting his brain off"
- trouble sleeping, replaying conversations in his head from earlier in the day
- muscle tension
- tinnitus (ringing in the ears)

He also has some signs of hypogonadism (low testosterone):
- fatigue
- lower energy levels
- decreased libido
- sleep apnea
- some days hard to focus and concentrate
- less frequent morning erections
- still has morning erections, not sure if it's every day
- harder to obtain orgasms than before

I told Fred my preferred approach is to focus both on the focal (his neck), and the global (Fred as a human being, rather than as a collection of body parts)

We imaged his neck, and sure enough his cervical MRI demonstrated some disk disease affecting his nerve roots and touching on his spinal cord

I also ordered a comprehensive hypogonadal assessment, which showed:
- low testosterone
- high estrogen
- elevated glucose

I discussed with him that the body is in a constant battle between being anabolic (building up) and catabolic (breaking down).  You need both, since you need catabolism to healthily remodel tissue.  But his system was out of whack, and was in the process of breaking down from the load of complexity in his life.

So we put a plan in place.  To Fred's credit, he bought in 100%.  (.... I was afraid that he would insist on buying in 110%.  That would have made things worse - I needed him to resist the temptation to do too much- I didn't want him doing the mathematically impossible).

I am so impressed with Fred.  Changes he's made:
- changed his diet to a 1:1 protein:carb diet, using tracking software to stay accountable
- used propranolol 30 mg at night to help with sympathetic overdrive
- started meditating at night to help with sympathetic overdrive and sleep
- prioritizing sleep
- modifying job to allow his brain to be less intense
- drinking less coffee (needs less now that he sleeps more, and excessive coffee was increasing his sympathetic overdrive)

The next major step for him is getting him to be in compliance with the American College of Sports Medicine exercise guidelines, particularly in regards to aerobic conditioning

I may eventually perform some injections in his neck, but Fred has already seen how lifestyle changes have made a huge impact in his well being, is costing him less money (less medications!), and will make any spinal procedure I perform on him more effective

Fred- thanks for being an inspiration!

Friday, February 14, 2014

Meet the Expert: Brian White, DO- particular focus on patient satisfaction

Meet the Expert: Brian White

For our next feature, we are interviewing Brian F. White, DO my co-author on the article "Patient Satisfaction Surverys: Tools to Enhance Care or Flawed Outcome Measures?" in the December, 2013 issue of PM&R the journal of injury, function, and rehabilitation.

First off Brian, thanks for participating in this Q&A session. It's a privilege to have you here. From a standpoint of introduction, can you tell us about your background, and your journey in becoming a physician.

Thanks Gary, it is a real pleasure to be involved in the fantastic work that you and Garret are doing at Lake Washington Sports and Spine.  In regards to my own background, when I graduated from high school a career in Medicine was pretty far from my mind.  I attended the University of New Hampshire, initially as Mechanical Engineering major, but during my junior year decided to complete my degree in Business Administration.  At that time, I was not thinking of pursuing a career in engineering, or medicine for that matter. 

I had been an alpine ski racer in high school and when I began my studies at UNH I envisioned competing on the UHN alpine ski team, unfortunately, as a ski racer I was not competitive at the Division 1 level and stopped ski racing after my sophomore year.  As part of training for the ski team, I became involved with the UNH cycling team which at the time was a regional and national collegiate cycling powerhouse.  I ended up living at the US Olympic training center in Colorado Springs as part of the National Team Development program for three different winters and while I competed for UNH we won the US National Cycling Championship title. 

I know that you were involved in both skiing and cycling.  How did you make the transition from skiing to cycling?

Once I stopped skiing during my sophomore year of college, I transitioned to cycling fulltime and for the next several years hardly ever got on snow.  In order to take my cycling to the next level, I moved to Boulder Colorado, initially in 1992 to train for Olympic trials, and then on a permanent basis in 1994. 

For various reasons cycling was a good fit for me as an athlete, a much better fit than alpine skiing had been.  I competed at Olympic trials in 1992 and 1996 as well as more than a score of National championship events, finishing in the top 20 on multiple occasions.  I also represented the US National Team in many International events and wore leader’s jerseys in the Tour of Venezuela as well as the Tour of Panama.

I also know that you have had some success with coaching, both skiers and cyclists, I believe your former athletes were National Champions and even an Olympian.  How did you move from athlete to coach?

One of my main cycling training partners in Boulder, Peter Davis, had been a ski racer at the storied Burke mountain academy.  Given my background in alpine racing, he suggested that I get involved with coaching youth ski racing as an off season activity.  He introduced me to a friend of his Matt Lyons, who was the Program Director at the local ski team.  We met and discussed my involvement in the program and I began coaching 9 and 10 year olds the winter 1994.  Although an unplanned diversion in my life, I took to coaching and was able to combine the understanding of elite athletics I had learned as a cyclist with my prior knowledge of ski racing.  This combination of skills proved quite useful as a ski coach and I ended up coaching full time, six days per week, for the next seven years. 

Ultimately I developed a cycling team in association with the Eldora ski racing program, one of my athletes, Ian MacGregor, went on to win the US national road championship in 2004 and 2005, and another, Timmy Duggan, won the US professional national road championship in 2012 and was also a member of the 2012 US Olympic cycling team that competed in London.  Ian has retired from cycling and since has gone on to co-found Skratch labs with physiologist Alan Lim.  In another selfless act that continues to make me swell with pride, Timmy and Ian developed a non-profit organization to help young athletes get funded to further their own Olympic dreams; Just Go, check out their web page, and more importantly, make a donation.

During my time in Boulder, even more important than success as an athlete and a coach, was the meeting of the Head ability coach at Eldora, Susan Holes, who eventually agreed to become my wife in 1998 and then the mother of our two sons.  As fate would have it, we were first introduced to each other by the same training partner who suggested that I get involved with coaching young kids.  I suppose that sometimes it is better to be lucky than good.

Related media:

So you went to UNH and obtained a business degree, competed as a cyclist at the Olympic Trials level both domestically and internationally.  Then you coached skiing and cycling with some success, how did this pathway during the 1990’s lead to your current career as a Physician?

Susan and I were married in 1998 and decided that developing a more long term profession was in order to facilitate building a life together and planning for a family.  To that end I enrolled at the University of Colorado and pursued a second degree in Biochemistry.  I considered a few alternative professional pathways, but given my history in athletics and coaching, Medicine was really the best fit and best way to use my prior skill set to give back  

I ultimately began Osteopathic medical school at Midwestern University – AZCOM in the late summer of 2000.  I continued to coach skiing during the first year of medical school and continued to compete as a cyclist into the second year of medical school.  Medical school was very challenging, but I found that leaving the life of an athlete was an even more challenging; it was very difficult to give up that way of life and the intensity and singularity of mind it provided after so many years.

More specifically, how did you decide on Physiatry?

During medical school, like most medical students I struggled with the decision of which specialty to pursue.  I eventually narrowed it down to orthopedic surgery and Physiatry.  In the end I chose Physiatry, in many ways guided by my beliefs and the experiences I had as an athlete.  I experienced several significant injuries as a cyclist, in fact in 1997 I missed the entire competitive season due to a recalcitrant Achilles tendionopathy; this lost season was especially disappointing given the success I had during the 1996 season.  

When I was injured, surgical debridement of the tendon was offered as a treatment option, an option I ultimately chose not to pursue.  This desire to avoid surgical intervention drove my recovery process as an athlete for this as well as other chronic musculoskeletal injuries I suffered over the years.  Given the non-surgical pathway I had mapped out for myself as an athlete I thought that pursuing a musculoskeletal care pathway that minimized surgical options as much as possible would be the best pathway for me advise to my patients; to this end I choose Physiatry over Orthopedic surgery. 

I had a similar experience, though at a lower level of competition.  When I graduated from the University of Wisconsin in 1995, I was training for an Ironman, and tore my right PCL in my knee.  I ended up spending the summer between college and medical school rehabilitating my knee.  My personal experience with rehabilitating this injury is what led me to choose PM&R as a career as opposed to Orthopedics.

It is very interesting to hear you describe a similar early story and tying your personal desire to avoid surgery if possible with your ultimate decision to pursue Physiatry over Orthopedics.  I know many Physiatrists who were would be Orthopedists but ultimately choose Physiatry as their life pathway. This includes several of our mutual friends such as Ethan Colliver, Marla Kaufman, and a host of other notable physicians.

Getting back to the line of thought regarding the pathway that brought you to where you are today.  We initially met in Cooperstown when you were an Intern.  I had completed the Internship at Bassett two years prior. We met again at Kessler where we were both residents. Tell me a bit about your experience with Bassett as well as at Kessler.

Sure, as you note we had a similar training pathway with me following two years behind you at the Bassett Internship program and then again at the Kessler PM&R residency program.  After graduating from medical school in 2004, I completed a Columbia University associated Rotating Internship at Bassett Medical Center in Cooperstown, NY.  It was a challenging but wonderful year in Cooperstown. I learned a lot about medicine, made many friends, and continued to train along side one of my medical school classmates, Ethan Colliver.  My wife and children made many friends and despite the long hours and stress involved in Internship, we had a great year, it was good for me as a growing physician but more importantly it was a very good year for our family.

I left Cooperstown and again followed you to engage in the rigorous, academic residency at the Kessler PM&R program in NJ.  While at Kessler I was exposed to many great musculoskeletal attending physicians such as Gerry Malanga, Greg Mulford, Jeff Cole, Todd Stitik, Gautam Malhotra, and Pat Foye among others.  I also had the benefit of excellent mentors such as Steve Kirshblum and Susan Garstang.  Further, the Kessler program also afforded me the good fortune of meeting like minded and very gifted musculoskeletal colleagues in residency such as yourself, Jim McLean, Casey O’Donnel, and Chris Visco.  Chris and I were residency classmates and two of our other Kessler class of 2008 classmates, Rich Dentico and Ron Karnaugh, also did post residency fellowships and chose to pursue a career as musculoskeletal Physiatrists; it was a great bunch of talented individuals to be mixed together with during our formative training years.  All of these individual provided direction to my education and career pathway, and more importantly remain my close friends to this day. 

I left Kessler to pursue a Fellowship year at the University of Massachusetts in Worcester, MA where I furthered my knowledge of EMG and musculoskeletal medicine as well as developing an interventional skill base.

Your question regarding Cooperstown and my time at Bassett I think can be best answered by where I live and practice now. When it came time to select a job post fellowship, I gave my wife the choice of pursuing a position in San Francisco or returning to Bassett Medical Center in Cooperstown; she chose Cooperstown as the place to grow our lives together and to raise our sons.  We have been here ever since and so far have been quite happy with our choice. 

You describe a bit of a convoluted pathway toward you current career as a musculoskeletal physiatrist, given my personal pursuit of a PhD in Anatomy as part of my own medical pathway, I can see value your unique process.  Is there anything special you think that you bring to the table in treating patients that you might not have in your bag of tricks had you pursued a more traditional pathway to Medicine?

Yeah, it was a bit of a road getting here, but life is about the journey much more so than the destination.  I believe that this unique and protracted pathway to Medicine has afforded me many unique tools to bring to bear in the treatment of my patients.  Graduating with a business degree provides an insight into the business aspect of Medicine and the requirements to run a successful business.  Competing at an elite level has given me an understanding of what it takes to be successful at a high level and of how hard I can push my body and mind in the pursuit of excellence.  Coaching high level athletes helped me to develop the capacity to teach and nurture individuals to push themselves to attain goals that they once did not think possible.  All these are qualities I use on a daily basis in the course of providing care to my patients.

I had the good fortune of recently being featured in the quarterly edition of CORE which may be an interesting read for your readers.

Let’s switch gears a bit.  Tell us more about patient satisfaction surveys. For those who don't know much about these surveys, they sound like a great idea, but you argued that they may actually be harmful for patients. While I obviously agree with you (since I was your co-author), that may not be apparent to most people. Why are patient satisfaction surveys harmful?

As you mention, you and I wrote an in-depth opinion piece on the subject published in the December issue of the PM&R Journal.  I would encourage your readers to review the article for themselves and get a more informed perspective. (Gary's Note: full access to article only available for PM&R Journal subscribers.  Please contact Gary if interested)

There are many problems with patient satisfaction surveys.  These surveys are marketed as a tool to grade healthcare quality but are deeply flawed.  First, they are not particularly accurate measures of what they purport to evaluate.  Second, the measures these surveys do evaluate do not equate to improved healthcare.  So in the end these surveys are a poor measurement of data that is not relate to the quality of healthcare provided. 

A big flaw is that patient satisfaction surveys ask the wrong question.  The goal of medical care is not to engender satisfaction, but rather to improve health and function of our patients; satisfaction surveys miss the point.  What we should be doing is looking at how we can better engage our patients to further their personal goals for health and function rather than look to see if they are satisfied with us or not. 

There are not a lot of scientific studies on the topic, but those studies that do exist actually demonstrate that high patient satisfaction correlates with poor patient outcomes.  This may, at first glance, seem counter intuitive but this unexpected result is likely related to what physician behaviors and activities engender patient satisfaction and what physician behaviors foster better patient health; these two sets of behavior are often in direct opposition to each other.  

As we noted in the article we co-authored, the best study to date on clinical outcomes and patient satisfaction scores demonstrated that the patients who were most satisfied with their physicians died at a much higher rate than those patients who were relatively unsatisfied.  A further point we made in our article was to note the moral inappropriateness of using satisfaction scores to evaluate physicians, as is well described in the article we referenced by Labig
Unfortunately these surveys aren’t just a benign waste of time, but rather are misguided tools. In their application, they are often used to manipulate physician behavior, often in ways that might not be best for either the patients or the doctors.  The unintended consequences of these surveys are potentially great and argue against their use. 

The patient-physician relationship is not a symmetric one.  The physician brings to the table a set of knowledge and insight that the patient does not possess and then uses this insight for the benefit of the patient rather than leveraging the inequality in the relationship for personal gains.  As physicians, we use our skills for our patients benefit rather than for our own good despite the frequent sacrifice on our part required to do so.   Our role in the relationship is not to engender a fondness for us, nor to get our patients to like us or feel a high degree of ‘satisfaction’.  Rather our role is to selflessly care for and guide patients on their road to improved health and function.  However, if we were to focus on getting patients to ‘like’ us, we would often make decisions counter to the real goal of helping patients improve.

So this brings us back to the prior thought that measuring a patients’ satisfaction with their physician is looking at the wrong factor and in doing so could very likely alter the relationship in a manner that is harmful to the patient.  As improving patient welfare is the goal of physicians, engaging in satisfaction scores is the wrong thing to do.

For a small private practice like what Garrett Hyman and I run here at Lake Washington Sports & Spine, how would you advise we improve the patient experience? Are there methods that would work better than using commercial survey tools? For example, would simply asking patients directly for their feedback be more helpful?

I think that there is a cluster of features that help define the patient experience in regards to clinical quality.  The first two aspects directly tie to the physician, in this case Garrett and yourself, and what you bring to the table.  The second two aspects apply to the patients and what they bring to the table.  The quality of the clinical experience lies in the interplay between theses facets of this relationship and both parties need to have responsibilities to, and expectations of, that relationship.

So part of the relationship is the responsibility of the physician and part is the responsibility of the patient?

Exactly, the first set of features in this relationship puzzle relate directly to the physician.  I see two big items that the physician controls.  The first is development and fostering of a caring relationship and the second is striving to continue ongoing development of clinical excellence.  

At the heart of the patient physician relationship is the relationship itself; this is often the key to clinical excellence.  In order to care for patients, you must first ‘care’ about them, and directly engaging them is a fundamental component of the process of caring.  To that end physicians need, as your question suggests, to directly engage their patients and discuss their needs in a proactive manner as a starting place for maximizing patient care. 

However, although fostering a relationship based on compassion and caring provides a starting point, this is not enough. You and Garrett need to continue to expand on your already considerably clinical skills.  Pursuit of clinical excellence needs to be the second step in this relationship pathway. 

When you and I were in residency, one of our mentors, Dr. Kirshblum, often talked about the three ‘A’s’: Affability, Availability, and Ability as the key to excellence as physicians.  The two components I am discussing here as the province of the physician within the relationship is really another way of stating the three ‘A’s’ to excellence as Dr. Kirshblum taught us years ago.    

The second set of features comes from the patient, but as physicians you can help teach and mentor the patients in these components.  The first is management of expectations, and the second is embracing personal accountable for health and outcomes by the patients themselves.

I think that appropriate expectation management is especially important.  As we care for an ever aging patient population there are real, as well as perceived, limitations on what people can do.  The limits of human ability is always expanding, but that said, there are limits and sometimes what a patient desires for their healthcare outcomes may not be realistic; we need to counsel and educate them about what is reasonable, we just need to do so in an optimistic and positive manner.

For example, I often counsel my patients with back pain, that their desire for complete, permanent eradication of their lumbar pain while engaging in any activity they desire may be unrealistic.  However, addressing underlying factors effecting the development of their pain and having a goal of increased function in an age appropriate fashion is usually very realistic. 

People tend to be disappointed, complain, and have reduced satisfaction when their expectations are not met.  As such, if their expectations are not obtainable in 99% of the circumstance, they will end up disappointed 99% of the time.  We need to set high goals, but obtainable one that can be achieved with discipline, hard work, and the patient’s full engagement in the process of achieving health and improving function.

This brings me to the next patient driven aspect.  Patients need to be accountable for their ultimate health and outcomes.  As an athlete, if I didn’t train, I was the one who did not succeed; I was responsible, there was no one else to blame.  We can control our efforts, the time we put into our training and the attitude we bring to the training environment, but we can not control the outcomes; control of outcomes is an illusion.  In this vein, we need to teach our patients to focus on what they can personally address, the controllable factors, and try not to get hung up on what they can not address, the uncontrollable factors.  As a coach, and with my own children, I teach that your personally controllable factors are: the time you put in; the effort you are making; and the attitude you bring to the task.  This perspective has wide spread utility in healthcare, especially healthcare intimately directed by small practice physicians such as Garrett and yourself. 

That sounds great, be realistic and take responsibility in your own healthcare, do you have an example?

Sure, let’s look at a patient that would be common in both your practice as well as my own.  Let’s look at low back pain.  When we look at a clinical issue such as back pain we know that there are many factors that are involved in a complex interplay of genetics, phenotype, environment, injury, etc.  For back pain we know that obesity and smoking play a large role as does age and gender.  We also know that strength, flexibility, and neuromuscular patterning also play a role as does daily activity, personal biomechanics, and ergonomics. 

Some of these factors, for example genetics, gender, and age, are not modifiable, so we need to teach patients to try not to get too caught up in worrying about these issues; they can’t change them anyways.  Other factors are modifiable and patients need to be counseled to fully engage these factors.  Are the patients aggressively trying to get their weight down to a BMI <25?  Have they stopped smoking? Are they doing a daily home exercise plan?  Are they avidly addressing their deconditioning?  Are they engaging in activity that requires inappropriate duration or intensity of activity for their body and age?  Have they modified their expectations to include reasonable goals?  And so forth. 

In all of these examples, you and Garrett can directly improve the quality of patient care by keeping the patients focus on modifiable, controllable factors, the time that the patients are putting into these issues, the effort they are applying to make changes, and the attitude that they bring to the process.  This effort on your part will potentially have a much more lasting impact that any particular intervention or medication. 

For you or your family, which would you prefer for a better patient experience- a small independent practice, or a large practice that is part of a system or Accountable Care Organization?

For my family, my primary concern would be excellence of care. To that end, I would prefer to see the components discussed above brought to bear for the benefit of my family member.  I would like to see care provided by a physician with demonstrated excellent clinical skills and academic knowledge and an obvious desire to continue to develop and improve their knowledge base and acumen.  I would like to see this physician provide care within a compassionate, concerned relationship with an eye toward an end point of great care for my family member. 

Care such as this could be provided in many settings, this would include small independent practices as well as larger organizations.  However, I think that a small independent practice is better positioned to give this type of care.  In the small setting, the patient typically has direct access to their physician and the goals of the practice are more in line with the goals of the individual patient.  In larger organizations, even with the best intentions by individual physicians, often the organizational goals are more aligned with the overall care of a patient population rather than an individual patient.  This bigger picture, population driven focus of healthcare in a large organization works well for the management of demographic data but not necessarily for any given individual patient. 

When caring for an individual, we get back to the keystone word ‘caring’; I think that the small physician centric independent practice is better positioned to provide that ‘care’.  This focus on direct patient relationships and ‘caring’ can happen in larger organizations, but I think it is more difficult.  In a small practice such yours, because you have both direct authority over care and direct responsibility for the patient relationship, I think that you can be more responsive to individual patient needs and in most cases provide better care.

At the end of the day, healthcare is about two people in a closed room having a private, intimate conversation.  One of those two people brings a deep knowledge about medicine to the discussion and the other person brings a deep knowledge of their personal problem.  After a private discussion and evaluation, the two people come up with a plan and then leave the room.  What happened inside this room is ‘healthcare’. Everything else in the system exists to support that private conversation and patient-physician relationship.  The closer we can get to this idealized situation the better it is for patients.  In general, I think that at this point in time, the small independent practice is best positioned to provide for and support this private interaction.

Do you think physician ownership of a medical practice, as opposed to a medical practice run by an administrator, makes a difference in a quality patient experience?

I think that in general medical care should be directed by physicians, both for the individual patient as well as for organizations and policy.  This need for physician control and direction holds true at a local level for a small practice such as yours but also expands upward to control and direction of larger healthcare organizations and even to state and national healthcare policy objectives. 

To use a sports metaphor, many great coaches were not great athletes themselves, but they were nearly always good athletes.  How can you coach and direct a team or an individual athlete if you do not ‘know’ the game.  When I coached alpine skiing, I was a better coach than I was a ski racer.  But I had ski raced at a high enough level to have some insight into the ‘game’ and by competing at a much higher level as a cyclist, I knew what it took to compete on a National level and beyond.  By combining those two skills along with some other personal skills, I developed into a good coach, much better than my personal history of ski racing would have suggested.  But the important point is that I had been a ski racer. 

I think that it would be very tough to coach any sport that you had not played yourself and it would be very hard to help an athlete be successful at a high level if you hadn’t been at a high level yourself; how could you understand the process or mindset without the experiences yourself?  Extending this metaphor, the direction and management of medical care must be via physicians.  How can non-physicians directly lead or direct healthcare without the background that the process of becoming a physician and obtaining Board certification affords?

I think that a natural career pipeline for physicians is to practice for 15 – 20 years and be mentored in leadership during that clinical phase of their careers.   Following this phase they can have a leadership / administrative role for 10 – 15 years leading into retirement.  This is a natural flow that allows for development of a deep understanding of patient care, healthcare process and delivery, as well as development of leadership skills.  All while directly engaged in the relationship and pursuit of clinical excellence that we discussed above.

To have non-physicians in a role of supervising, directing, or controlling physicians is a mistake.  Non-physicians’, that includes mid-level providers and nurses, do not have the same ‘buck stops here’ experience with medical care that physicians do, as such, they are not positioned to evaluate or direct physicians in the execution of patient care.  This is much the point of our point-counter point article on patient satisfaction scores.   I make a strong point on the importance of physician control and leadership of healthcare, but we must also remember that other players perform unique and useful tasks within the patient care pipeline and we need to respect and support them in the course of their filling those support roles.  The non-physician colleagues can play a very important and much needed role as our allies, but not as our leaders, ‘owners’, or ‘bosses’.

What does your vision for better health care in 5 years look like?

I think that the tea leaves on this issue are in really muddy water at this point in time.  The current trials and tribulations of the ACA and the obvious public distain for much (but admittedly not all) of the contents make any forecasting very difficult.  Further obscuring the future pathway is that the pendulum has swung very far towards the business / administrative side of healthcare.  It is crazy that people with business degrees are in positions to tell physicians how to run their clinics, that administration is having a say in the schedules of residents and fellows during their training, that in many large healthcare organizations there is one administrator for every 3 or 4 physicians.  The inappropriateness of these and many other things are being noticed by those outside the ranks of physicians and I believe that the pendulum will swing back toward physician drive patient care as the cornerstone of health care, the question is when.

As a nation we are also going broke providing healthcare in the manner that we currently do, so things must change.  We have an annual GDP of about $15 trillion in the US and medical care expenditures of more than $2.2 trillion.  That can’t keep happening; we simply can not afford this amount of cost over the next 15 or 20 years.  It is a fact that this expanding expenditure will get cut, but the question is where to cut? 

A large part of the problem is the almost complete lack of national discussion on the real source of these runaway costs.  Physician salaries make up only 8% of the total healthcare costs, so even if every physician in America worked for free we would still spend nearly $2 trillion per year on healthcare in the US.  So, obviously targeting physicians is the wrong way to go, even if only for pragmatic reasons that chopping doctors will have minimal to no effect on the cost problem. 

So where to address things?  My personal belief stems back to the above mentioned patient centered aspect of care; personal responsibility.  Modifiable factors are the biggest cost in healthcare in America.  Obesity and smoking combine to directly tie to >50% of all healthcare costs in America. In other words, if everyone in the US had a BMI <25 and no one smoked, we could move toward a future with healthcare costs <$1trillion per year; now that is a significant difference. 

The escalation of healthcare costs is really a demand side economic problem and as a nation we continue to attempt to address the issue by making supply side regulations and attempting to change payments in order to change the slope of the supply curve.  But supply is not the problem, demand is the problem.  In most large hospital systems the top 100 utilizers of emergency department services (the 100 patients who use the ER the most) spend a wildly disproportionate amount of the healthcare dollars in those systems.  I do not have an article to cite, but I have heard it stated that overall 10% of the patients spend 90% of the healthcare dollars. 

Until we address the demand curve for healthcare, the US healthcare expenditures as a percentage of GDP will never get ‘fixed’.   The great news is that if we can get politicians on board and decrease the disproportionate input that ‘big’ medicine has on the system, and focus on the quality of care issues you and I discussed above, then we can find a solution.   But there is almost no discussion on a national level regarding this issue; instead our national and state leaders continue to throw regulatory requirements into the marketplace that make healthcare more expensive all the while ignoring patient responsibility for cost control and their own personal health.  We must move on a national scale toward the above noted components for excellence, with a national focus on excellence in physician directed care and on patients having realistic expectations and taking personal responsibility for their healthcare and outcomes.

There are several well known national voices that have espoused a future of medicine in the model of Wal-Mart or the Cheesecake factory.  They envision large corporate entities providing homogenized, albeit acceptable (but not excellent), healthcare to the masses.  This vision is deeply flawed because of it continues to focus on the supply side of the healthcare equation while lacking in the much more financially salient demand side of healthcare in the US. 

Further, is shopping at Wal-mart a better retail experience than shopping at a local merchant?  Is it better for the community at large?  Is it better for the workers?  I would ask what community has seen its local population benefit from the invasion by Wal-Mart and the subsequent decimation of local retailers. Does eating at Cheesecake factory offer a better meal or quality of product than could be provided by local chefs using local or regional products in a small to medium volume format?  If you are looking for a quality dinning experience would you rather eat at Cheesecake factory or at The French Laundry or Blue Hill at Stone Barns (look them up)?  Or, if you are looking for less financial challenging quality food, I would suggest that the Panini sandwich at your local deli is both higher quality and lower cost than a similar lunch at the Cheesecake factory.  What community has seen an expansion in the quality of local food when a Cheesecake factory opens up in the local shopping center? 

These giant organizations offload their profits away from the local community, pay relatively lower wages than would be making by the owners of local establishments, and degrade the quality of product in terms of both product and the quality of relationship available.  This corporate homogenization does not improve the retail experience or the dinning experience, and I do not think corporatization will benefit the healthcare experience. 

So the future is murky, but I think that there will always be a role for small physicians groups providing outstanding clinical care and forming lasting and quality relationships with their patients and communities.  Excellence never goes out of style, so I think that you and Garrett have a bright future.