Amaze your interviewers with this one weird trick

[Med Ed]

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I thought that might get your attention.

Anyways, in 2009 Atul Gawande published a now infamous article, "The Cost Conundrum," in the New Yorker. It detailed his exploration into how medicine was practiced in McAllen, Texas. That particular location was not a random assignment; at the time it has the dubious honor of having the highest per capita Medicare spending in the country. McAllen has many demographic similarities to El Paso, which spent about half as much without any apparent negative consequences.

This would be old news, but last year Gawande published a follow-up article called Overkill, in which he spent some time revisiting McAllen and examining the fallout from his first piece. The medical community in McAllen garnered a lot of attention in that aftermath, much of it national, and almost none of it positive.

While Gawande does a beautiful job exposing some of the deep problems in our healthcare system, I would not have started this thread to tell everyone the sky has fallen. Rather, in the second half of Overkill he delves into some of the efforts aimed at fixing an inherently dysfunctional triad of patients, providers, and payers. Of particular interest to anyone contemplating a career in medicine is the story of Dr. Armando Osio, a family practice doctor who linked up with WellMed Medical Group, which seeks to align the incentives of the aforementioned patients, providers, and payers. Some of the new reimbursement models that are being piloted seek to do the same thing. Here is an excerpt (emphasis added):

Osio was skeptical, but he agreed to see some of WellMed’s patients. When he was in training, he’d been interested in geriatrics and preventive medicine. In practice, he hadn’t had time to use those skills. Now he could. With WellMed’s help, Osio brought on a physician assistant and other staff to help with less complex patients. He focussed on the sicker, often poorer patients, and he found that his work became more satisfying. With the bonuses for higher patient satisfaction, reducing hospital admissions, and lowering cardiology costs, his income went up. This was the way he wanted to practice—being rewarded for doing right rather than for the disheartening business of churning through more and more people. Within a year, he’d switched his practice so that he was seeing almost entirely WellMed patients.

To medical school hopefuls, I think you would do well to read these articles and ponder the issues within. The shifting of payment models is one of the most significant changes in the modern healthcare landscape, and regardless of the outcome this effort will impact everyone in medicine, including those who are just starting out.

 

[Holmwood]

Appreciate the clickbait and the article. 😀

 

[LizzyM]

Osio was skeptical, but he agreed to see some of WellMed’s patients. When he was in training, he’d been interested in geriatrics and preventive medicine. In practice, he hadn’t had time to use those skills. Now he could. With WellMed’s help, Osio brought on a physician assistant and other staff to help with less complex patients. He focussed on the sicker, often poorer patients, and he found that his work became more satisfying. With the bonuses for higher patient satisfaction, reducing hospital admissions, and lowering cardiology costs, his income went up. This was the way he wanted to practice—being rewarded for doing right rather than for the disheartening business of churning through more and more people. Within a year, he’d switched his practice so that he was seeing almost entirely WellMed patients.

And note the role in this scheme for physician extenders.

 

[Sanguis]

And note the role in this scheme for physician extenders.

I've seen that quite a lot. I have actually never talked to the Dr., and instead have always been attended by a PA.
Is this a correct thing to do for a future practice?

 

[allantois]

On topic, by (now) Harvard provost:

 

[zero0]

Must... Not... Click...


dang it

 

[LizzyM]

I've seen that quite a lot. I have actually never talked to the Dr., and instead have always been attended by a PA.
Is this a correct thing to do for a future practice?

Read the passage again and apply your critical thinking skills.

 

[DKMA]

@Med Ed but how does it go in medicolegal terms? As a premed, it hard to separate exaggerations from realities when talking to older physicians.

In the case of the microcarcinoma: If it was left and the doctor told the patient to monitor it and then it ended up progressing and doing major damage to the patient, would the physician be sued? The way I always understood it is that our system encourages overtesting and punishes normal testing if somethings ends up going wrong and now we are moving to a system that doesn't encourage overtesting and then still punishes undertesting.

If another surgeon turned around and said, "I would've done surgery right away and then Ms. Jones would've been perfectly fine today," would the surgeon who chose not to do surgery be held liable?

 

[justadream]

On topic, by (now) Harvard provost:

Can you give us a tl;dw?

 

[Sanguis]

Read the passage again and apply your critical thinking skills.

Thanks, Lizzy.
Do you know if nejm has articles of this kind?

 

[DokterMom]

The takeaway idea is that aligning the interests of the patient, the provider, and the payer is the best long term solution. The current setup is a zero-sum game, and it really doesn't have to be. But it IS a pretty fundamental overhaul to make it happen.

 

[Med Ed]

@Med Ed but how does it go in medicolegal terms? As a premed, it hard to separate exaggerations from realities when talking to older physicians.

In the case of the microcarcinoma: If it was left and the doctor told the patient to monitor it and then it ended up progressing and doing major damage to the patient, would the physician be sued? The way I always understood it is that our system encourages overtesting and punishes normal testing if somethings ends up going wrong and now we are moving to a system that doesn't encourage overtesting and then still punishes undertesting.

If another surgeon turned around and said, "I would've done surgery right away and then Ms. Jones would've been perfectly fine today," would the surgeon who chose not to do surgery be held liable?

In general you shouldn't worry about getting sued because of a bad outcome, you should worry if you've been negligent. In this instance, explaining to a patient the nature of microcarcinomas and the risk of leaving it versus the risk of removing it, while holding a medically informed opinion that one risk outweighs the other, is not negligent. That said, physicians are human, and we are subject to normal psychological foibles, such as assessing risk subjectively rather than objectively, and letting past events unduly influence current decisions. I have suspected for years that so-called defensive medicine is, at least in part, an external mechanism to alleviate internal anxieties rather than a genuine risk reduction strategy.

That's not to say you cannot be sued over a bad outcome. Anyone can, in theory, sue anyone else for any reason. If you practice long enough, especially in certain fields like spine surgery, eventually you'll get served. It comes with the territory. Unless the plaintiff is fabulously wealthy, trial lawyers are loathe to bring suits they don't think they can win. Most cases with merit get settled out of court. In many cases with merit a suit is never brought, for one reason or another. Most cases that do go to court are won by the defendant (i.e. doctor/hospital).

All this is to say that whenever someone asks me for informal medical advice I always tell them the same thing: get a second opinion.

 

[LizzyM]

Thanks, Lizzy.
Do you know if nejm has articles of this kind?

NEJM is usually more "big picture". JAMA is where you'll usually find more of the "first person" essays, particularly in the feature called "Piece of My Mind".

 

[avgn]

@Med Ed @DKMA
Find Michelle Mello's articles on impressions of the medical community on malpractice vs. reality. Largely concludes what everyone knows: physicians are paranoid, the real malpractice landscape is nowhere near as bad as they think. However, a plurality of doctors do at some point in their careers find themselves with an open malpractice case against them, but the legal system overall is pretty good at sifting through the bull**** and dismissing frivolous cases. Costs are still high and psychological stress still present, but constant worrying every day about getting sued arises from a severe lack of understanding of tort law and its implications.

 

[oobie]

Thank you @Med Ed for the wonderful links. I read the overkill article back when I was writing secondaries (What do you think is the biggest problem in healthcare?/How would you help fix it?). I knew this was a potential research topic for my interests in med school, and I want to learn how to decrease the overkill method we have in healthcare, and help spread this idea to all doctors/future doctors to whom I can. On a very similar note, I heard this on the Freakonomics radio hour (I think) and thought it would bring up a good discussion as well: http://fivethirtyeight.com/features/are-mammograms-worth-it/

Also, do you think that if I were to get a residency position in locations where there are low Medicare costs per person, I would learn better to not overprescribe/overdiagnose?

 

[Goro]

Fascinating! Many thanks for posting!

I thought that might get your attention.

Anyways, in 2009 Atul Gawande published a now infamous article, "The Cost Conundrum," in the New Yorker. It detailed his exploration into how medicine was practiced in McAllen, Texas. That particular location was not a random assignment; at the time it has the dubious honor of having the highest per capita Medicare spending in the country. McAllen has many demographic similarities to El Paso, which spent about half as much without any apparent negative consequences.

This would be old news, but last year Gawande published a follow-up article called Overkill, in which he spent some time revisiting McAllen and examining the fallout from his first piece. The medical community in McAllen garnered a lot of attention in that aftermath, much of it national, and almost none of it positive.

While Gawande does a beautiful job exposing some of the deep problems in our healthcare system, I would not have started this thread to tell everyone the sky has fallen. Rather, in the second half of Overkill he delves into some of the efforts aimed at fixing an inherently dysfunctional triad of patients, providers, and payers. Of particular interest to anyone contemplating a career in medicine is the story of Dr. Armando Osio, a family practice doctor who linked up with WellMed Medial Group, which seeks to align the incentives of the aforementioned patients, providers, and payers. Some of the new reimbursement models that are being piloted seek to do the same thing. Here is an excerpt (emphasis added):

Osio was skeptical, but he agreed to see some of WellMed’s patients. When he was in training, he’d been interested in geriatrics and preventive medicine. In practice, he hadn’t had time to use those skills. Now he could. With WellMed’s help, Osio brought on a physician assistant and other staff to help with less complex patients. He focussed on the sicker, often poorer patients, and he found that his work became more satisfying. With the bonuses for higher patient satisfaction, reducing hospital admissions, and lowering cardiology costs, his income went up. This was the way he wanted to practice—being rewarded for doing right rather than for the disheartening business of churning through more and more people. Within a year, he’d switched his practice so that he was seeing almost entirely WellMed patients.

To medical school hopefuls, I think you would do well to read these articles and ponder the issues within. The shifting of payment models is one of the most significant changes in the modern healthcare landscape, and regardless of the outcome this effort will impact everyone in medicine, including those who are just starting out.

 

[The Knife & Gun Club]

Wow great duo of articles. These are the sort of things I feel like should be required reading for med students.

"But even after overhead doctors in one group took home almost eight hundred thousand dollars each (some of which they shared with their mid-level staff). It was proving to be a very attractive way to practice."

Also, primary care doctors making $800,000?! Move over cosmetic plastics in LA!

 

[Med Ed]

Also, do you think that if I were to get a residency position in locations where there are low Medicare costs per person, I would learn better to not overprescribe/overdiagnose?

That's a very good question, although I think the answer will require looking well beyond one statistic. There are some health systems, like Geisinger, that have been on the leading edge of payment reform programs. On the west coast, Kaiser has been doing its own thing successfully for many years. When you start looking at residency programs it will probably be more common for medical centers to be tinkering with new payment systems, so you can add that to your wish list. When you start residency, a lot of your practice habits will develop by absorbing the institutional culture and through mentoring, both formal and informal. It's always great if you can learn from someone who practices the way you aspire to.