Your take on "Big Medicine"?

[dudeliness]

Ok so on the plane on my way home, a guy was reading this article http://www.newyorker.com/reporting/...all?mobify=0&intcid=full-site-mobile&mobify=0 about hospitals conglomerating into large chains and standardizing procedures and patient care in order to bring better service to patients. The author of the article uses a very interesting comparison between successful chain restaurants (specifically the cheesecake factory) and how they are able to provide pretty decent quality food in a standardized format while keeping costs low and satisfaction and quality high.
It's kind of a long read, but well worth it in my opinion. I'd really like to know what others think about it.

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[MedPR]

Ok so on the plane on my way home, a guy was reading this article http://www.newyorker.com/reporting/...all?mobify=0&intcid=full-site-mobile&mobify=0 about hospitals conglomerating into large chains and standardizing procedures and patient care in order to bring better service to patients. The author of the article uses a very interesting comparison between successful chain restaurants (specifically the cheesecake factory) and how they are able to provide pretty decent quality food in a standardized format while keeping costs low and satisfaction and quality high.
It's kind of a long read, but well worth it in my opinion. I'd really like to know what others think about it.

Interesting you should mention this, I was reading that article the other day. Too many doctors and differing opinions to make this work imo.

 

[ResearchRetMD]

Ok so on the plane on my way home, a guy was reading this article http://www.newyorker.com/reporting/...all?mobify=0&intcid=full-site-mobile&mobify=0 about hospitals conglomerating into large chains and standardizing procedures and patient care in order to bring better service to patients. The author of the article uses a very interesting comparison between successful chain restaurants (specifically the cheesecake factory) and how they are able to provide pretty decent quality food in a standardized format while keeping costs low and satisfaction and quality high.
It's kind of a long read, but well worth it in my opinion. I'd really like to know what others think about it.

This is an interesting take. But if you went this way, then what would happen to patients getting a second opinion? I also think that some doctors are good at solving a problem in a certain way. This might make it hard to standardize imo.

 

[dudeliness]

Interesting you should mention this, I was reading that article the other day. Too many doctors and differing opinions to make this work imo.

Well I would agree it may be near impossible to implement this in a nationwide format, but the reality is that some hospital groups, albeit only in certain departments, are already implementing these business sense tactics. I personally would love to be part of an organization that chose to streamline patient care like that, provided that quality of care was the top objective. If utilized correctly, this standardized system could vastly improve patient care and dramatically cut health care costs. Sounds like exactly what this country needs.
Also, in response to the guy who posted above me (can't multi-quote on my phone. Lol), while it may be true that some doctors do some procedures best a certain way, that doesn't mean they can't learn to do it a different way, and if that different way is scientifically proven to be better for the patient, they would be remiss in their duty if they didn't change their preferred procedure to benefit the patient.
In the article he used the example of using beta blockers after a heart attack. It was 15 years after the research proved that it helped before there was widespread use of this new technique. To me that is appalling, especially when you consider that one of the main causes in that decade long delay in health care advance came simply from doctors who didn't want to change how they do things.

 

[UrshumMurshum]

Here's an idea. Why don't we just have a big conveyer belt. When a patient walks into the hospital, group practice, private practice, or whatever, they sit on this belt. The belt then takes them to a station where their heart rate, O2 stat, blood pressure, and temperature are taken. The patient then immediately gets taken to another station where a CBC, Basic Metabolic Panel, and other general blood tests are run. The patient then goes to a station that x-rays them, mri's them, and takes an EKG of them. The records are then shipped to one of many doctors at the next station who quickly reads the results as they're transported to them, and the patient then proceeds to this final station where they're given exactly 2 minutes to talk about their symptoms. The doctor can either follow what the patient is saying or choose to read more into the labs. If the patient can't talk fast enough before they're shipped to the next station that's too bad. They have to go again.

The doctor then based off this 2 minute conversation chooses a treatment which they register in a computer and gets shipped to a predetermined pharmacy that the patient can go pick up. If additional labs/tests needs to be ordered, the patient can go to a specialized conveyer belt for those.

 

[dudeliness]

Here's an idea. Why don't we just have a big conveyer belt. When a patient walks into the hospital, group practice, private practice, or whatever, they sit on this belt. The belt then takes them to a station where their heart rate, O2 stat, blood pressure, and temperature are taken. The patient then immediately gets taken to another station where a CBC, Basic Metabolic Panel, and other general blood tests are run. The patient then goes to a station that x-rays them, mri's them, and takes an EKG of them. The records are then shipped to one of many doctors at the next station who quickly reads the results as they're transported to them, and the patient then proceeds to this final station where they're given exactly 2 minutes to talk about their symptoms. The doctor can either follow what the patient is saying or choose to read more into the labs. If the patient can't talk fast enough before they're shipped to the next station that's too bad. They have to go again.

The doctor then based off this 2 minute conversation chooses a treatment which they register in a computer and gets shipped to a predetermined pharmacy that the patient can go pick up. If additional labs/tests needs to be ordered, the patient can go to a specialized conveyer belt for those.

Sigh. I really wanted some serious discussion on this topic. I'm going to give you the benefit of the doubt here and assume you mean to illustrate the possible danger of lowering the quality of patient care by attempting to streamline or regulate a system for diagnosing and treating patients. This is a valid concern, and that's why I tried to specify that such a system could only work if the main goal was improving patient care, NOT just cranking out as many office visits as possible. This depends on who is administrating or managing this system or network of care.
In the article, the author discussed how the cheesecake factory gets their management. They aren't just business degree holders, they've actually worked their way up through the ranks or had some kind of training so they know what actually works in practice and what doesn't. The same would need to be the case in a clinical setting. The clinic manager, or whoever is setting the standard procedures that will be followed, should ideally be someone who is an expert in that field. There were two very detailed and specific examples of how this could work in the article, the orthopedic surgeon who regulated knee replacements, and the centralized ICU.
I think that such regulations could be useful in a primary care setting as well. For example, the widespread use of antibiotics is causing a large increase in antibiotic resistant "superbugs". There has been a lot of research done recently into when and what types of antibiotics should be used in specific circumstances. What could theoretically be done is to implement a standard procedure regarding antibiotic prescription in an effort to more closely follow the recent research findings instead of each doctor doing it his own way.
There are some doctors that will bridle at being so regulated, but I really think that it could improve patient care and web cut costs.

 

[MedPR]

Well I would agree it may be near impossible to implement this in a nationwide format, but the reality is that some hospital groups, albeit only in certain departments, are already implementing these business sense tactics. I personally would love to be part of an organization that chose to streamline patient care like that, provided that quality of care was the top objective. If utilized correctly, this standardized system could vastly improve patient care and dramatically cut health care costs. Sounds like exactly what this country needs.
Also, in response to the guy who posted above me (can't multi-quote on my phone. Lol), while it may be true that some doctors do some procedures best a certain way, that doesn't mean they can't learn to do it a different way, and if that different way is scientifically proven to be better for the patient, they would be remiss in their duty if they didn't change their preferred procedure to benefit the patient.
In the article he used the example of using beta blockers after a heart attack. It was 15 years after the research proved that it helped before there was widespread use of this new technique. To me that is appalling, especially when you consider that one of the main causes in that decade long delay in health care advance came simply from doctors who didn't want to change how they do things.

I think many current and future physicians won't like a system where they have less freedom to control their practice, pick procedures and treatments, etc. Part of the reason all of us pick MD/DO over NP/PA is leadership and autonomy. The current system, more or less, is setup where all physicians can tell the NP/PA what to do. The system we're talking about, in my opinion, seems like it would be setup with the most prestigious, oldest, or wealthiest (like politics) physician in charge of a group of other physicians (and all the other clinicians too). Kind of takes out the leadership aspect for the vast majority.

Also, the high cost of care is primarily attributable to uninsured people and I'm not really sure how a standardized care system would alleviate that. At least that's what I learned in UG public health class.

Edit: I'm not necessarily against the idea, but I would like to be autonomous.

 

[HalfListic]

I want to read this and comment later...I have some opinions on the matter, and basically it seems inevitable.

I'll read it and comment later...unless this is a new article, I like the idea in a lot of ways.

 

[dudeliness]

I think many current and future physicians won't like a system where they have less freedom to control their practice, pick procedures and treatments, etc. Part of the reason all of us pick MD/DO over NP/PA is leadership and autonomy. The current system, more or less, is setup where all physicians can tell the NP/PA what to do. The system we're talking about, in my opinion, seems like it would be setup with the most prestigious, oldest, or wealthiest (like politics) physician in charge of a group of other physicians (and all the other clinicians too). Kind of takes out the leadership aspect for the vast majority.

Also, the high cost of care is primarily attributable to uninsured people and I'm not really sure how a standardized care system would alleviate that. At least that's what I learned in UG public health class.

Edit: I'm not necessarily against the idea, but I would like to be autonomous.

Well you're right, it is a setup very much like politics, where the professionals really should be trying to help people but we all know that their main concern is something else $. That's the real danger of big medicine, centralized power is much easier to corrupt and control than many smaller autonomous units right? But the centralized power runs smoother and can arguably effect more positive change. You could even argue that improved quality of care is the responsibility of each physician, meaning that they need to make sure they are utilizing their CME to keep up on the latest treatments and such for their specialty so they can get rid of outdated practices and stay current. Anyway, there's a million different angles to consider on this subject and frankly it's too late in the day to do that anymore. Lol

 

[azide10]

I wrote up a bunch but it was too long. I’ll summarize a bunch of what I said by saying that patient’s are counter productive to their own care and are a huge part of the cost issue. He does nothing to even address this and the scenario’s he describes ignore this component.

He describes a patient with alzheimer's that apparently had a syncopal episode. What would the system he describes do differently? He offers no solution or even a hint of it. The fact is often times syncopal episodes go undiagnosed to perfection in completely healthy patient's who describe their scenario perfectly. Humans are complicated and we do not know everything yet. What tastes good on the other hand is much simpler to standardize and reproduce. Now of course the patient described "apparently" had a syncopal episode, it is unknown and the patient is not of the utmost reliability even though it is only early onset. That gives a decent shot that they are looking for answers to something that didn't happen. If it did happen, she may be missing vital information. Of course they are unhappy with this scenario, most patients that show up to the ED are unhappy when what they think is an MI is probably GERD. “You mean you can’t give me an answer? You don’t think this is serious? I CAN’T BELIVE THIS, WHAT A WASTE OF TIME.” Then go to a different doctor for a second opinion, which is good, but do not provide any of the results and of course they go outside the system so that doctor is unable to obtain the results. Maybe in the future this will change but at this time it is wise not to go into medicine if you are uncomfortable giving diagnosis that aren’t 100% absolute. Started to go on the patients being counter productive to their own care here... I can't believe this was ignored.

The surgical part is nice, surgery is a more definite area. Though what he describes is a small fraction of money saved. It is probably worth it. The biggest issue I had with this part is “we only learn when we want to.” That’s not true at all. We learn during an extended period of time called residency. After that we apply what is learned and are afraid to change due to something called lawsuits. My hunch is that if you change the tort system, you will get more doctors willing to follow new and potentially better ways of doing things than sticking with what has worked for them. Again a learning curb is described, but these are attendings… a less than satisfactory outcome leads to a lawsuit. Better to stick with what you know than to evolve right? I want to do the best for my patient's but a couple million and months of stress on me is more of a risk to my other patients to be completely honest, really puts minds in a different place.

The command center is a nice idea… I would appreciate it but I don’t see most doctors that I know or those that are applying that would like it. Nor do I see it saving much money and he didn’t really describe that.

Usually a fan of his writing, to at least get me thinking. This I wasn’t a fan of. I feel like it misleads the readers big time. Also I feel as though it vilified healthcare workers and made patients out to be saints. He really should have been more realistic in this area if he wanted to produce a good article.

 

[oms2]

this doesn't look like gawande's finest work. extrapolations from the restaurant business are too simplistic.
maybe his next piece will be based on a visit to ikea's furniture factory in china?

 

[WorldChanger36]

The second and sometime 3rd opinion is really an essential part of the healthcare system. Think about it. How many time will a patient go into a hospital and get a diagnosis they did not want to hear then get up and go to another hospital get that same diagnosis but get treatment at the other hospital? The second opinion help more people get the best treatment. Some time docs so get it wrong and some times an angry patient needs to go some place else so they can get away from what is angering them and make better choices. We all need to remember the patient is always in charge of his or her healthcare.

 

[dudeliness]

I wrote up a bunch but it was too long. I'll summarize a bunch of what I said by saying that patient's are counter productive to their own care and are a huge part of the cost issue. He does nothing to even address this and the scenario's he describes ignore this component.

He describes a patient with alzheimer's that apparently had a syncopal episode. What would the system he describes do differently? He offers no solution or even a hint of it. The fact is often times syncopal episodes go undiagnosed to perfection in completely healthy patient's who describe their scenario perfectly. Humans are complicated and we do not know everything yet. What tastes good on the other hand is much simpler to standardize and reproduce. Now of course the patient described "apparently" had a syncopal episode, it is unknown and the patient is not of the utmost reliability even though it is only early onset. That gives a decent shot that they are looking for answers to something that didn't happen. If it did happen, she may be missing vital information. Of course they are unhappy with this scenario, most patients that show up to the ED are unhappy when what they think is an MI is probably GERD. "You mean you can't give me an answer? You don't think this is serious? I CAN'T BELIVE THIS, WHAT A WASTE OF TIME." Then go to a different doctor for a second opinion, which is good, but do not provide any of the results and of course they go outside the system so that doctor is unable to obtain the results. Maybe in the future this will change but at this time it is wise not to go into medicine if you are uncomfortable giving diagnosis that aren't 100% absolute. Started to go on the patients being counter productive to their own care here... I can't believe this was ignored.

The surgical part is nice, surgery is a more definite area. Though what he describes is a small fraction of money saved. It is probably worth it. The biggest issue I had with this part is "we only learn when we want to." That's not true at all. We learn during an extended period of time called residency. After that we apply what is learned and are afraid to change due to something called lawsuits. My hunch is that if you change the tort system, you will get more doctors willing to follow new and potentially better ways of doing things than sticking with what has worked for them. Again a learning curb is described, but these are attendings… a less than satisfactory outcome leads to a lawsuit. Better to stick with what you know than to evolve right? I want to do the best for my patient's but a couple million and months of stress on me is more of a risk to my other patients to be completely honest, really puts minds in a different place.

The command center is a nice idea… I would appreciate it but I don't see most doctors that I know or those that are applying that would like it. Nor do I see it saving much money and he didn't really describe that.

Usually a fan of his writing, to at least get me thinking. This I wasn't a fan of. I feel like it misleads the readers big time. Also I feel as though it vilified healthcare workers and made patients out to be saints. He really should have been more realistic in this area if he wanted to produce a good article.

You have some good points there and I appreciate you sharing. I guess what struck me most was the fact that some advances in research can take so long to be implemented at the detriment of the patients. What you said about getting sued is valid, but if we're talking about small changes that really shouldn't throw a good surgeon for a loop, why not do it?
I guess the bottom line is, I think that health care is going to move towards being more centralized and it will be up to us, in part at least, to help guide it so that it doesn't just become the "conveyor belt" health care that urshum was describing above.

Edit: then again, not really too sure how we can do that. Lol

 

[MedPR]

Well you're right, it is a setup very much like politics, where the professionals really should be trying to help people but we all know that their main concern is something else $. That's the real danger of big medicine, centralized power is much easier to corrupt and control than many smaller autonomous units right? But the centralized power runs smoother and can arguably effect more positive change. You could even argue that improved quality of care is the responsibility of each physician, meaning that they need to make sure they are utilizing their CME to keep up on the latest treatments and such for their specialty so they can get rid of outdated practices and stay current. Anyway, there's a million different angles to consider on this subject and frankly it's too late in the day to do that anymore. Lol

I'm not trying to be argumentative, but do you really think that big medicine puts more pressure on individual physicians to be responsible for quality of care/keeping up with CME? It seems like physicians in big medicine would always have someone else to blame or make responsible for a mistake. In a small practice, where the only person the patient sees is that one physician, there is no passing the buck.

I definitely think that big medicine opens the door to pooling resources and making higher quality care possible, but I don't think it will necessarily end up that way.

 

[UrshumMurshum]

Sigh. I really wanted some serious discussion on this topic. I'm going to give you the benefit of the doubt here and assume you mean to illustrate the possible danger of lowering the quality of patient care by attempting to streamline or regulate a system for diagnosing and treating patients. This is a valid concern, and that's why I tried to specify that such a system could only work if the main goal was improving patient care, NOT just cranking out as many office visits as possible. This depends on who is administrating or managing this system or network of care.
In the article, the author discussed how the cheesecake factory gets their management. They aren't just business degree holders, they've actually worked their way up through the ranks or had some kind of training so they know what actually works in practice and what doesn't. The same would need to be the case in a clinical setting. The clinic manager, or whoever is setting the standard procedures that will be followed, should ideally be someone who is an expert in that field. There were two very detailed and specific examples of how this could work in the article, the orthopedic surgeon who regulated knee replacements, and the centralized ICU.
I think that such regulations could be useful in a primary care setting as well. For example, the widespread use of antibiotics is causing a large increase in antibiotic resistant "superbugs". There has been a lot of research done recently into when and what types of antibiotics should be used in specific circumstances. What could theoretically be done is to implement a standard procedure regarding antibiotic prescription in an effort to more closely follow the recent research findings instead of each doctor doing it his own way.
There are some doctors that will bridle at being so regulated, but I really think that it could improve patient care and web cut costs.

Let me put it this way. Medicine is a personalized art, a very large part of it requires an intuitive human connection. The recent methods of trying to standardize health care is essentially ruining medicine. You simply can't treat patients this way. People's welfare, health, happiness, and perhaps even their lives are being sacrificed for this. ACO's, HMOs, and legal bureaucracy are the bane of medicine. There is no such thing as a statistical patient, a patient presents with their own history, their own symptoms, and their own lifestyles that need molding and accounting for. Standardized time limits, useless bureaucratic checklists, and limits on the physician's ability to execute action and judgement only hinders their ability to accommodate patient's needs, which is always the top priority. The treatments that can be "standardized" already are. If you have appendicitis, there's not going to be a lot of different ways doctors are going to go about treating that. The only place where "standardizing treatments" would actually change anything would be in the realms of illnesses that are not currently standardized already, and that's generally because there is either a lack of evidence based medicine on how to do it or because there's a host of side effects and/or patient lifestyle that needs to be taken into account. Either way, in this context, "standardizing" treatments, even with an expert "case manager" is just going to lead to a host of patient concerns going unaddressed, and ultimately harm the patient.

Never compromise with bureaucrats, they are our enemies.

When I become a doctor I'll fight the good fight, my middle fingers will always be ready and pointed at any bureaucrat who gets in the way of me and my patient.

The way to cut costs isn't compromising on the essential doctor patient relationship. It's attacking diseases directly. Funding community wellness programs to prevent obesity and the associated illnesses would go a long way for saving money. In addition prioritizing our scientific funding to medical research to discover cures, not treatments for diseases would also be of great benefit. For instance if the IVIG treatments pan out for Alzheimers, you're looking at hundreds of billions of dollars saved over the coming decade.

 

[MedPR]

Let me put it this way. Medicine is a personalized art, a very large part of it requires an intuitive human connection. The recent methods of trying to standardize health care is essentially ruining medicine. You simply can't treat patients this way. People's welfare, health, happiness, and perhaps even their lives are being sacrificed for this. ACO's, HMOs, and legal bureaucracy are the bane of medicine. There is no such thing as a statistical patient, a patient presents with their own history, their own symptoms, and their own lifestyles that need molding and accounting for. Standardized time limits, useless bureaucratic checklists, and limits on the physician's ability to execute action and judgement only hinders their ability to accommodate patient's needs, which is always the top priority. The treatments that can be "standardized" already are. If you have appendicitis, there's not going to be a lot of different ways doctors are going to go about treating that. The only place where "standardizing treatments" would actually change anything would be in the realms of illnesses that are not currently standardized already, and that's generally because there is either a lack of evidence based medicine on how to do it or because there's a host of side effects and/or patient lifestyle that needs to be taken into account. Either way, in this context, "standardizing" treatments, even with an expert "case manager" is just going to lead to a host of patient concerns going unaddressed, and ultimately harm the patient.

Never compromise with bureaucrats, they are our enemies.

When I become a doctor I'll fight the good fight, my middle fingers will always be ready and pointed at any bureaucrat who gets in the way of me and my patient.

The way to cut costs isn't compromising on the essential doctor patient relationship. It's attacking diseases directly. Funding community wellness programs to prevent obesity and the associated illnesses would go a long way for saving money. In addition prioritizing our scientific funding to medical research to discover cures, not treatments for diseases would also be of great benefit. For instance if the IVIG treatments pan out for Alzheimers, you're looking at hundreds of billions of dollars saved over the coming decade.

nevermind.

 

[UrshumMurshum]

nevermind

HMOs and ACOs do not pay for my education. I pay a large segment of my education, with some subsidy from the states depending on if you go to a public school in your state. In graduate training, medicare funds the training of residents, but the value of the work the residents put in FAR outweighs the amount of cost of their training. In any event, the funds are directed from society to deliver good quality doctors, not to indoctrinate robotic minds to centralized policies. That defeats the purpose of training them, because tools make for horrible doctors.

Bureaucrats have no ability to create resources, they are dependent entirely on the productive sources of society to obtain their wealth and through their own designs decide how to distribute the resources. The free market is what has the resources and the fundamental assumption is to give these resources to partition a segment of it towards health care. Of course doctors are dependent on resources to deliver health care, but to claim that it's the ownership of bureaucrats who have the resources is just flat out wrong. As I see it and I was arguing - the management of these resources towards centralized planning defeats the original purpose of using these resources - towards patient care and health care. Therefore I am attacking the way the resources are being used, not the resources themselves.

Pharmaceuticals are not the only ones conducting research. In any event, as I read recently from a doctor's blog - treatments for many common illnesses have not changed over the past few decades. There really has not been a plethora of new drugs coming out, probably because of the very high financial bar imposed by the bureaucratic regulations that have strongly inhibited pharmaceutical innovation. To the detriment of many patients. Again, I am arguing against the system, not the application of resources. To say that because the system provides the resources currently we must therefore blindly obey what they say is just wrong. Like really wrong. So wrong it's almost dangerous.

What I meant by attacking diseases was research. Medical innovation. Actually targeting new pathways to diseases to give clinical doctors better and stronger weapons to attack the disease. That's not standardizing anything, research comes out every day, and it just provides doctors more weapons to choose from, not necessarily which weapons they must choose. Of course if a treatment or drug proves so successful that it becomes the logical choice of treatment then it will de facto standardize treatment, not by a centralized law or overmind, but by common sense. That is realistically the only way forward, we have to launch offensives against illnesses because I realize the patient volume burden is getting to be so substantial that it's just not even practical to have personalized medicine. But the solution isn't to just capitulate, give up, and retreat further. Stand your ground. We have to attack it from another angle. We have to change the system, cut regulations, allow for easier medical innovations, and allow for easier access to research because cures or treatments that can impact diseases - I cited IVIG for Alzheimers, can ultimately rescue A TON more resources than what would otherwise have been used in the conservative "same old same old" model where we disallow medical innovation, retreat back on patient care, and create statistical models to deal with the current patient burden.

I might be idealized, I don't compromise when it comes to my patient care, and I **** well am not going to listen to some pencil pusher in some office tell me how to treat my patients.

 

[411309]

I really don't like it. Just seems creepy to me. Sorta seems like were just throwing people into categories and treating them as a whole rather than an individual, as if we lose focus on the fact that we are serving these people's needs individually by treating them as if they're anther cog in the machine.