Over on CNN.com, I came across one of the most wrong-headed arguments against health care reform that I’ve ever seen in my life. Here’s the gist of it: we can’t reform the health care system until doctors are nicer to their patients. Perhaps unsurprisingly, this gem comes from a TV pundit.
The talking head in question this time is the lamentable Glenn Beck, CNN’s go-to ‘irreverent conservative’ voice. In an online Op-Ed, Beck details his miserable experience with doctors after getting surgery and works very hard to turn his displeasure into an argument against health care reform—with little success.
Long story short, Beck had surgery on his butt, things went horribly awry, and he was seriously medicated in order to dull the pain. The combination of drugs Beck received “took [him] to an incredibly dark place…Every time I closed my eyes…I would see horrific, unimaginable images of death and after two and a half days…I was literally suicidal. It felt like there was no hope…”
Beck’s despair went more or less ignored by doctors, who he says "treated [me] more like a number than a patient. At times, staff members literally turned their back on my cries of pain and pleas for help. In one case a nurse even stood by tapping his fingers as if he was bored while my tiny wife struggled to lift me off a waiting room couch."
This is unsettling stuff that I wouldn’t wish even on Glenn Beck. Predictably, but not unjustly, Beck uses his experience as a launching pad to assert the importance of compassion and bedside manner in medical professionals. Here here! But then Beck really, really jumps the tracks:
"…I don’t want to hear anymore about universal health care or HMOs or
the evils of insurance companies until each and every hospital in this
country can look me in the eye and tell me that they their staff is
full of truly compassionate people who treat their visitors like
patients, not products. Hire and train the right people, and then and
only then come talk to me about everything else you need.
"Our politicians are right; we do have a health care crisis in this
country. But it’s not going to be fixed by them, it’s not going to be
fixed by some government agency, and it’s certainly not going to be
fixed by throwing more money around. No, if you really want to fix our
healthcare system, then look no further than the word ‘healthcare’
itself because the secret is right there."
In other words, Beck wants to put the ‘care’ back in ‘health care.’
Fair enough. But the behavior of health care professionals is
inextricably linked to the health care system in which they work.
Granted, it’s not as though there’s a simple, direct line from
institutional design to the hearts and minds of doctors; but systems
set incentives and define interests that ultimately encourage, reward,
or penalize certain behavior—including negligence and coldness.
While Beck is being tight-lipped as to the exact surgery he underwent,
he calls it a "routine" outpatient surgery, so there’s a good chance it
was a lackluster procedure that had a low reimbursement rate attached
to it. That would mean that the surgeons who worked on Beck had an
incentive to sew him up ASAP in order to move on to more lucrative
procedures. When it comes to reimbursements for doctors, there’s a
hierarchy to medical procedures, and if you’re at the bottom of it, God help you.
You can thank our fee-for-service system for this incentive structure.
By scaling reimbursement rates to the procedures—not effectiveness—the
system already de-prioritizes the health of the patient in favor of the
complexity and professional prestige attached to certain procedures.
Moreover, as Karen Davis from the Commonwealth Fund noted last month,
our current system rewards "inputs," i.e. things like hospital stays,
physician visits, procedures—and readmissions. Therefore hospitals and
doctors have no incentive to try to "ensure [that] we won’t come back
through their doors."
I’m not saying that Beck’s doctors schemed to botch his operation so
that he would have to come back; but you can see how a system that
actually rewards future complications might encourage a certain degree
of unconscious negligence. Alternatively, you can see how the volume
imperative could lead to less than thoughtful care in order to cycle through patients.
Beck also makes a point of illustrating how impatient a nurse was
toward him. We need to cut nurses a little slack here—they often find
themselves at the bottom of the medical staff food chain. Back in
October, Maggie noted
that the life of a nurse is an extremely stressful one, and that this
stress has led to a nursing shortage. At the average hospital, eight
percent of the nursing slots remain open.
Is stress an excuse for being a jerk? Not really. But part of the
reason nurses are in short supply is that our system doesn’t reward
generalists—those professionals who are most likely to address patients
as integrated wholes rather than the objects of specialized procedures.
In fact, our health care system is highly biased toward specialists.
Only about 15 percent of doctors in training today will become primary
care physicians, because of low reimbursement rates and huge workloads.
The low reimbursement rates come from the fact that the Relative Value
Scale Update Committee—the folks who update reimbursement fee
information every five years—ties reimbursement rates to the
“complexity” and “objective difficulty” of procedures. And as Maggie pointed out recently, the Committee is composed primarily of specialists.
Consider these numbers: In 2004, the average specialist salary was
$298,000, compared to $161,000 for primary care physicians. The type
of care we associate with compassion and humanity—ongoing consultation,
integrating information over time, building a relationship—actually
ends up being a raw deal for medical professionals.
None of this means that there aren’t doctors that rise above our
mixed-up system. But let’s not claim that medical professionals act in
a vacuum, as though our health care system doesn’t put very specific
pressures on them. Just as importantly, let’s not forget that in this case, the medical staff did have to
put up with Glenn Beck—surely enough to put anyone in a foul mood.
It may seem like a waste of time to take on Beck. He’s not really the
type of person a respectable wonk worries about. But he has an
audience, and now he has a new sound bite: there’s nothing wrong with
our health care system that nicer doctors won’t fix. That’s unfair,
uninformed, and just plain wrong. Unfortunately, it’s exactly the sort
of superficially snappy meme that you can imagine making the rounds in
the media, especially amongst bloviators who object to health care
reform. So I wanted to nip this one in the bud. We don’t need another
contrived escape hatch for those opposed to systemic change in health
care.
The most significant decision you make in setting up your medical care is choosing a hospital or medical center. A smart medical consumer will zero in on the hospital. One reason is that all hospitals are not created equal. Another is that once you’ve chosen a hospital, you’re well on your way to getting your personal medical care system in place.
Doctors function as part of a larger organization. When in search of a treatment or diagnosis, rarely do you consult and receive care from just one doctor. As a consumer, you need to think in terms of the larger organization and choose on the basis of the quality and availability of resources, for that one choice will determine every other aspect of your health care.
Many physicians will serve at that hospital. When you work with a doctor, you are really working with a team of doctors, a team of generalists, specialists and subspecialists continually working together through consultation and referral. No doctor works in a vacuum, so you want to know your doctor has good teammates, which means that other medical personnel are already part of your care. They rarely see a patient without ordering something or interacting at least informally with someone else.
The competence, timeliness and judgment of these teammates can have a great impact on the treatment you get, without your necessarily knowing it. Although you did not select these other medical professionals individually, you have de facto selected them by choosing a particular institution. Every patient benefits from the connections between physicians that evolve over time. Collegial relationships are part of an institution’s package.
What you are looking for in a hospital is internal quality control. A hospital will allow only people with a certain level of credentials to get on staff. You want to know that the hospital you go to has a level of quality control that’s extremely rigorous and goes across all the specialties.
What kind of hospital to go to? Tertiary Medical Centers? Pick one that’s affiliated with a medical school. Tertiary hospitals are full-service, major medical centers. They have a helipad, a full surgical team (doctors, an anesthesiologist and specialized nurses) not merely “available” but actually ready to take care of you and every specialist and subspecialist known to man.
There are not just neuosurgeons, but neuosurgeons who do backs, neurosurgeons who do tumors inside the head, neurosurgeons who work with seizures. There are ENT (ear, nose and throat) people who specialize in ears, who specialize in noses, who specialize in cancer, and so on. Sometimes you need all this, sometimes you don’t. But what you’re getting at a major medical center is predictability in circumstances that may be unpredictable. Whatever you come in with, they’ve seen it before.
A hospital is all about the people who staff it. It’s not just about a pretty place or the lastest equipment. A fine major medical center may have dingy offices or hallways, but when you get down to the issue of what’s being done for you, don’t reject an old physical plant. Because it’s not the machines that are important, but the people who run them!
What you want from a hospital is staff with expertise and judgment. You want people who have seen what you have as well as variations of what you have so they see the patterns and understand how it all fits together, diagnostically. You want to be prepared for every contingency!
Did Beck do his homework? Or did he just rely on his so-called journalistic skills? From what I’ve read about him, those skills seem to be debatable. Give us back the good ole CNN journalistic reporters of the ’90s!
It was a hemorrhoidectomy. You can read about it here on the exellent blog of an ER doc. (I’m not sure if the linky thing will work.)
http://allbleedingstops.blogspot.com/2008/01/couldnt-happen-to-nicer-guy.html
There are an awful lot of people who would pay to participate in the bungling of Glenn Beck’s hemorrhoidectomy.
This is a case of resource management and economics. When the profit margin for medical centers is tight, they have no control of reimbursement rates and little control of payroll for professionals who recieve a particular standard. Answer; squeeze as much as you can out of what you have, nurses have more patient’s to care for (thus are in a hurry, I am sure the guy dieing in the other room of an MI would rather more nurses than wait for glenns butt to be looked at) Doctors actually get “performance” bonuses based on the number of patient’s they see. If you see more and more patients, there will be a critical mass, you will make mistakes and there will no time to be nice. If Beck doesn’t want to be “treated like a product” than he needs to seek out medical care that is not profit driven, he subverts his own point really.
Nick:
“…the behavior of health care professionals is inextricably linked to the health care system in which they work.”
I think you mean system based outcomes related to providers, or something similar. To me, behavior can be ethical (or not), satisfying to staff or patients (or not), and much of this is doctor dependent and has absolutely nothing to do with the “system” in which they practice. I am sure there are extremes, ie, if you are working in a bottom decile hospital and you are unhappy, it might be reflected in your approach, but that is more of an exception. Show me some data and make a believer out of me.
Brad
Maggie,
This story highlights all the problems in medicine if you assume Mr. Beck was truly treated the way he describes. Usually the post op care is designated to lower level practitioner these days (residents in training or nurse practitioners) since the services for surgeries are bundled, meaning the surgeon is paid the same whether he returns to see the patient post op or not. In the hospital where I work, it is becoming rarer to for the surgeons even see a patient that spends a few days in the hospital post op. Thus you get rather impersonal care from providers who have no relationship previously with the patient and come to view their jobs with a widget mentality. The whole process seems to be becoming more dehuminizing.
A part of the problem does lie in the way providers are compensated. If you pay largely for the procedure, then what you will get is a concentration on the system performing that procedure and the place to cut the corners in time and energy are on the post op side or in taking time to explain the process to the patient, which is very helpful in releiving thrir anxiety over the whole process. But the current system provides little incentive for this. Proceduralists, for the most part, conciously or unconsiouly, are doing proceures for which they are well compensated. If I now have a choice of spending my time doing another well paid procedure or spending my time seeing my patients post- operatively, what do you think will happen if their is no additional payment for seeing and talking to the patient? The surgeon will chose to spend his time in the operating room which is really what he wants to be doing anyway and designate this care to someone else if he can.
This is why the cognitive specialties are slowly fading into oblivion and proceduralists are becoming wealthier and weathier. And this is also why costs are increasing overall for health care.
As an internist, if I recommend some treatment for a patient that doesn’t involve some outrageously expensive cost, and it proves effective, I save the health care system alot of money, but my compensation pales to what the proceduralist will make if he sees the patient and reccommends a procedure. What do people expect in this perverse system of incentives that does nothing to promote cost efficient medical care?
I hear stories like Mr. Becks on a regular basis since the hospitals and proceduralists extract themselves from the picture as quickly as they can once their procedure is accomplished, leaving the patient to the primary care docs and nurses to do the good work of treating the patient in a compassionate way. Bottom line, compassion doesn’t pay the bills in health care, although it’s the right thing to do.
The U.S. health care system is the best in the world except when your death can be prevented by access to timely and effective health care.
And Glenn Beck? I stopped paying attention to him when I found out what he did to all those dogs (pit bulls).
the commentary above states that doctors have no incentive to keep patients from coming back, but ignores the fact that there is a global period following procedures during which care provided is not reimbursed. isn’t that an incentive?
what performance bonus for volume is dr matt referring to?
and
“Is stress an excuse for being a jerk? Not really. But part of the reason nurses are in short supply is that our system doesn’t reward generalists—those professionals who are most likely to address patients as integrated wholes rather than the objects of specialized procedures.”
someone please explain that link to me.
sometimes the nature of problems lends itself to be taken care of once. if specialists continued to follow them annually, there would be a howl of protest from the patients about wasting their $$$.
still, i wish we could differentiate in these discussions the are many specialists who need to follow patients for the rest of their lives.
lastly as a specialist i find the insinuation that specialists do not have these characteristics and do not perform these functions particularly insulting(“The type of care we associate with compassion and humanity—ongoing consultation, integrating information over time, building a relationship”).
anonymous–you’re right, re-reading that, it comes off as too harsh to specialists. my apologies. what i was trying to get across is that beck’s desire for doctors to “see me as a person” is hampered by the fact that our system takes a position of compartmentalized, disconnected care–not that specialists were somehow less compassionate people than PCPs.
Brad–all i’m saying is that, the way our system works, it’s entirely rational for doctors to de-emphasize bedside manner. if we want to guarantee that doctors are as “nice” as possible across-the-board, we can’t ignore the incentive structure in which they work.
Glenn sounds like a big baby and a whiner.
Post-surgery hurts. The staff are not your personal servants — even if you don’t feel well. You are not the only person they’re caring for and most of the time somebody else is in more need than you — which is a good thing!
I’ve been in and out of surgery centers multiple times in the past few years and I have yet to meet nursing staff who weren’t nice.
One thing I’ve surmised from reading MediBlogs is that if you want to be treated nicely in a health care setting then you need to be nice yourself. That means you wait your turn and you act like an adult.
It’s too bad he used his access to the national media to spout off about his personal experience.
As an er doc hearing him comlain about a 20 minute wait for a non emergency- clearly indicates most people expect more than we can deliver.
Also since he was a celebrity – he got more pain meds than he needed because he kept complaining of pain
Instead of admitting him, he should have been given a pain shot and sent home. When i had minor surgury i didn’t think i could make it at home, thank god the nurse and my wife essentially picked me up and threw me in the car. It was the best thing that could have happened !!
To claim nurses and physicians are not caring is absolutey ludicrious. Lets have Beck lift 300 lb patients up all day — most nurses and doc’s i know and are very caring. No one including maggie ever suggested that area as a focus in the health care monetary crises mtopinka
“That would mean that the surgeons who worked on Beck had an incentive to sew him up ASAP in order to move on to more lucrative procedures. When it comes to reimbursements for doctors, there’s a hierarchy to medical procedures, and if you’re at the bottom of it, God help you.”
Great point you made here. Too bad it actually supports Beck’s conclusions. Under a nationalized health care system incentive, on ALL levels, is eliminated…God help us all!
There is an argument that bigger is better. Bigger schools have bigger alumni networks, graduates have more networking opportunities, etc. Adjusting for class size is not obviously right and really hurts big schools like Georgetown. Really, it depends on where you want to work. If you want to work on Wall Street, go to Harvard or Yale. If you want to work in DC, Georgetown. If you want to work in Tallahassee, go to University of Florida. If you want to work in Maui, go to University of Hawaii. These one-size-fit-all rankings have limited value. If you are really smart, don’t go to law school.
Did Beck do his homework? Or did he just rely on his so-called journalistic skills? From what I’ve read about him, those skills seem to be debatable. Give us back the good ole CNN journalistic reporters of the ’90s!