Likewise,

The happiest days in a doctor’s life are the day he get his license and the day he figures our how to make a good living without it.

I.e. This profession is rapidly going to shit in hand basket and everybody is pretending not to notice.

The process for making rules is long and rigorous, and new rules often have to go through multiple agencies and departments. It will also take many more people with specific expertise to carry out the various parts of the law, and hiring in itself can be a slow process in the federal government.

“The average rule takes 18 months, which means that there are many of those that take two or three years to do, because they have controversy or they require integration with some other rulemaking process. So this is a tsunami of rulemaking that has tipped the Department of Health and Human Services,” said Michael Leavitt, HHS secretary under former President George W. Bush.

I like to think of the new health reform law – which, if anything, is more of an insurance reform law – as being similar to the creation of the Department of Homeland Security. Both laws are attempts to address and correct significant institutional problems with massive amounts of money and additional layers of government bureaucracy. Both are more accurately thought of as massive spending bills that take advantage of a “crisis” to funnel billions towards specific private sector industries while the benefit to the greater population is dubious and difficult to verify.

Let me put this another way.

If the Federal government were a small town council then their response to a crime spree would be to spend tens of millions of tax payer funds to purchase an M1 Abrams tank and parade it in front of city hall. This after salesmen from General Dynamics spent millions of dollars taking various city council members on exotic vacations and to fancy dinners and conferences where they were given presentations on the crime fighting and deterrent effects of the M1.  Town citizens who haven’t been a victim of crime since the tank arrived are more than happy to give credit to the high spending council.

Americans generally support massive spending bills – like a big, expensive tank that sits in front of city hall – because the perception is that anything that is expensive must work. The economic reality is that everything else being unchanged, the prices for goods and services in a system will invariably increase in response to any massive infusion of cash. This is already beginning to happen to health insurance premiums and the funding hasn’t even started.

The political reality is that most Americans wanted secure affordable health insurance – hence, the name of the new law.

The reality is that most Americans are not going to get it.

The vuvuzela is like a straightened trumpet and is played by blowing a raspberry into the mouthpiece. The player’s lips open and close about 235 times a second, sending puffs of air down the tube, which excite resonance of the air in the conical bore. A single vuvuzela played by a decent trumpeter is reminiscent of a hunting horn.

Americans wear their team colors and cheer . . at specific exciting times during the game. Soccer fans wear their team colors and blow vuvuzelas . . . continuously during the match. Oddly, the only time the drone appears to abate is right after a goal.

. . the eye actually has an angular resolution of 50 cycles per degree. Therefore, if we were to compare the resolution limit of the eye with pixels on a screen, we must convert angular resolution to linear resolution. After conversions are made, a more accurate “retina display” would have a pixel resolution of 477 pixels per inch at 12 inches, Soneira calculated.

It’s understandably easy for Apple and Mr. Jobs to –   s  t  r  e  t  c   h  -  the truth a little since very few people know that the resolution of the human eye is most commonly measured in cycles per arc-minute and that a calculation would require changing cycles per degree to arc-minutes per cycle (1 cycle/degree = 0.01 arc-minutes/cycle) divided by 2 since 2 pixels are needed to define a cycle, and this result is taken and divided into the number of degrees of the area to be viewed (which itself is a function of distance and angle of view) to calculate the total number of pixels in the viewing area and then divide by the area in inches to get the number per inch.

Dr. Soneira refers to this truth stretching as “marketing puffery” which is endemic in the consumer electronic industry. It’s so bad that Sharp recently tried to convince consumers that its  Quattron TV line includes a FORTH primary color in addition to the usual three of Red, Green, and Blue. Never mind that all you need to create any color including black and white is the three primary colors hence, the reason they are called primary colors.

This is like when the little known Greek Philosopher Sharpacleze tried to add mud as the fifth element to the ancient 4 elements of Earth, Water, Air, and Fire. A confused Plato asked Sharpacleze what is so elemental about mud since it can be formed by combining Earth and Water, to which Sharpacleze replied, “it’s better for marketing”. This is true. If it’s anything that intellectually lazy American consumers will respond to, it is the concept that if x is good then x+1 is even better even if it makes no sense.

First there is Iron Man aka Tony Stark who’s life is dependent upon an “arc reactor” implanted in his chest that is made, in part, out of the metallic element palladium which, along with rhodium, ruthenium, iridium and osmium, is a platinum group metal with widespread uses as a catalyst, in electronics, and even as jewelry.

I have no idea how the arc reactor is supposed to generate such a massive amount of power coming from such a small device without an obvious fuel source. And what does this have to do with Palladium? Actually, there has been theoretical work done in the field of “cold fusion” (i.e. generating energy from the fusion of two hydrogen atoms at room temperatures and one atmospheric pressure) utilizing palladium as the catalyst. But no actual device has ever been created or proven to work.

However, Mr. Stark is stuck with this palladium arc reactor in his chest and it is causing toxicity from the palladium manifesting as great looking engorged veins that coarse up his chest to his neck and make really interesting 90 degree turns giving one the impression that this is . . not natural. Which is just as well since the vast majority of branching patterns in nature do not form at 90 degrees like a microchip. If anything, this should have looked like a fractal.

And what is palladium toxicity? It’s not uncommon that direct contact with palladium as with other metals can cause dermatitis which is a localized inflammatory skin reaction. There are no known systemic effects of palladium in the literature even though there have been studies showing palladium’s toxic effects on cells in vitro. If anything, Mr. Stark would have had a raging case of contact dermatitis involving the skin around the implantation site. I suppose the itching from this skin reaction alone would be enough to make him get drunk, put on the iron man suit, and go skeet shooting watermellons at his birthday party. But I digress.

And what about the “treatment” of “lithium dioxide” given to Mr. Stark for his palladium toxicity? Lithium is an element with a valence of one meaning that it can only form a single chemical bond. Two lithium atoms can bind to a single oxygen atom to from lithium oxide (Li-O-Li with two lithium atoms in place of the two hydrogen atoms in water H2O). Or two lithium atoms can combine with two oxygen atoms to form lithium peroxide (Li-O-O-Li). But there is no chemical way to get lithium DIoxide O-Li-O. Evidently, Tony Stark was the victim of medical quackery (and bad script writing) although there was quite a placebo effect on the a fore-mentioned microchip venous dilatation pattern on his skin which disappeared within seconds of being injected with . . something that was not “lithium dioxide”.

So Mr. Stark makes an arc reactor out of a new element that he synthesized himself using a do-it-yourself room sized laser. Don’t you need a particle accelerator the size of a small country to create a new element and that this element would be extremely radioactive and unstable and have a half-life measured in seconds? Ok, I’m not going there.

Probably the most realistic aspect of Iron Man 2 was when Tony Stark promoted his personal assistant, a woman with no formal business training, to be CEO of a multi-billion dollar company. This I could see happening.

Pediatricians’ pay took a tumble. Hospital nurses questioned why we took on so much responsibility and worked such long hours for paychecks significantly smaller than theirs. Insurance companies kept ratcheting back both on our reimbursements and on the level of patient care until there was little left.Patients naturally became disgruntled. They got angry about the insurance denials and took out their frustration on our office staff. We needed to see more patients to make ends meet, so the waiting room became more crowded and waiting times increased. I had nightmares about running hours behind, patients yelling at us to “hurry up!” There were days when we would skip basic necessities like eating lunch or going to the bathroom; we didn’t want patients to wait. Days “off” were often spent seeing patients, catching up on paperwork, and calling back families who had questions too lengthy for regular office hours. Lunch was typically spent tackling the accumulated stacks of charts and callbacks to patients from the morning, in addition to holding office staff meetings or attending meetings at the hospital. A typical call night would entail the beeper going off every five to 10 minutes throughout dinner, and my often spending a good part of the night at the hospital. In the morning we’d arrive at the office and try to smile through another full day of patients.

Sounds like a dream job. Yep, and a great investment: spending 7 years of medical training to make less than what an RN makes with 2 years of training (kudos to the happy RNs who figured this out before it was too late).

Dr. Li encountered the paradox of traditional high volume primary care. Insurance reimbursement rates fall so the provider sees more patients but higher volume means higher overhead costs and more non-reimbursable obligations (phone calls, medication refills, paperwork) and therefore less take home pay. Too bad Dr. Li didn’t consider changing to a concierge medical practice model.

In Ohio – where this case was filed – a plaintiff in a medical malpractice case is required to obtain an “affidavit of merit” from and “expert” witness essentially stating that the case is legitimate from a medical standpoint. Apparently, the plaintiffs attorney was unable to locate a physician to sign an affidavit. Maybe it was because . . I don’t know. . the case had no merit?

The plaintiff was granted two 45 day extensions as they searched the Ohio country-side in vain for a medical professional to certify the case. After several months, Dr. Kirsch was dropped from the suit and according to Dr. Kirsch’s malpractice insurance company, the cost of “defending” this suit on behalf of Dr. Kirsch came to $9,120.85.

And like other health care costs, this one does not evaporate into the ether. This cost – and who knows how many thousands of other cases like this each year in the US – add to malpractice insurance premiums and likely eventually find their way into the health system as a whole in the form of higher costs. In short and as usual for litigation in this country, we all end up paying the costs of excessive litigation.

Of course, the US is one of the few countries in the world that does not have the so-called “English Rule” or to put it bluntly, the loser pays (the winner’s legal bills). The rational behind this rule is not to impair an injured party’s access to compensation for legitimate cases but to impede the type of gaming of the system that goes on too frequently with personal injury attorneys. Dr. Kirsch’s case is just one example of suing every physician who ever saw the patient regardless of merit or encouraging prospective clients to file suits by taking them on contingency.  These tactics  are designed to maximize the statistical probability that at least one case will yield a large settlement before trial thus minimizing risk and maximizing reward for the firm.This is especially important since the majority of malpractice cases that go to trial are won by the defendant! The key strategy is to cast a wide net and try to settle early.

But as we see in Dr. Kirsch’s case, these aborted merit-less cases still incur costs in the initial and intermediate litigation period that must be compensated for. A 1992 analysis of a 1980s era experiment in Florida with the English Rule found that that not only were more claims dropped in the initial litigation period with fewer cases being settled but cases that went to trial had a higher chance of success and settlements were generally larger, all of which suggests that the merit quality of the cases improved overall.

Ohio’s 2005 statute that requires an “affidavit of merit by a properly qualified expert with respect to each defendant against whom expert testimony is needed” also allows for extensions to made for “good cause.” What causes would be good? How about not being able to find a qualified expert witness to certify a case as having merit because your case has none? It would seem that this statute is somewhat self defeating in its aim to reduce costs by limiting access to only cases with merit. Either the plaintiff is able to dredge up some paid expert with questionable qualifications to certify the case or waste even more time and money with extensions trying to find any expert to certify a case that even the expert prostitutes won’t touch! A better system is to utilize a pretrial screening panel that decides the merits of a case and has been shown to improve case quality and reduce costs.

Just as there are plenty of wasteful medical practices that increase overall costs, there are wasteful legal practices that increase overall costs and measures can be put in place for both without limiting access to medical care or to be compensated as a result of injuries from medical malpractice.

From 1999 to 2007,  35 medical facilities of Kaiser Permanente in Northern California, were given financial incentives  for ensuring that their patients got regular screening for diabetic retinopathy and screening for cervical cancer – eye exams and PAP smears*.

The results were less than stellar. In eligible patients (i.e. diabetics and sexually active women without hysterectomies) over 4 years, the rate of screening for diabetic retinopathy increased a little over 3 percentage points from 84.9 to 88.1% and over one year the rate for screening for cervical cancer increased by a paltry 0.6 percentage points. And then it got worse.

After these financial incentives were stopped, the screening rates for these tests fell dramatically to levels that were significantly lower than they were before the bonuses were started. After the incentives were stopped, screening rates for diabetic retinopathy dropped to 80.5% over 4 years and the screening rates for cervical cancer dropped to 74.3% over 5 years. What is going on?

This is yet another example of how economic motivation theory can be very counter-intuitive. One would assume that performance would increase linearly with increased rewards but in many contexts researchers have found the opposite effect. The mechanism is thought to work this way; an external reward or punishment (apart from base compensation) has the effect of decreasing  internal motivators (based on autonomy, mastery, and purpose) so much so that this negates or even reverses the positive effects of a person’s external motivators (the drive to earn more) such that their total motivational drive and hence, their work performance, is decreased. Economists say that the internal motivators are “crowded out” in these cases.

The financial incentives in this study were given to be distributed throughout each facility rather than to each physician and as part of this program regular reminders for screening exams were sent out to staff. The modest but statistically significant increases in the rates for these two screening tests were likely as a results of the regular reminders rather than any financial incentives (unfortunately there was no control group without incentives to test this).

But the negative effects of monetary incentives on performance can clearly be seen after the incentives are discontinued. This is what economists call “motivational spillover.” This is what happens when you start giving someone an external or financial motivation to do something that they were already doing as part of the internal motivators of their job (mastery and purpose). Take, for example, the economic parable of the man and his lawn.

The story goes that a man was upset that his neighbor kids would always play on his lawn and damage it. So he decided to pay each child to play on his lawn. The surprised kids gladly accepted. After a few days the man told them that he could only afford to  pay them half of the initial rate. The kids accepted this reduced rate but were less then enthusiastic. After a few more days the man cut his pay to almost nothing and the children were so upset that they left, vowing never to play on his lawn again unless he increased their pay. Problem solved.

In this case, the man’s pay “crowded out” the kid’s internal motivators (autonomy, and fun as the purpose) for playing on his lawn and the dominance of the external motivator spilled over into further activity. In the case of the medical incentives, regular screening exams are supposed to be part of what the staff at the clinic does and involves internal motivators as part of their autonomy, mastery, and purpose (taking care of patients) and it is these internal motivators that were impaired by the incentives. Clearly the clinic lost far more than they gained by instituting incentives and then discontinuing them. Interestingly the screening rates increased slightly after incentives were reinstated but did not get back to the original levels. Thus there was a net loss in performance even after restarting the incentives.

This is likely the reason why small monetary or other incentives for performance rarely work in socialized medical systems.

This study is consistent with a growing body of evidence that pay-for-performance does not work and can reduce overall care, continuity of care, and impair further efforts to improve care. So what is to be done?

The first thing is to try and get policy makers to understand that efforts to increase overall compensation by relatively small incremental increases tied to performance are very unlikely to work and as in the case above, will lead to minimal gain for money spent and may lead to a net loss in performance.

To properly compensate primary care practitioner’s level of education, effort, and time, a significant net increase in base pay should be provided and performance should be enhanced or maintained by efforts that maintain or improve the staff’s perceptions of autonomy, mastery, and purpose. For example, money is probably much better spent on regular educational activities for the staff that enhances their intrinsic motivators. I.e. education for staff members about the importance of and new methods of preventative care is much more likely to be effective than rewarding and/or punishing them for specific outcome indicators.

*The BMJ study did find that diabetic control and blood pressure control did improve significantly over the time span of the study however, there were no internal or external controls for these measures nor any way to differentiate them from other variables such as notifications and increased staff awareness of these measures that may had significant influence and so these measures were not included in the results of this study.

The socioeconomic study of what motivates people is a fascinating field of study, not the least of which is because of how counter-intuitive it is. For example, it seems normal to assume that the more someone is rewarded for their efforts, the more effort they will put forth toward those rewards. These rewards (increasing salary, bonuses, benefits, status, etc) are known as “extrinsic” motivators and for  menial and/or repetitive jobs that have little need for regular complex planning, evaluation, or creative problem solving like unskilled manufacturing, manual labor, or GOP membership, the system works as expected with bigger monetary rewards leading to bigger efforts.

However, this simple linear model of economic motivation begins to break down as “intrinsic” motivators start to dominate the picture. Intrinsic motivators are such psychological variables as the perception of autonomy, mastery of the task or role, and purpose. It turns out that not only do extrinsic variables not work as predicted for motivating a worker tasked with performing complex work that requires thought and problem solving skills but this kind of motivation actually reduces job performance (particularly time spent per task).

This counter-intuitive result is what economists refer to as “crowding out” of the intrinsic values with the extrinsic values. The offer of an extrinsic reward tends to cheapen or dampen the intrinsic rewards and the negative effect on your intrinsic motivations is enough to negate and even reverse any positive extrinsic motivators. External motivators tend to come with conditions that hamper autonomy, mastery, and purpose. A job that was once “fun” has now become burdened with the demands of higher expectations even though a reward is bundled in there somewhere. Extrinsic rewards also impair creativity and thinking by narrowing down the focus of the task (i.e. getting it done faster or more efficiently).

The key to having a happy employee who’s job involves cognitive skills, creative thinking, and problem solving is to 1.) ensure that they are paid enough to close the gap between what they are paid and what they think they should be paid based on their education, training, and experience so that base pay is no longer an issue and 2.) allow the intrinsic motivators of autonomy, mastery and learning, and purpose to flourish. There is a great “whiteboard” animation of a presentation on this by Daniel Pink for those who think I’m crazy. This is not neo-hippy, socialistic, Montessori style, feel-good new management methods. This is real world and is already yielding benefits for companies like Google.

This got me thinking about physicians and motivation. We like to say that what motivates us is the chance and desire to save lives and improve lives. That’s purpose. We like to be our own boss and work on our own schedule. That’s autonomy. And we like what we do. We find it interesting and strive to learn more and improve our skills. That’s mastery.

With so many intrinsic motivators for doctors, why then, do many appear to defy the evidence for the establishment of motivations stated above and simply increase their work loads to obtain the higher salary or bonus or base income? I have seen physicians who round on 15-20 complex hospitalized patients in an hour and others who see a complex medical patient in the span of a 3 minute office visit. Then there are those who push the boundaries of the vast gray area of test and procedure indications (like ordering expensive nerve studies on every diabetic patient regareless of symptoms) and then there are those who commit outright fraud.

Many doctors are employees but the type of excessive extrinsic motivated behavior I’ve seen comes from physicians who are self-employed, while the studies for the effects of extrinsic and intrinsic motivators were done mostly in the context of employee-management relationships. Is this the reason for the discrepancy? I don’t think so. Self-employed doctors function as employee-owners, doing the brunt of the work for their practices while being beholden to insurance companies and the government for their compensation. It’s still very much of an employee-like relationship with the promises of increased compensation for increased work. The same basic motivator mechanisms should still apply.

I believe that the problem starts with insufficient compensation which in of itself is an extrinsic motivator that compels the worker/doctor to try and close the gap between effort and proper compensation. This seem to help explain why higher paid specialists, though they work hard, tend not to follow a pure profit motive pattern. Surveys have found that specialists are more satisfied with their jobs than their lower paid colleges in primary care. Specialists are also more likely to be self-employed (autonomy) and in my experience, they tend to express more interest in and a desire for mastery of their field and skills than many primary care docs.

I believe that the second culprit is the per-patient or per-procedure way that doctors are compensated. This a system that already has multiple levels of bonus and reward built into it just like the unskilled laborer who gets paid more to move more rocks, so to do physicians get paid more to see more patients. So how does a physician with a high level of intrinsic motivators convert to a profit driven machine with the extrinsic motivation profile that is on par with an unskilled rock mover?

The key concept is that they convert the essence of their job from creative problem solving of multiple complex tasks to following more linear basic rule sets. In short, they go from practicing medicine to practicing “cookie-cutter” medicine. You would think that this would apply more for specialists who often deal with more linear decision making for their many technical skills and procedures they perform but I’ve seen profit driven “cookie-cutter” medical practice behavior more often in primary care docs and I think that it is their lower compensation that is to blame.

“Cookie-cutter” physicians try to minimize risk while maximizing profits. One way to do this is to minimize the time spent with the patient and on complex problem solving. It is more efficient and profitable to perform a very basic linear diagnostic and treatment evaluation. If knee pain then –> MRI. If nervousness then –> prescribe sedatives. If fever –> antibiotics. If chest pain then –> cardiologist referral. If vomiting then –> gastroenterologist referral. Most of the complexities and nuances of medical care are tossed aside in favor of a rote if-then decision tree that can be done by any couch potato who’s watched too many episodes of “er”.

Usually, this type of medical care increases overall utilization of resources. Expensive tests and procedures are more likely to be ordered both because the physician believes that they reduce their liability risk  which they have acquired from spending too little time with too many patients and/or because they  increase profit. Medications are more likely to be ordered for each and every symptom because it takes less time to explain to and convince a patient – who is usually expecting some type of medication – why they need the medication than why they don’t.

Needless to say, this type of medical practice does NOT improve overall care quality or patient satisfaction and may very well  decrease  care quality in many circumstances. This apparent paradox in decreasing health care quality in areas of high health care resource utilization has been extensively studied using natural  geographic variations in Medicare spending.  These physicians tend to prescribe too many referrals, tests, procedures, and medications and they all come with risks. Physicians who practice this way are likely to be too aggressive with diagnostic modalities and treatments for certain subsets of patients. For example,  in patients with mild conditions in whom the side effects may outweigh the benefits or those with advanced disease for whom aggressive treatment is more likely to hasten death than to prolong life.

The study of economic motivation models may help to explain and predict that inadequate compensation is more likely to change physician motivation and practice patterns from an intrinsic system to an extrinsic profit driven system which increased health care utilization and ultimately higher costs for no quality benefits. This is particularly true for primary care practitioners and does not bode well for Obama’s new-American health care mecca.

There are some obvious solutions. First, pay primary care physicians an increased amount so that they are adequately compensated for their time, effort, and level of training and that this issue is “taken off the table.” Next, change the per-patient, per-procedure scheme to an annual fixed amount based on a set panel of patients.

Greed is “good” in that it leads to capital investment in macroeconomic systems but in the microeconomic context of skilled health care worker, greed – external profit motives – suppress intrinsic motivators and invariably leads to sub-par performance, increased costs, and decreased care quality and decreased satisfaction values among patients and physicians.

We prescribe antacid medications by the ton in this country, not because people’s stomachs have developed increased acidity, but because people in our modern society are generally overweight, like to eat large meals, and prefer fatty foods and things like alcohol, chocolate, and tobacco, all of which tend to worsen acid reflux.

Physicans like to prescribe many different types of antacids because the patients like them and there are no perceived down sides (except cost). In particular, we prefer the so-called, proton pump inhibitors (PPIs) like omeprazole (Prilosec), lansoprazole (Prevacid), esomeprazole (Nexium), pantoprazole (Protonix), and rabeprazole (Aciphex) because PPIs are the most potent inhibitors of gastric acid secretion available are very effective treatment of moderate to severe gastritis, reflux, and peptic ulcer disease. So of course, if PPIs are good enough for the serious gastric illnesses, then they must be great for just about everything else! Right?

Proton pump inhibitors are prescribed  for even the slightest bit of heart burn or dyspepsia even though there is no good evidence for the effectiveness of intermittent use of PPIs for the treatment of the occasional over-eating  syndrome or that they are better for mild conditions than over-the-counter Tums, Pepcid, or Zantac.

PPIs are also heavily used in the hospitalized patient, especially those in the ICU, where various conditions like sepsis, hypotension, hypovolemia, stress, medications, and increased intracrainal pressure are risk factors for the development of gastritis and ulcers. Often the PPI therapy follows the patient home from the hospital and continues to be prescribed long after the original need for it has been forgotten.

There have been concerns about long term acid suppressive therapy, but until recently there has not been much hard data on the risks. That has now changed with the addition of two studies appearing in the archives of internal medicine.

• If used within 14 days of the initial infection, PPIs  increased the risk of recurrent Clostridium difficile infection in hospitalized patients from 18 to 25%. Especially in patients over 80 and on antibiotics (for other infections).
• Long term (> 7-8 years) use of PPIs was associated with about a 25% increased risk of fractures of the spine, wrist, and forearm in postmenopausal women 50-80 years old compared to only an 8% increased risk with the use of other antacids. Interestingly, there was no associated increased risk of hip fracture and there was little difference in the measured bone mineral densities of women on PPIs compared to those not on these medications.
• Starting PPIs  within the preceding week was associated with an increased risk of developing pneumonia. This risk was not found with the use of antacids like Pepcid or Zantac.
• There is limited data to suggest that PPI use may decrease absorption of iron, calcium, magnesium, and vitamin B12.
• Several studies have suggested (thus far not definitively proven) that the use of PPIs decreases the effectiveness of clpidogrel (Plavix) when used to prevent a second cardiac event.

From 53 to 70% of prescriptions for PPIs are written for mild to moderate and intermittent conditions such as gastric reflux or dyspepcia for which the use of over-the-counter antacids may be safer, cheaper, and more than adequate. However, physicians must cringe at the idea of seeing a patient with mild, intermittent heart burn and simply tell them to stop eating large fatty meals and take Pepcid. If the patient takes the time to come for an expensive medical evaluation then they must get an expensive medication.

Thus it is said, the modern medical mantra: expensive is, as expensive does.