Why Doctors Hate Science

[Professor Yaffle]

Thank God doctors in the United States are free to treat patients as they deem best, free from interference by faceless bureaucrats. If bureaucrats were in charge, physicians might have to prescribe the newest hypertension drugs as a first-line therapy, do MRIs to diagnose back pain and give regular Pap tests to women who have had total hysterectomies. Oh, wait—they do. All these medical practices are common, despite rigorous studies showing how useless or wrongheaded they are. Definitive studies over many years have shown that old-line diuretics are safer and equally effective for high blood pressure compared with newer drugs, for instance, and that MRIs for back pain lead to unnecessary surgery. And those Pap tests? Total hysterectomy removes the uterus and cervix. A Pap test screens for cervical cancer. No cervix, no cancer. Yet a 2004 study found that some 10 million women lacking a cervix were still getting Pap tests.
It's hard not to scream when you see how many physicians, pharmaceutical companies, medical-device makers and, lately, hysterical conservatives seem to hate science, or at best ignore it. These days the science that inspires fear and loathing is "comparative-effectiveness research" (CER), which is receiving $1 billion under the stimulus bill President Obama signed. CER means studies to determine which treatments, including drugs, are more medically and cost-effective for a given ailment than others. A study in February in the journal Lancet, for instance, compared treatments for severe ankle sprains, concluding that a below-the-knee cast is superior to a tubular compression bandage. A 2006 study of schizophrenia drugs found that old-line antipsychotics were as effective as pricey new ones.
<snip>

http://www.newsweek.com/id/187006

[macdoc]

How much of this is

Cover my ass?

Profit driven?

Ignorance of current best practice?

In Canada the latter would predominate and there are programs to enhance physicians skills.

[paximperium]

My anecdotal experience:
How much of this is

Cover my ass? 50%

Profit driven? 10%

Ignorance of current best practice? 40%

[fls]

http://www.newsweek.com/id/187006

Do you know who she's reacting to?

Linda

[JJM]

I haven't followed this; but here are some opinions:

http://scienceblogs.com/insolence/2009/03/doctors_hate_science_more_like_sharon_be.php

http://www.sciencebasedmedicine.org/?p=381

[jimtron]

Thank God doctors in the United States are free to treat patients as they deem best, free from interference by faceless bureaucrats.

Ooh, I saw that Twilight Zone episode...

[Dr. Imago]

I couldn't have penned better, more succinct answers myself than the first two replies below the article...

Here's another thought, the "useless" or "wrongheaded" medical testing or expensive drug therapies ordered by physicians can occasionally be attributed not the the physicians "hatred of science" but the the litigious nature of our society. When a patient comes into the doctor's office demanding the "new medication" they saw advertised on TV, no amount of education can effectively combat mass media. When patients demand an MRI for their back pain, when the simple truth of their being overweight or stress injury is the answer, physicians hands are tied. The American public for all it's glory is the chief evil of the high cost of health care in this nation. The misuse of the nation's emergency rooms for the convenience factor for non-emergent conditions is a gross misuse of resources. But again because of the litagious nature of the American public you can't be told to go home, take 2 aspirin and call your doctor's office in the morning.

Just a thought: personally, I think this article has the depth of thought atributable to most mass/mainstream-media. Issues distilled to an easily digetsible sound-bite (or web blog). Heck, if we wanted to do "comparative medicine", perhaps we should compare two things:

The Institute of Medicine report and other articles state that between 44,000 and 195,000 preventable deaths occur at the hands of healthcare professionals in this country every year.

The Department of Justice reports approximately 30,000 homicide deaths in the country from firearms.

Therefore, a superficial comparative analysis suggests that we should be banning doctors, not handguns.

~Dr. Imago

[Ivor the Engineer]

Of course, it has nothing to do with the fact hospitals and many medical professionals make more money from providing unecessary healthcare.

No, let's just assume those in the medical profession are not influenced by incentives.

Anybody want angioplasty and a stent fitting for their chest pain?

[Dr. Imago]

Of course, it has nothing to do with the fact hospitals and many medical professionals make more money from providing unecessary healthcare.

No, let's just assume those in the medical profession are not influenced by incentives.

Anybody want angioplasty and a stent fitting for their chest pain?

You'd be surprised how little physicians, at least in academia, know about how much particular tests and procedures cost the patient. Most are paid a flat salary, and receive no specific and direct remuneration for performance.

~Dr. Imago

[Travis]

Not having any health insurance I have to pay cash for all my procedures, medicines and doctor visits. I always ask what something will cost and the doctors usually have no idea how much any one thing is. They are often quite surprised how much, or little, some things cost when they look into it for me.

[paximperium]

Of course, it has nothing to do with the fact hospitals and many medical professionals make more money from providing unecessary healthcare.

No, let's just assume those in the medical profession are not influenced by incentives.

Ivor, can't you at least hide your bias a bit better?
I find your bigotry against the medical profession one of the most unintelligent I've ever seen.

There are many issues with medicine. Incentives are not one of the major problems. Butt protecting and just intellectual laziness is more a problem.

Wanna change this overuse of procedures? Change the reimbursement scale to pay more for using the brain than for procedures.

Anybody want angioplasty and a stent fitting for their chest pain?
If it meets criteria and I have heart disease most definitely. Did you have a point?

[paximperium]

You'd be surprised how little physicians, at least in academia, know about how much particular tests and procedures cost the patient. Most are paid a flat salary, and receive no specific and direct remuneration for performance.

~Dr. Imago
The entire County Hospital I work in is salaried. They actually get no benefit in seeing more patients or doing more procedures...the opposite is true actually but we still do tons of colonoscopies, mammograms, Paps, caths etc.

[Yuri Nalyssus]

Of course, it has nothing to do with the fact hospitals and many medical professionals make more money from providing unecessary healthcare.

No, let's just assume those in the medical profession are not influenced by incentives.

Anybody want angioplasty and a stent fitting for their chest pain?
If that was the case then presumably more unnecessary procedures would be done in places where doctors were on performance related pay. Is there any evidence for this?

Yuri

[JWideman]

Heh. My doctor, fully aware that I have pins in my hip, tried to send me for an MRI.

[paximperium]

If that was the case then presumably more unnecessary procedures would be done in places where doctors were on performance related pay. Is there any evidence for this?

Yuri
Actually there is. Patient's with better insurance will tend to get more procedures compared to those with lousy insurance.

The definition of "unnecessary" is the contention.

[paximperium]

Heh. My doctor, fully aware that I have pins in my hip, tried to send me for an MRI.
If the pins were placed within the last 2 decades, they are titanium and can be put through an MRI.

[Yuri Nalyssus]

Actually there is. Patient's with better insurance will tend to get more procedures compared to those with lousy insurance.
That doesn't necessarily support Ivor's assertion; patients on insurance isn't the same as docs being on performance related pay.

My take on your insured patients statement would be that insured patients have less financial constraints therefore receive better healthcare than someone who is counting the pennies (or nickels or dimes or whatever passes for currency in the colonies these days) :D.

Yuri

[T.A.M.]

Here are my thoughts on her article. I will only quote the bits I have a problem with, or need to comment on:


If bureaucrats were in charge, physicians might have to prescribe the newest hypertension drugs as a first-line therapy, do MRIs to diagnose back pain and give regular Pap tests to women who have had total hysterectomies. Oh, wait—they do.

She is generalizing here. There are times when an MRI is needed to diagnose the cause of the back pain. There are women, who had their hysterectomy done years ago, where in some cases part of the cervix may have been left in. As well, some doctors will do Vaginal Vault smears to screen for vaginal cancers (rare). Overall, I agree with others, that if these are done to excess (she is commenting on the USA, and I am a Canadian GP), it is through CYA and lack of knowledge on current diagnostic and therapeutic guidelines.


Definitive studies over many years have shown that old-line diuretics are safer and equally effective for high blood pressure compared with newer drugs

I would say diuretics are AS SAFE as the newer drugs, and in most cases, SUPERIOR in terms of blood pressure reduction. However, what she fails to explore, are side effect comparisons (ARBs have way fewer side-effects compared to older meds such as diuretics and B-Blockers). She also fails to look at cases beyond the otherwise normal Hypertensive. For instance, with the diabetic, the benefits of an ACE inhibitor or a Calcium Channel Blocker wrt Renal Protection have to be considered.


MRIs for back pain lead to unnecessary surgery.


Sometimes, how often is the question, and based on what? If there is a surgically correctable lesion, then it is up to the orthopedic surgeon to inform the patient, and to present the options, and their repercussions.


And those Pap tests? Total hysterectomy removes the uterus and cervix. A Pap test screens for cervical cancer. No cervix, no cancer. Yet a 2004 study found that some 10 million women lacking a cervix were still getting Pap tests.


See my above comment earlier. However, even what I had said, cannot account for this many unneeded pap smears. Interesting to see how many were done at the suggestion of the physician versus the insistence of the patient.


A 2006 study of schizophrenia drugs found that old-line antipsychotics were as effective as pricey new ones.

Once again, side effects in the two drug classes are not considered. (compare rates of occular-gyric crisis with haldol versus Zyprexa for instance)


You might attribute Coburn's rant to his small-government ideology, but I say blame his profession—not politics but medicine. Doctors have long resisted having science guide their practice.

Absolute crock based generalization, unfounded opinion, poppycock.


That's obvious from the disparity in clinical practices from one region of the U.S. to another,....the enormous disparity in how doctors in different regions treat the same condition reflects medical culture, not medical science. Docs influence each other—"How would you handle this?"—at the local medical association and even on the golf links. "Doctors want to do what their colleagues are doing,"

There is an element of truth to the above. There is no doubt that medicine is clinically taught based on the mentoring and peer consensus, but there are standards, their are guidelines, not just based on what your colleague is doing, but based on what experts recommend, and based...yes...ON science.



In one infamous case in the mid-1990s, a federal agency concluded that spinal fusion doesn't help back pain, a decision that threatened insurance coverage for it. Surgeons, who stood to lose piles of money, got Congress to decimate the agency's budget, forcing it to pull back from making recommendations.

"a federal agency"? Well which one, and based on what?


A younger generation of doctors, perhaps more comfortable with science and clinical studies, is embracing CER. Dr. Kevin Pho, who practices internal medicine in Nashua, N.H. (and blogs at kevinmd.com), says that at least once a day he has a patient for whom there are numerous treatment options—the new diabetes drug or an old one? "An unbiased source of data, not drug companies, could really help us in primary care," he says. "There have to be allowances for individual differences, but you need standards." What a concept.

I would agree that younger physicians are more eager to embrace evidence based medicine, etc... but who do you think are conducting the studies that produce the evidence?? Not just young doctors.

Any way, some of my thoughts.

TAM:)

[Ivor the Engineer]

If that was the case then presumably more unnecessary procedures would be done in places where doctors were on performance related pay. Is there any evidence for this?

Yuri

Yes.

http://cat.inist.fr/?aModele=afficheN&cpsidt=15075159

This paper investigates on the existence of physician-induced demand (PID) for French physicians. The test is carried out for GPs and specialists using a representative sample of 4500 French self-employed physicians over the 1979-1993 period. These physicians receive a fee-for-services (FFS) payment and fees are controlled. The panel structure of our data allows us to take into account unobserved heterogeneity related to the characteristics of physicians and their patients. We use generalized method of moments (GMM) estimators in order to obtain consistent and efficient estimates. We show that physicians experience a decline of the number of consultations when they face an increase in the physician: population ratio. However this decrease is very slight. In addition physicians counterbalance the fall in the number of consultations by an increase in the volume of care delivered in each encounter. Econometric results give a strong support for the existence of PID in the French system for ambulatory care.

http://www.esri.go.jp/en/archive/e_dis/abstract/e_dis147-e.html

Percutaneous Transluminal Coronary Angioplasty, henceforth (PTCA) for patients with acute myocardial infarction (AMI)-a high-tech treatment-is more frequently used in Japan than in other developed countries. This paper adopts the two-phase model to examine whether the high PTCA use is driven by the self-interest of physicians, or by behavioral character. After controlling for a patient's detailed characteristics, we found that increases in the relative numbers of hospitals and physicians are significantly related to physician-initiated expenditures and the effect is higher for high-tech treatments. The results based on municipal-level aggregated data also support this conclusion.

http://www.socialpolitik.de/tagungshps/2007/paper/Juerges.pdf

Using German SOEP 2002 data, I estimate a hurdle model for the effect of district (Kreis-) level physician density on the individual number of doctor visits – accounting for the possibility of simultaneously determined physician density. The paper has four main findings. First, I find no evidence that physician density might be endogenous. Second, conditional on health, privately insured patients are less likely to contact a physician but more frequently visit a doctor following a first contact. Third, physician density has a significant positive effect on the decision to contact a physician and on the frequency of doctor visits of patients insured in the statutory health care system, whereas, fourth, physician density has no effect on privately insured patients' decisions to contact a physician but an even stronger positive effect
on the frequency of doctor visits than for the statutorily insured. These findings give indirect evidence for the hypothesis that in Germany, physicians induce demand for medical services among privately insured patients but not among statutorily insured.

[luchog]

I would say diuretics are AS SAFE as the newer drugs, and in most cases, SUPERIOR in terms of blood pressure reduction. However, what she fails to explore, are side effect comparisons (ARBs have way fewer side-effects compared to older meds such as diuretics and B-Blockers). She also fails to look at cases beyond the otherwise normal Hypertensive. For instance, with the diabetic, the benefits of an ACE inhibitor or a Calcium Channel Blocker wrt Renal Protection have to be considered.

That's my biggest peeve with people who whinge on about "expensive new drugs that are no better than the cheap old stuff". Yes, they may be equivalent in effectiveness; but typically have far fewer and less severe secondary effects, particularly with regard to LTU and potential toxicity.

[BillyJoe]

There is no doubt that medicine is clinically taught based on the mentoring and peer consensus, but there are standards, their are guidelines, not just based on what your colleague is doing, but based on what experts recommend, and based...yes...ON science.

It has been shown that experts' recommendations are often based on their own experience, which is often very unreliable. And, although expert opinion may be the only useful consideration when there is no evidence base, it should not be relied upon when there is an evidence base.

BJ

[BillyJoe]

http://cat.inist.fr/?aModele=afficheN&cpsidt=15075159
We show that physicians experience a decline of the number of consultations when they face an increase in the physician: population ratio. However this decrease is very slight. In addition physicians counterbalance the fall in the number of consultations by an increase in the volume of care delivered in each encounter. Econometric results give a strong support for the existence of PID in the French system for ambulatory care

That is the result of their study. Now you need to interpret the result. This is not clear cut. For example, one interpretation is that when the doctor/population ratio was low, doctors spent less time with each patient (because there were more patients waiting to be seen) with a consequent reduction in the quality of care. As the ratio increased, they were able to spend more time with patients and provide a better quality of care.

(http://www.esri.go.jp/en/archive/e_dis/abstract/e_dis147-e.html)http://www.esri.go.jp/en/archive/e_dis/abstract/e_dis147-e.html
After controlling for a patient's detailed characteristics, we found that increases in the relative numbers of hospitals and physicians are significantly related to physician-initiated expenditures and the effect is higher for high-tech treatments. The results based on municipal-level aggregated data also support this conclusion.

Same as above. Your assumption is that in countries with a relatively greater number of hospitals and doctors, patients get unnecessary treatment. However, it might be the case that, in countries with insufficient doctors and hospitals, patients may be missing out on appropriate care.

(http://www.socialpolitik.de/tagungshps/2007/paper/Juerges.pdf)http://www.socialpolitik.de/tagungshps/2007/paper/Juerges.pdf
These findings give indirect evidence for the hypothesis that in Germany, physicians induce demand for medical services among privately insured patients but not among statutorily insured.

The study concluded that privately insured patients are less likely to attend a physician but, once they did, they were likely to have more follow up visits. A possible explantion is that privately insured patients are higher money-earners, more intelligent, and therefore more likely to attend a physician only when they have significant symptoms and significant symptoms are more likely to require more investigation and follow up.

BJ

[BillyJoe]

JWideman,

Heh. My doctor, fully aware that I have pins in my hip, tried to send me for an MRI.
If the pins were placed within the last 2 decades, they are titanium and can be put through an MRI.

So...do you have titanium pins? :cool:

[Ivor the Engineer]

More evidence that medical professionals (as a group) are excellent at gaming the system to maintain or increase their remuneration:

http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1069862

The effect of cost sharing on health services utilization is analyzed from a new perspective, that is, its effects on physician response to cost sharing. A primary data set was constructed using medical records and billing files from a large multispecialty group practice during the three-year period surrounding the introduction of cost sharing to the United Mine Workers Health and Retirement Fund. This same group practice also served an equally large number of patients covered by United Steelworkers' health benefit plans, for which similar utilization data were available. The questions addressed in this interinsurer study are: (1) to what extent does a physician's treatment of medically similar cases vary, following a drop in patient visits as a result of cost sharing? and (2) what is the impact, if any, on costs of care for other patients in the practice (e.g., "spillover effects" such as cost shifting)? Answers to these kinds of questions are necessary to predict the effects of cost sharing on overall health care costs. A fixed-effects model of physician service use was applied to data on episodes of treatment for all patients in a private group practice. This shows that the introduction of cost sharing to some patients in a practice does, in fact, increase the treatment costs to other patients in the same practice who remain under stable insurance plans. The analysis demonstrates that when the economic effects of cost sharing on physician service use are analyzed for all patients within a physician practice, the findings are remarkably different from those of an analysis limited to those patients directly affected by cost sharing.

...

DISCUSSION

The results provide substantial empirical evidence consistent with the predictions of the physician-induced demand hypothesis. First, a positive effect on total fees per episode is found following the introduction of cost-cutting measures to the UMWA. This result is contrary to the predictions of traditional competitive market models. While the price of an episode of treatment for UMWA beneficiaries did decrease following the introduction of cost sharing, the price of episodes of treatment (in constant dollars) increased for other patients in the practice, holding constant the variables of age, sex, diagnosis, severity, complexity, new patient status, prior use, and physician characteristics.

The source of the price increase comes totally from physician initiated characteristics of treatment, that is, from increased ambulatory fees, increased inpatient fees, and increased length of stay in the hospital. When patient-initiated characteristics- the number of visits made during an episode of treatment -are analyzed, the effect of cost sharing becomes statistically insignificant; while visits per episode decreased for UMWA beneficiaries following cost sharing, visits per episode for other patients in the practice were unaffected by UMWA cost sharing.

[GreyICE]

Motives:

Profit

In most cases of using new drugs over old drugs, drugs where the formula has become free gain are very rarely large moneymakers. In these cases, when a fortune has been spent in research on a drug that is no more effective, in most cases, than an older drug, there's a significant drive to make it seem better. If it isn't actually better (once again, in most cases) that drive has to be done through marketing.

Ignorance

It's easy to give women pap tests. Check off the box. No check if box is actually a SANE box.

Cover my ass

Less than you'd think. Rarely are less-effective procedures performed because of CYA. Less COST effective long term over a large population? Yup. But doctors rarely cover cost effectiveness, in part because many people get icky about declaring that there's a financial value on human life.

[BillyJoe]

More evidence that medical professionals (as a group) are excellent at gaming the system to maintain or increase their remuneration:
An argument is made against your first three examples and, instead of responding to those criticisms, you introduce yet another example. Are you just searching for confirmation of your view?

Edit:
Ivor, your 4th example is a report that is 45 pages long, of a study that was done in 1977, so I'm not sure I'm going to spend much time analysing it.
If refers to an unusual situation that occured when physicians faced a substantial loss of income as the result of contraints placed on a proportion of their patients (miners) who were suddenly required to pay part of the cost of their treatment. The sudden loss of income caused them to increase their fees to other patients, decrease the times between follow up visits, and increase the time in hospital.

[Cuddles]

Profit

In most cases of using new drugs over old drugs, drugs where the formula has become free gain are very rarely large moneymakers. In these cases, when a fortune has been spent in research on a drug that is no more effective, in most cases, than an older drug, there's a significant drive to make it seem better. If it isn't actually better (once again, in most cases) that drive has to be done through marketing.

Doctors are not pharmaceutical companies. What you say could certainly apply to the people who develop and distribute drugs, but it has nothing to do with the doctors who actually prescribe them. If anything it would be the exact opposite, since doctors could make much more money by prescribing cheap drugs with a significant mark-up.

Ignorance

It's easy to give women pap tests. Check off the box. No check if box is actually a SANE box.

This is likey true, but fails to take the context into consideration. For example, if a woman has moved to a different area, her medical notes may very likely not be available. In addition, the organisations in charge of screening are usually completely separate from hospitals and GPs, and it is likely to actually be illegal for them to see any medical notes due to data protection laws. This is certainly the case in the UK. Unless the woman in question specfically tells the screening centre that she has had a hysterectomy, they have no way of knowing about it.

Yes, it is technically ignorance, but it's hardly fair to put the blame on doctors. Or anyone else for that matter.

Cover my ass

Less than you'd think. Rarely are less-effective procedures performed because of CYA.

Well, there are two points here. Firstly, the main issue was not about less effective procedures, it was about uneccessary ones. And there will be a lot of those because of covering of asses. If you're not absolutely sure someone doesn't have a cervix, then you take a smear anyway, just in case. If there's even a very small chance an MRI will pick up something, you're likely to do it to avoid being sued if the patient turns out to have that something.

The second point is that less effective procedures may well be performed because of CYA. If you have a choice between a well established treatment and a new one that may be more effective but hasn't entered general use because it is so new, the older, less effective one is likely to be the most common choice. The ********* that occurs every time a new drugs turns out to have nasty side-effects, or is simply not as effective as advertised, is far worse than the occasional suing because the established treatment wasn't quite as effective as a newer may have been.

[T.A.M.]

It has been shown that experts' recommendations are often based on their own experience, which is often very unreliable. And, although expert opinion may be the only useful consideration when there is no evidence base, it should not be relied upon when there is an evidence base.

BJ

Agreed. Medicine, where I was taught, was a mixture. Where evidence confirms clinical accuracy, that clinical information/technique is taught. Where evidence proves it useless, it is typically thrown to the back of the bus. Where there is no evidence (science based) we tend to go with expert consensus.

TAM:)

[paximperium]

Motives:

Profit

In most cases of using new drugs over old drugs, drugs where the formula has become free gain are very rarely large moneymakers. In these cases, when a fortune has been spent in research on a drug that is no more effective, in most cases, than an older drug, there's a significant drive to make it seem better. If it isn't actually better (once again, in most cases) that drive has to be done through marketing.
Uh how does that make doctors money?


Ignorance

It's easy to give women pap tests. Check off the box. No check if box is actually a SANE box.
Partly. It is an issue of habit as well as the inability to find old records.

I see some with a massive headache. He says that he had a CAT scan done a day ago. He says it is "my doctor told me it was ok." I'm worried about a head bleed. I make tons of calls to get a copy of this scan but I can't get it.

Tell me what I should do?

Cover my ass

Less than you'd think. Rarely are less-effective procedures performed because of CYA. Less COST effective long term over a large population? Yup. But doctors rarely cover cost effectiveness, in part because many people get icky about declaring that there's a financial value on human life. I do place a financial value in not getting sued for bad outcomes(just bad outcomes, not malpractice).

[Ivor the Engineer]

An argument is made against your first three examples and, instead of responding to those criticisms, you introduce yet another example. Are you just searching for confirmation of your view?

<snip>

Actually, I think the reason I generally provoke so much hostility when I bring up the issue of supplier induced demand with respect to provision of healthcare is that it threatens what most people would like to be true, but probably is not. i.e. people want to believe that the medical professionals they see when they or a loved one is ill do not use their superior knowledge to benefit themselves over patients and the rest of society, yet given the reasonable assumption medical professionals are rational, self-interested agents, this is exactly how we would expect them to behave, unless extra constraints or incentives are in place to modify their behaviour.

I can only assume the reason no country has ever managed to place reasonable constrains on and incentives for medical professionals' behaviour compared to other providers of public services is because of the profession being well-connected with the rich and powerful throughout history.

As with most things in life it's not what you know, but who you know, that counts.

[T.A.M.]

The patient first, is suppose to be the motto. Nice to see what you think of us...as a group of course.

TAM:)

[paximperium]

I can only assume the reason no country has ever managed to place reasonable constrains on and incentives for medical professionals' behaviour compared to other providers of public services is because of the profession being well-connected with the rich and powerful throughout history.

As with most things in life it's not what you know, but who you know, that counts.
Thanks for coming clean with your bias and ignorance about the history of medicine and healthcare.

[paximperium]

The patient first, is suppose to be the motto. Nice to see what you think of us...as a group of course.

TAM:)
We should not pay attention to it. We shall absorb all in the end. Resistance is futile.

[Ivor the Engineer]

Thanks for coming clean with your bias and ignorance about the history of medicine and healthcare.

http://www.historylearningsite.co.uk/ancient_egyptian_medicine.htm

Physicians lived even earlier in Ancient Egypt. Imphotep was the physician to King Zozer and lived in about 2600 BC. Imphotep was considered so important that he was, after his death, was worshipped as a god of healing.

[paximperium]

Hey, you can use Google. Good for you.

[T.A.M.]

http://www.historylearningsite.co.uk/ancient_egyptian_medicine.htm

yes and Caesar was as well (treated as a god, labeled by some as one), and that was what, 2500 years later? Ancient history, now we are stretching, are we not?

TAM:)

[Skeptic Ginger]

How much of this is

Cover my ass?

Profit driven?

Ignorance of current best practice?

In Canada the latter would predominate and there are programs to enhance physicians skills.In my experience I think the last one also predominates in the US. As for covering one's ass, that's hard to judge but I can say the legislature in our state has no clue when they pass some legislation, they might as well be practicing without a license.

There is some profiteering but I don't think it predominates.

[Skeptic Ginger]

Of course, it has nothing to do with the fact hospitals and many medical professionals make more money from providing unecessary healthcare.

No, let's just assume those in the medical profession are not influenced by incentives.

Anybody want angioplasty and a stent fitting for their chest pain?Your cynicism is unfounded, Ivor. There are of course some providers who pad their bills but it is not part of the culture of the vast majority of providers. Most health care providers are motivated to provide good care.

And what evidence do you have stents are overused?

[paximperium]

yes and Caesar was as well (treated as a god, labeled by some as one), and that was what, 2500 years later? Ancient history, now we are stretching, are we not?

I do wish I was worshiped as a god but the nurses keep me in line.

[Skeptic Ginger]

Actually there is. Patient's with better insurance will tend to get more procedures compared to those with lousy insurance.

The definition of "unnecessary" is the contention.Which is reasonable if you consider sometimes it is the provider trying to save the patient money. You sometimes have to compromise if you cannot afford all the care that you would benefit from.

[Skeptic Ginger]

Yes.

http://cat.inist.fr/?aModele=afficheN&cpsidt=15075159



http://www.esri.go.jp/en/archive/e_dis/abstract/e_dis147-e.html



http://www.socialpolitik.de/tagungshps/2007/paper/Juerges.pdfOr another hypothesis might be that with more providers you don't have patients squeezed into 5 minute appointments to see them all, giving you time to do more for each one.

[Skeptic Ginger]

More evidence that medical professionals (as a group) are excellent at gaming the system to maintain or increase their remuneration:

http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1069862That's called the hidden tax paying for the uninsured. Cost shifting is one reason the US needs national health insurance. People often have no clue the people who can pay their bills pay for the unreimbursed care given to the people who do not pay their bills.

There's no gaming going on there. If the government mandates a hospital cannot turn a patient who cannot pay away from the ED, while that same mandate is unfunded, the cost accrues as an expense of doing business. I'm not quite sure what you think is going on here.

[Skeptic Ginger]

Actually, I think the reason I generally provoke so much hostility when I bring up the issue of supplier induced demand with respect to provision of healthcare is that it threatens what most people would like to be true, but probably is not. i.e. people want to believe ....

:id:

[Skeptic Ginger]

I do wish I was worshiped as a god but the nurses keep me in line.One of my favorite jokes (multiple sources) : The Ranks of a Hospital

Surgeon:
Leaps tall buildings in a single bound
Is more productive than a train
Is faster than a speeding bullet
Walks on water
Talks with God

Internist:
Leaps short buildings in a single bound
Is more powerful than a switch engine
Is faster than a speeding BB
Walks on water if the sea is calm
Talks with God if special request is approved

General Practitioner:
Leaps short buildings with a running start and favorable winds
Is almost as powerful as a switch engine
Nurse Practitioners
Can fire a speeding bullet
Walks on water in an indoor swimming pool
Is occasionally addressed by God

Resident:
Barely clears a picket fence
Loses tug-of-war with a train
Can sometimes handle a gun without inflicting self-injury
Swims well
Talks with animals

Intern:
Makes high skid marks on a wall when trying to leap buildings
Is run over by a train
Is not issued ammunition
Dog paddles
Talks to walls

Medical Student:
Runs into buildings
Recognizes a train 2 out of 3 times
Wets himself with a water pistol
Cannot stay afloat without a life preserver
Mumbles to himself

Nurse:
Lifts buildings and walks under them
Kicks trains off the track
Catches speeding bullets with her teeth and eats them
Freezes water with a single glance
The Nurse IS God!!!!

[luchog]

As with most things in life it's not what you know, but who you know, that counts.

Or, in your case, what you do not want to know.

[Ivor the Engineer]

That's called the hidden tax paying for the uninsured. Cost shifting is one reason the US needs national health insurance. People often have no clue the people who can pay their bills pay for the unreimbursed care given to the people who do not pay their bills.

There's no gaming going on there. If the government mandates a hospital cannot turn a patient who cannot pay away from the ED, while that same mandate is unfunded, the cost accrues as an expense of doing business. I'm not quite sure what you think is going on here.

You will note that the idea of the cost-sharing scheme was to attempt to contain costs, yet all that happened was the physicians made up for the loss of income from fewer visits by the cost-sharing insured group by charging their other insured patients with no cost-sharing for such things as longer stays in hospital.

If that's not gaming the system I don't know what is.

[BillyJoe]

Ivor,

As I said, this was the result of an unusual situation that occurred in a certain area of England about 30 years ago.

I don't know what the situation is in England at present (or in America) but, in Australia, you can't get an appointment for a week because of a shortage of doctors (or too many people who imagine there is something wrong with them), so I doubt any thing like that happens here these days.

Also my posts are not intended to be hostile.

BJ

[Dancing David]

Nothing like a little snippet to mislead people:

A 2006 study of schizophrenia drugs found that old-line antipsychotics were as effective as pricey new ones.

Who ever wrote this nonsense editorial has not a clue!

They have not seen the side effects of Prolixon or Hladol (US names) or even worse the old line Navane and Thorazine.

First off, the symptom mangement oprofiles are different for the old line drugs, the level of side effects for effective treatment is abyssmal.

Second the side effects are horrific
-EPS: extra pyramidal side effects, also called 'neo-parkinsons', shaking, hand flapping, unintended spasms.
-Tardive dyskinesia: a permanent and life threatening motion disorder, pill rolling, tounge thrusts and eventually disrupts breathing.
-akesthesia: feeling of intense disconfort and need to move and pace, very uncomfortable
-dopaminergic effects: dry mouth (to the point where teeth rot), constipation, drooling in some people, shuffling gait, suppression of many systems.

So the editor who wrote that piece is full of crap.

[Professor Yaffle]

Nothing like a little snippet to mislead people:

Who ever wrote this nonsense editorial has not a clue!

They have not seen the side effects of Prolixon or Hladol (US names) or even worse the old line Navane and Thorazine.

First off, the symptom mangement oprofiles are different for the old line drugs, the level of side effects for effective treatment is abyssmal.

Second the side effects are horrific
-EPS: extra pyramidal side effects, also called 'neo-parkinsons', shaking, hand flapping, unintended spasms.
-Tardive dyskinesia: a permanent and life threatening motion disorder, pill rolling, tounge thrusts and eventually disrupts breathing.
-akesthesia: feeling of intense disconfort and need to move and pace, very uncomfortable
-dopaminergic effects: dry mouth (to the point where teeth rot), constipation, drooling in some people, shuffling gait, suppression of many systems.

So the editor who wrote that piece is full of crap.

I assume he is referring to this:
http://archpsyc.ama-assn.org/cgi/content/short/63/10/1069

Some interesting letters and related articles linked to there too.

ETA: or possibly this:
http://pt.wkhealth.com/pt/re/ajhp/abstract.00043627-200611150-00006.htm;jsessionid=J2cW0JqrXKvm22Dg5tsF3gcvXg2Br V7TWVDMfnd41SyjpYvKM9lR!751744069!181195628!8091!-1

[Skeptic Ginger]

You will note that the idea of the cost-sharing scheme was to attempt to contain costs, yet all that happened was the physicians made up for the loss of income from fewer visits by the cost-sharing insured group by charging their other insured patients with no cost-sharing for such things as longer stays in hospital.

If that's not gaming the system I don't know what is.I'm not sure what cost sharing you are talking about, nor how it was supposed to "contain costs". Your version makes no sense.

[Ivor the Engineer]

I'm not sure what cost sharing you are talking about, nor how it was supposed to "contain costs". Your version makes no sense.

It's described in the article:

Mineworkers, steelworkers, and their families constituted over 80 percent of the patients seen by the RMG physicians. Steelworkers were privately insured by Blue Cross/Blue Shield and Metropolitan Life. Their benefits remained constant over the study period, 1976-1979. Following the introduction of cost sharing to the UMWA beneficiaries, average monthly visits to the group practice decreased by 13.5 percent. The major share of the decline was due to reduced utilization by UMWA-represented patients, whose visits decreased by 25.3 percent.

This setting has several advantages in a study examining how economic incentives influence physician behavior. First, the change in cost-sharing rates was an exogenous one, that is, it was beyond the influence of physicians. Second, the change that occurred was a large one, from no cost sharing to $7.50 per patient per visit. Third, physician membership in the RMG remained constant throughout our study period. And finally, miner and steelworker patients were fairly evenly distributed across physicians in the practice both before and after UMWA cost sharing. Thus, as a natural experiment, the experience of the RMG following the introduction of cost sharing to the UMWA offers a unique opportunity to study ways in which a substantial drop in utilization by one group of patients can affect physician
treatment patterns for all patients in the practice.

So the idea was that by making people pay a fee from their own money to see a physician, it would reduce the number of 'frivolous' visits and hence claims on their insurance policy, reducing overall costs.

[Dancing David]

I assume he is referring to this:
http://archpsyc.ama-assn.org/cgi/content/short/63/10/1069

Yes but that is discussing first and second generation, I think that Clozaril, Olanzapine, Zyprexa would be thrid generation, I can't read the full article or see if they even discuss side effect profiles.

they are also choosing the non-refractory patients and still no mention of why the pharmaceuticals charge 3x-5x more for the newere medications.

Thanks


Some interesting letters and related articles linked to there too.

ETA: or possibly this:
http://pt.wkhealth.com/pt/re/ajhp/abstract.00043627-200611150-00006.htm;jsessionid=J2cW0JqrXKvm22Dg5tsF3gcvXg2Br V7TWVDMfnd41SyjpYvKM9lR!751744069!181195628!8091!-1

Not working at this time, maybe later.

Other issues mentioned in the responses:

Compliance. 50% vs 70%
Methodology of effectiveness.
Reduction of negative symptoms.
Quality of life. Which I am curious how they rated the scales.
Use of SGA (and should include FGA) to treat bipolar disorder.
Marketing of drugs (a real issue)

Some suggestions that cost is more important than side effects! (Boo hiss, stupid researchers.) Let us ee the researcher take 10mg-30mg of Haldol.

No mention of tardive dyskenisia that I could see at all in the abstracts, or the comparative cost benefits fo side effects, those side effects are really bad. As in terrible. As in I wouldn't wish them on my next to worst enemy.

When we have people who pay $15 for an erection or get Botox fo $300 but grudging payment to people with a serious disability.

Arggghhh!

[Dancing David]

It's described in the article:



So the idea was that by making people pay a fee from their own money to see a physician, it would reduce the number of 'frivolous' visits and hence claims on their insurance policy, reducing overall costs.

Any larger or more recent studies?

No?

Figures.

[fls]

Yes but that is discussing first and second generation, I think that Clozaril, Olanzapine, Zyprexa would be thrid generation, I can't read the full article or see if they even discuss side effect profiles.

I read the full article. It focuses on differences (or not) in efficacy and effectiveness, rather than side-effects. And I agree with you that that issue (side-effects) is of far more concern to psychiatrists and patients than variations in efficacy. It's more than a little disturbing to see the avoidance of TD used as an example of non-science-based recommendations.

Linda

[Professor Yaffle]

Just to be clear - I wasn't linking to those articles to say she had a point, I was just providing what I thought might be the source for her assertions.

I totally agree that side effect profiles are a major issue in prescribing any psychotropic medication.

[fls]

Just to be clear - I wasn't linking to those articles to say she had a point, I was just providing what I thought might be the source for her assertions.

I totally agree that side effect profiles are a major issue in prescribing any psychotropic medication.

Yeah, I was referring to being disturbed by the author of the article (which I did not make clear).

Linda

[Ivor the Engineer]

Any larger or more recent studies?

No?

Figures.

There are more recent studies. Most (but not all) find exactly what would be expected if SID was occurring.

Here's another paper which discusses SID:

http://www.buseco.monash.edu.au/centres/che/pubs/wp123.pdf

3 Supplier Induced Demand: Evidence

3.1 Overseas Evidence

Like many theories in the physical sciences Supplier Induced Demand was first suggested to explain observations which were not convincingly explained within the orthodox framework. The theory is commonly attributed to Evans (1974) who observed that across the province of British Columbia there was little variation in doctor incomes despite very significant variation in their supply. As doctors could not charge fees above the benefit (rebate) this implied service use in proportion to the doctor supply. This is, of course, consistent with orthodox economics if supply had adjusted to demand or if there had been a permanent excess demand. It is at this point of the argument—both with respect to Evans’ data and the observations in many subsequent studies—that a difference of interpretation arises. Critics of SID have generally argued that as the observations are consistent with theory, then SID is ‘unproven’. Evans and others appeal to judgement. Is it likely that variation in service use of 200 - 400 percent could be attributed to other causal factors? The effects of age, sex, income and medical status are independently known and cannot explain the discrepancy. Anecdotal evidence did not indicate significant queuing. SID was therefore proposed as an alternative explanation.

A more rigorous statistical analysis had, in fact, been published in 1972 by Fuchs and Kramer. In this, and in subsequent, similar, studies doctor supply is endogenised and explained, in large part, by doctors’ propensity to work in congenial residential areas. Inserted in the demand equation the endogenised doctor supply has had significant explanatory power.

This latter approach has been criticised statistically as discussed briefly below and various other sources of evidence have been used to support SID. For example a number of studies report an otherwise inexplicable increase in services per person following the freezing of the fee schedule. Perhaps the most notable evidence is the result of a random control trial which ‘converted’ Charles Phelps, one of the most trenchant critics of SID (see Phelps 1997 p254). In this, doctors at a university hospital clinic were randomised to receive income by salary or a fee for service. Patients attending the clinic were randomly assigned to doctors. The result was that fee-forservice doctors scheduled almost 30 percent more return visits than those on salary. Most of the discrepancy was attributable to a 50 percent greater scheduling of (medically doubtful) well care visits (Phelps 1997).

Direct financial reward is not the only incentive for medical professionals to engage in SID.

It has already been mentioned that physicians in the US often perform tests they know are pointless to protect themselves from being sued (though this may also be used as a rationalisation to justify extracting more money from the patient:)). This would be SID to avoid a possible loss of money and public image. SID may also occur for internal rather than external payoffs. E.g., associating more care with better care.

[BillyJoe]

So the idea was that by making people pay a fee from their own money to see a physician, it would reduce the number of 'frivolous' visits and hence claims on their insurance policy, reducing overall costs.

I didn't read the whole 45 pages, but I guess you did...
...so perhaps you'll point out where they said it reduced the number of frivolous visits.
Or is that just your take?

[Ivor the Engineer]

I didn't read the whole 45 pages, but I guess you did...
...so perhaps you'll point out where they said it reduced the number of frivolous visits.
Or is that just your take?

It's not just my take, it's the idea behind making people pay some of their own money to access a service; it focuses the mind as to whether or not the service is really wanted and mitigates against moral hazard.

Unfortunately, in the case of medical services, it can also discourage people from seeking necessary care, particularly those on low incomes.

Do you need me to provide evidence for these assertions, or do you trust me?:)

[BillyJoe]

Ivor,

Do you need me to provide evidence for these assertions, or do you trust me?In fact, no, I don't need you to provide this evidence, and, no, I don't trust you, sorry :(
Because I think I'm having the effect I intended, which was to get you to see alternative explanations...

it's the idea behind making people pay some of their own money to access a service; it focuses the mind as to whether or not the service is really wanted and mitigates against moral hazard...Unfortunately, in the case of medical services, it can also discourage people from seeking necessary care, particularly those on low incomes.Yes, there is more than one reason for the results as I have been trying to point out to you all along. First of all, if it is a fact that having to pay a certain amount of the consult fee reduces the number of visits, that is a patient determined change, not a doctor determined change. And yes, they may not be frivilous visits being avoided but necessary visits being discouraged. And If you read all of those studies with these sorts of alternatives in mind, you will find that the conclusions of the authors are not the only ones supported by the evidence they obtained.

That was my point and I am glad you now see this. :)

regards,
BillyJoe

[Ivor the Engineer]

<snip>

Because I think I'm having the effect I intended, which was to get you to see alternative explanations...

<snip>

What you have failed to consider is that I may have already looked at the alternative explanations even before I made my first post in the thread.

Do you put as much effort into looking for alternative explanations of the data in negative homoeopathic trials?

The reasoning is straightforward:

1) Humans respond to incentives.

2) Physicians are human.

3) Physicians have the ability to induce demand.

Given (1), (2) and (3), it is reasonable to expect that physicians will respond to incentives and use their ability to induce demand. And this is what the data overwhelmingly supports. E.g.,

Perhaps the most notable evidence is the result of a random control trial which ‘converted’ Charles Phelps, one of the most trenchant critics of SID (see Phelps 1997 p254). In this, doctors at a university hospital clinic were randomised to receive income by salary or a fee for service. Patients attending the clinic were randomly assigned to doctors. The result was that fee-forservice doctors scheduled almost 30 percent more return visits than those on salary. Most of the discrepancy was attributable to a 50 percent greater scheduling of (medically doubtful) well care visits (Phelps 1997).

As far as I can see I'm the one using the logic, while you and others are trying desperately to come up with alternative and emotionally satisfying explanations for why physician SID does not occur.

[Skeptic Ginger]

It's described in the article:



So the idea was that by making people pay a fee from their own money to see a physician, it would reduce the number of 'frivolous' visits and hence claims on their insurance policy, reducing overall costs.I was thinking of cost shifting, rather than cost sharing.

I'll have to revisit my previous reply.

[Skeptic Ginger]

More evidence that medical professionals (as a group) are excellent at gaming the system to maintain or increase their remuneration:

http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1069862Revisiting my previous answer:

I don't want to search through 20 pages to find what I need to know. If the physicians maintain a full schedule as a busy practice would, having one group of patients decrease their number of appointments would simply result in an economic control decreasing visits instead of a limit of physician time decreasing visits. So did they control for this?

In other words, factors which influence patient utilization can be either cost, as expected in cost sharing, or it can be the amount of time available for appointments. A provider may be short changing visits because of work load and if more time were available, the provider could address more patient problems per visit. Good care would still be the motivation of doing so, not bill padding as you suggest.

Or the provider schedule could limit requested appointments. Maybe you'd like to be seen within the week but the next available appointment isn't for 3 weeks. Having some of your patient load decreased would mean patients could be seen sooner. But the provider's schedule of appointments would be just as full each day despite the decrease in patient appointments.

Again, the result of no change in billable services is not due to provider bill padding, it would be due to one's appointments just not being made as far out.

Does the study address this or did it just look at total costs without analyzing what actually changed?

[BillyJoe]

As far as I can see I'm the one using the logic, while you and others are trying desperately to come up with alternative and emotionally satisfying explanations for why physician SID does not occur.

I don't know what others are doing but that definitely is not what I'm doing. I'm not saying that SID does not occur. In fact, I agree that it would be surprising if it does not occur, though to what extent is impossible to say. My point was that there are alternative explanations for the results obtained in all of those studies (I haven't looked at the last one you quoted because I have been sinfgularly unsuccessful in getting you to respond to the other four), yet you chose to accept the authors' conclusion that it is support for their SID hypothesis.

I am wondering whether you have had any negative experiences with doctors that have slanted your view.
(If you have, you wouldn't be alone ;
However, let's be impartial in our evaluation.)

BillyJoe


Edited to add:
I see skeptigirl has listed some reasons which build on those I mentioned on page 1. So I'm asking you if you have really considered the alternatives as you said you have. And, if you have, why you haven't responded when these alterntives explanations have been suggested. In other words, why have you chosen to accept SID and not the aternatives mentioned here which are equally consistent with the results obtained in those studies.

[Dancing David]

Just to be clear - I wasn't linking to those articles to say she had a point, I was just providing what I thought might be the source for her assertions.

I totally agree that side effect profiles are a major issue in prescribing any psychotropic medication.


Prof. Yaffle, you are cool as always. :cool:

[Dancing David]

There are more recent studies. Most (but not all) find exactly what would be expected if SID was occurring.

Here's another paper which discusses SID:

http://www.buseco.monash.edu.au/centres/che/pubs/wp123.pdf



Direct financial reward is not the only incentive for medical professionals to engage in SID.

It has already been mentioned that physicians in the US often perform tests they know are pointless to protect themselves from being sued (though this may also be used as a rationalisation to justify extracting more money from the patient:)). This would be SID to avoid a possible loss of money and public image. SID may also occur for internal rather than external payoffs. E.g., associating more care with better care.

Except most doctors in US practice do not profit from lab results or tests.

I think that patients also push for tests. I have seen many parents and adults disappointed that their child or themselves did not receive an x-ray, whne the doctor thought it was most likely a strain.

But I know your bias. In the US most doctors work for a practice that farms out the labs and tests. My doctor does not stand to profit for running labs, nor my poutine tests. She tests based upon my conditions, age, lipid profile, etc...

I also forgot! Canada caps imcome at some level , personal profit and income are limited to $250,000 a year or something like that. There are also caps on industrial production and the like. I talked to number of bussiness owners in Windsor ONT about this. How do you know that it is not income caps that caus ethe effect you are discussing?

[fls]

I also forgot! Canada caps imcome at some level , personal profit and income are limited to $250,000 a year or something like that. There are also caps on industrial production and the like. I talked to number of bussiness owners in Windsor ONT about this. How do you know that it is not income caps that caus ethe effect you are discussing?

WTF?!

What on earth are you talking about?

Linda

[Ivor the Engineer]

<snip>

Does the study address this or did it just look at total costs without analyzing what actually changed?

On page 12:

http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1069862

PHYSICIAN-INITIATED AMBULATORY CHARACTERISTICS

The regression results for the first equation estimating physician initiated characteristics of ambulatory treatment find a negative effect of cost sharing on visit fees (AVGFEE) for the miners (COST + CXI = -.01988). However, the statistically significant (p < .01) and positive parameter for cost sharing (COST) indicates that visit fees for nonminers have increased following UMWA cost sharing.

The next equation analyzes a measure of utilization-average services per visit (AVGSVC) -that is also controlled by the physician. Again, a negative coefficient is associated with the interaction variable. Miners, in relation to nonminers, are getting fewer services per visit following cost sharing. However, there is no effect on services per visit for nonminers following cost sharing. Thus, in this study, the positive effect of cost sharing on utilization seems applicable to ambulatory fees, but not to ambulatory "intensity" as measured by number of services.

[Ivor the Engineer]

I don't know what others are doing but that definitely is not what I'm doing. I'm not saying that SID does not occur. In fact, I agree that it would be surprising if it does not occur, though to what extent is impossible to say. My point was that there are alternative explanations for the results obtained in all of those studies (I haven't looked at the last one you quoted because I have been sinfgularly unsuccessful in getting you to respond to the other four), yet you chose to accept the authors' conclusion that it is support for their SID hypothesis.

I've been singularly unsuccessful in getting anyone to read the evidence without spoon feeding it to them.

I am wondering whether you have had any negative experiences with doctors that have slanted your view.
(If you have, you wouldn't be alone ;
However, let's be impartial in our evaluation.)

BillyJoe

None that are relevant to the issue of SID. Quite the opposite in fact.:)

BTW, whatever SID physicians engage in, it is probably nothing compared to dentists. My current dentist and hygienist are always trying to sell me stuff at inflated prices.

Edited to add:
I see skeptigirl has listed some reasons which build on those I mentioned on page 1. So I'm asking you if you have really considered the alternatives as you said you have. And, if you have, why you haven't responded when these alterntives explanations have been suggested. In other words, why have you chosen to accept SID and not the aternatives mentioned here which are equally consistent with the results obtained in those studies.

Because the SID hypothesis is consistent with what we know about human behaviour, while the alternative explanations have to be stretched to breaking point to explain the observed variation in demand.

[blutoski]

I also forgot! Canada caps imcome at some level , personal profit and income are limited to $250,000 a year or something like that. There are also caps on industrial production and the like. I talked to number of bussiness owners in Windsor ONT about this. How do you know that it is not income caps that caus ethe effect you are discussing?

Because it's not true.

I think this is part of the problem: Americans seem to actually believe this stuff, even the ones with enough education and intelligence who I think should be grounded in enough common sense to know better.

The fear is based on incredible, widespread, consumer misinformation. I'm not sure how to get around that. I suspect part of it is also jingoism: some people in any country enter cognitive dissonance when exposed to evidence that other countries could be doing better in even a trivial way.

[Ivor the Engineer]

You've only got yourselves to blame; there's way too much red on your flag.:)

[blutoski]

You've only got yourselves to blame; there's way too much red on your flag.:)

Interesting enough, one of the proposed flags had blue bars and a red maple leaf, but people thought red-white-and-blue looked "too french."

[paximperium]

Except most doctors in US practice do not profit from lab results or tests.
It is illegal to refer patients for tests that a physician has a financial stake or to self refer a patient to anyone that the physician has a financial interest in.
http://www.cms.hhs.gov/physicianselfreferral/

This does not prevent mutual referrals ie. back scratching(I'll refer a lung patient to you if you'll refer a heart patient to me.) which I believe is fine as long as it is not abused.

[Tomblvd]

I couldn't have penned better, more succinct answers myself than the first two replies below the article...





~Dr. Imago

You quoted a statement that has taken on the status of urban legend, so I'll take the opportunity to address it:

The Institute of Medicine report and other articles state that between 44,000 and 195,000 preventable deaths occur at the hands of healthcare professionals in this country every year.

The main article debunking the number is here:

http://www.devicelink.com/mddi/archive/01/11/007.html

money graph:

"Much less attention was paid to a subsequent article, published in the Journal of the American Medical Association (JAMA) last July 25, which called into question the conclusions of the IOM report. According to authors Rodney Hayward and Timothy Hofer, the results of their study suggest that "these statistics are probably unreliable and have substantially different implications than have been implied in the media." Hayward has suggested that the number of deaths due to error is probably closer to between 5000 and 15,000 annually."

[paximperium]

You quoted a statement that has taken on the status of urban legend, so I'll take the opportunity to address it:

The Institute of Medicine report and other articles state that between 44,000 and 195,000 preventable deaths occur at the hands of healthcare professionals in this country every year.

The main article debunking the number is here:

http://www.devicelink.com/mddi/archive/01/11/007.html

money graph:

"Much less attention was paid to a subsequent article, published in the Journal of the American Medical Association (JAMA) last July 25, which called into question the conclusions of the IOM report. According to authors Rodney Hayward and Timothy Hofer, the results of their study suggest that "these statistics are probably unreliable and have substantially different implications than have been implied in the media." Hayward has suggested that the number of deaths due to error is probably closer to between 5000 and 15,000 annually."
That was the issue with how that report was reported. It was nonsense. It basically included a multitude medical related deaths including deaths from surgery or deaths from massive heart attack after cardiac stenting, not medial errors.

It was basically a nice report about the number of deaths of patients who die after any medical intervention...great whoop.

[blutoski]

That was the issue with how that report was reported. It was nonsense. It basically included a multitude medical related deaths including deaths from surgery or deaths from massive heart attack after cardiac stenting, not medial errors.

It was basically a nice report about the number of deaths of patients who die after any medical intervention...great whoop.

For the sake of lurkers, I'd like to emphasize that iatrogenic morbidity and mortality is taken very seriously. Even the low numbers of 5-15k/yr is the focus of study to create strategies to ultimately eliminate all avoidable situations.

[Skeptic Ginger]

On page 12:

http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1069862From my copy this is on page 38:
for the UMWA beneficiaries, these time intervals were increased...

for the other patients in the practive, follow-up visits were recommended at more frequent time intervalsYou cannot deduce from this data that the physicians only increased visit frequency to pad their bills. You cannot rule out increased followup visits because more physician time was available.

As for the increased hospital stays, that one is questionable. Third party payers in this country have been using DRGs to determine reimbursement for hospital stays since well before 1992. That means everyone is reimbursed, not by length of stay, but by diagnosis. Patients staying more days in the hospital do not result in more income for the provider, rather they result in less income. The study didn't address this as far as I could see if they only looked at patient hospital days.

It's possible all the providers needed was feedback about the frequency of follow up visits and outcomes. They could easily believe closer observation during followup was preferable but they had to consider availability of their time to meet all the patients' needs.

It's possible this particular "large multispecialty group practice" was the exception. They may have had corporate managers pressuring them to increase appointments.

The conclusion drawn by you is premised on the belief 'physician controlled' equals greed as the only possible motivation. That is a false premise.

I could generate a lot more business in my practice simply by telling employers that I recommended all their blood exposed employees have 6wk, 3mo, and 6mo follow up lab work. I don't do that because it is unnecessary if the person who is the source of the blood tests negative (with a few exceptions). I would say such recommendations are more usual than not and where they are not usual, the most common reason is provider belief such follow up tests are necessary.

[T.A.M.]

Some provinces do place Caps on physician income, this is (from memory after reading it years ago - I have never made so much as to have my fees capped), IIRC, how it works.


You have a cap of lets say $350,000 per year.

The payer (Provincial Health Care Plan) will then reduce the amount you can receive per billing by a percentage. This means that every $1 you make above the $350,000, you will only see a certain percentage of it. That leads to a second cap, and after that cap, every $1 you bill, you will see even less of it.

eg.

MD Bills the health care plan for $500,000 this year. He is in a province that has a 1st cap of $350,000, and a 2nd cap of $450,000. The first cap reduced billing payout by 33%, and the second cap reduces it by 50%.

So The doc gets $350,000 + $67,000 + $25,000 = $442,000 total instead of $500,000

Or at least, this the way I think it works.

TAM:)

[Miss_Kitt]

I do wish I was worshiped as a god but the nurses keep me in line.

Pax -- Are you coming to TAM? I can at least throw rose petals at your feet...:D

[paximperium]

For the sake of lurkers, I'd like to emphasize that iatrogenic morbidity and mortality is taken very seriously. Even the low numbers of 5-15k/yr is the focus of study to create strategies to ultimately eliminate all avoidable situations.

Sorry for the flippant tone but yeah, while 5000-15000 isn't that great a number compared to the millions treated each year, this number does not include the errors that don't kill people which is probably in the tens or thousands if not in the hundreds of thousands.

We will never be able to totally get rid of medical errors but I believe we can decrease to a few hundred a year if we properly take precautions.

[paximperium]

Pax -- Are you coming to TAM? I can at least throw rose petals at your feet...:D
Sorry, I just got back from Vegas a week back followed by a trip to LA for a friend's wedding...my liver will not survive another drinking binge.

I'll be happy with e-prayers.

[BillyJoe]

Skeptigirl,

I think it's time to give up.
Ivor has shown no interest in responding to the alternative explantions offered.
I believe he has his mind made up.

:(

BJ

[dudalb]

That is SOP for Ivor.
Ivor seems to have a great many "unusual" ideas. His "Doctors are corrupt" kick is just the latest.

[paximperium]

That is SOP for Ivor.
Ivor seems to have a great many "unusual" ideas. His "Doctors are corrupt" kick is just the latest.
It isn't all that new. I've already noticed a general anti-doctor/pharmaceutical industry tone from previous posts.

Now it seems to be significantly more unreasonable than I first thought.

[Ivor the Engineer]

Do you believe homoeopathic remedies really do cure colds in less than a week for most people?

The evidence which indicates otherwise can't rule this possibility out.

[Ivor the Engineer]

It isn't all that new. I've already noticed a general anti-doctor/pharmaceutical industry tone from previous posts.

Now it seems to be significantly more unreasonable than I first thought.

Do humans respond to incentives?

Are physicians human?

[Ivor the Engineer]

That is SOP for Ivor.
Ivor seems to have a great many "unusual" ideas. His "Doctors are corrupt" kick is just the latest.

I smell straw.

[BillyJoe]

Do humans respond to incentives?
Are physicians human?


This is your proof? :D

As I said, here in Australia you can wait a week for an appointment. Where is the incentive to overservice in this situation where the doctor is booked out for a week? Consider the alternative explanations, Ivor, they are at least as legitimate as yours.


None [bad experiences with doctors] that are relevant to the issue of SID. Quite the opposite in fact.:)

I have had only five doctor experiences in my life.
- tonsillectomy at age 4 because my brother had an attrack of tonsillitis (that's what they did in those days apparently!)
- malingering illness to get out of school picked up by doctor called in for a home visit by concerned parents (I should have been an actor)
- torsion of testicle misdiagnosed as infection (I told him, I was still a virgin!)
- sinus infection spreading into the eye socket correctly diagnosed and successfully treated with antibiotics - before I died of meningitis (Okay, exaggerating a little).
- laceration sutured by a medical student (it was that or wait another hour) in emergency department of local hospital.
A mixed bag for me.

BJ

[T.A.M.]

Do you believe homoeopathic remedies really do cure colds in less than a week for most people?

The evidence which indicates otherwise can't rule this possibility out.

evidence which indicates otherwise cannot rule out radio waves as a possibility either, can it? The fact is that the common cold, as you well know, will be gone regardless of treatment, in about a week for most people. If that was your point, well ok, but what of it.

Do humans respond to incentives?

Are physicians human?

Yes we respond to incentives, and yes we are human. Do you believe that the majority of the police force is corrupt? Do you believe that anyone who is susceptable to incentive is corrupt? Doctors have a moral code. Are there exceptions, people who will compromise care or ethics for extra dollars? of course.

Where I practice, the idea of Doctor Driven Demand is ridiculous, as there are not enough doctors to keep up with the demand as it already exists.

I smell straw.

I smell chicken soup.

TAM:)

[T.A.M.]

This is your proof? :D

As I said, here in Australia you can wait a week for an appointment. Where is the incentive to overservice in this situation where the doctor is booked out for a week? Consider the alternative explanations, Ivor, they are at least as legitimate as yours.


See my above post to Ivor. Similarly here in Canada, there already exists demand far exceeding supply. I think his argument, if there is a valid one to start, might have to apply to the USA.


I have had only five doctor experiences in my life.
- tonsillectomy at age 4 because my brother had an attrack of tonsillitis (that's what they did in those days apparently!)
- malingering illness to get out of school picked up by doctor called in for a home visit by concerned parents (I should have been an actor)
- torsion of testicle misdiagnosed as infection (I told him, I was still a virgin!)
- sinus infection spreading into the eye socket correctly diagnosed and successfully treated with antibiotics - before I died of meningitis (Okay, exaggerating a little).
- laceration sutured by a medical student (it was that or wait another hour) in emergency department of local hospital.
A mixed bag for me.

BJ

1. Torsion is a tough call. Epididymitis often presents similarly, as does a torsion of the Appendix testes if acutely inflamed. My approach is to assume it is a torsion if it is Red and swollen, get them to the ER for an emergency u/s, and if I am wrong, I don't mind taking the flack from the ER doc.

2. While meningitis caused by an untreated sinusitis gone periorbital cellulitis is rare, it does happen.

TAM:)

[Belz...]

You've only got yourselves to blame; there's way too much red on your flag.:)

No such thing.

[Dancing David]

WTF?!

What on earth are you talking about?

Linda

Two small bussiness owners in Canada, Windsor ONT specifically said that they have income caps. Both ran resteraunts we ate in and they said that their income was limited to $250,000. Now that could have been an urban myth or how they interpreted tax law. I don't know.

[BillyJoe]

T.A.M.,

Yeah, I'm not really knocking them. My father had great care during his final illness due to lung cancer, as has my son with his infected thyroglossal cyst, and my wife with her misscarriage and four subsequent pregnancies.

B.J.

[Dancing David]

Because it's not true.

I think this is part of the problem: Americans seem to actually believe this stuff, even the ones with enough education and intelligence who I think should be grounded in enough common sense to know better.

The fear is based on incredible, widespread, consumer misinformation. I'm not sure how to get around that. I suspect part of it is also jingoism: some people in any country enter cognitive dissonance when exposed to evidence that other countries could be doing better in even a trivial way.

Wow, I don't know about 'fear', 'jingoism', 'cognitive dissonance ' or what the fred you think I said. Maybe you should re-examine your prejudice. This was said to me by two owners of resteraunts in Windsor, ONT. They said that they could not earn more that $250,000/year.

Now as to why they said that I don't know. It could be tax law, I am not the one who made the statements to me.

To you and Linda!

Wow, did I hit a nerve, I am sorry but yo two are not reacting to me, but something that I am not. I support 'socialized medicine', 'single payor' and all sorts of things that the Canadians do, I grant that our US system wastes money in the private insurance game to the tune of 24% or something like that, as opposed to Cnada which is 6-8% administrative costs of insurance.

Just so you now, I am not jingoistic, I lived in Mexico for four years in my youth, as in really lived there, with Mexicans and every thing, not in some gringo colonia. I am a reformed socialist and if you spent any time reading my past threads in Current Events and Politics you might know that your assesment is way off base.

Shhesh, if I am wrong I am wrong, no big deal. I can give you the name of one of the bussinesses if you wish and you and Linda can contact the owner and browbeat him about it.

:)

[Dancing David]

That is SOP for Ivor.
Ivor seems to have a great many "unusual" ideas. His "Doctors are corrupt" kick is just the latest.


Not so new, this has different flavors and tones, there are many variations as well.

[Dancing David]

I smell straw.


Maybe you should wash it off?

;)

[fls]

Two small bussiness owners in Canada, Windsor ONT specifically said that they have income caps. Both ran resteraunts we ate in and they said that their income was limited to $250,000. Now that could have been an urban myth or how they interpreted tax law. I don't know.

Maybe it was a "This Hour Has 22 Minutes" episode.

http://en.wikipedia.org/wiki/Talking_to_Americans

Linda

[fls]

Now as to why they said that I don't know. It could be tax law, I am not the one who made the statements to me.

While they may have been having one over on you (it is kinda a national pastime ;)), I suspect they were referring to being taxed at a different level or something like that.

To you and Linda!

Wow, did I hit a nerve,

More like astonishment. I find the stereotype of the clueless American kinda cute and funny myself.

Does it not occur to you to check on something like that before you starting spreading it around?

Linda

[Ivor the Engineer]

evidence which indicates otherwise cannot rule out radio waves as a possibility either, can it? The fact is that the common cold, as you well know, will be gone regardless of treatment, in about a week for most people. If that was your point, well ok, but what of it.

What I'm being asked to provide is impossible to achieve in practice. There will always be sufficient wiggle room to claim any difference in cost and/or amount of treatment can be explained by other factors, even cases such as this one:

Perhaps the most notable evidence is the result of a random control trial which ‘converted’ Charles Phelps, one of the most trenchant critics of SID (see Phelps 1997 p254). In this, doctors at a university hospital clinic were randomised to receive income by salary or a fee for service. Patients attending the clinic were randomly assigned to doctors. The result was that fee-forservice doctors scheduled almost 30 percent more return visits than those on salary. Most of the discrepancy was attributable to a 50 percent greater scheduling of (medically doubtful) well care visits (Phelps 1997).

Fee for service provides an obvious temptation to exploit asymmetry of information.

Yes we respond to incentives, and yes we are human. Do you believe that the majority of the police force is corrupt?

In the UK it is required by law for the police to make audio recordings (http://www.icva.org.uk/site/downloads/PACE05/PACE_Chapter_E.pdf) of interviews with suspects. Video recordings (http://www.icva.org.uk/site/downloads/PACE05/PACE_Chapter_F.pdf) are currently optional.

Perhaps governments should try 'fee for arrests' remuneration for their police officers. What do you think might be the result of such a scheme?

Do you believe that anyone who is susceptable to incentive is corrupt?

I believe anyone is corruptible given the 'right' incentive(s).

Doctors have a moral code. Are there exceptions, people who will compromise care or ethics for extra dollars? of course.

Every group has a moral code. What makes doctors' moral code more robust than any other groups' moral code?

Where I practice, the idea of Doctor Driven Demand is ridiculous, as there are not enough doctors to keep up with the demand as it already exists.

<snip>

That does not mean what is being demanded is not being influenced by physicians.

[Ivor the Engineer]

This is your proof? :D

As I said, here in Australia you can wait a week for an appointment. Where is the incentive to overservice in this situation where the doctor is booked out for a week? Consider the alternative explanations, Ivor, they are at least as legitimate as yours.

<snip>

Do all treatments suggested by a physician result in the same remuneration to him/her?

If not then there is an incentive to recommend expensive treatments that are no better (as far as the patient is concerned) than cheaper alternatives.

An interesting fact is that as the number of GPs in an area increases, so does the demand for their services. E.g., figure 2 page 10 (http://www.buseco.monash.edu.au/centres/che/pubs/wp81.pdf).

The real significance of these two figures is twofold. First, they demonstrate the possibility of Supplier Induced Demand: such a correlation is an almost necessary, if not a sufficient condition for the existence of SID.

Secondly, it is possible that GPs locate their practices in areas of high autonomous demand. It is for this reason that a serious statistical analysis of cross-sectional data must attempt to take account of reverse causation and endogenise the GP supply. The importance of reverse causation could, however, be overstated. Age/sex standardization does not reduce the variation in either the 1976 or 1996 data significantly. Price, income and socio-economic variation are also insufficient to explain a significant part of the variation.

[blutoski]

Two small bussiness owners in Canada, Windsor ONT specifically said that they have income caps. Both ran resteraunts we ate in and they said that their income was limited to $250,000. Now that could have been an urban myth or how they interpreted tax law. I don't know.

Either way, I can't even concieve of an explanation other than just plain fabrication.

I am a part owner of many companies in Canada, - some in ON - and have never heard of such a thing, and it's ridiculous on the face. C'mon!

I was more marvelling that somebody could even think something as ridiculous as this was plausible, much less pass it on to a public skeptics forum without an attempt to verify.

UFOs: maybe; income caps: ridiculous.

[Dancing David]

While they may have been having one over on you (it is kinda a national pastime ;)), I suspect they were referring to being taxed at a different level or something like that.



More like astonishment. I find the stereotype of the clueless American kinda cute and funny myself.

Does it not occur to you to check on something like that before you starting spreading it around?

Linda

No, that is why I come here, to have my cherished beliefs trampled!

I think the man was sort of pining for a system more like the Us because he felt his income was limited. But you never know, he also told me the US dollar was trading 4 to the Canadian dollar. ;)

I was just trying to poke at Ivor, that was just one tactic. And it turns out i was told wrong. maybe I should check out that gold mine I bought as well.

[Dancing David]

Either way, I can't even concieve of an explanation other than just plain fabrication.

I am a part owner of many companies in Canada, - some in ON - and have never heard of such a thing, and it's ridiculous on the face. C'mon!

I was more marvelling that somebody could even think something as ridiculous as this was plausible, much less pass it on to a public skeptics forum without an attempt to verify.

UFOs: maybe; income caps: ridiculous.


I don't know, I find it hard to believe the way the lawe is enforced here is the south, we still have stupid stuff like pharmacists refusing to fill certain medications and the like.

So i was duped, no suprise to me, I suppose he was complaining about progressive taxation or some such. he also said that manufacturers have production limits, another fabrication I suppose.

I was more disappointed that I got 'table syrup' on my pancakes. The same corn fructose as in the US, I was hoping for a Mountie to serve my pancakes with fresh sirop d'erable. ;)

But i has a great time none the less, even the Leamington tomato festival was funny. It must be the only place that can grow tomatos , eh. If you start them in a greem house.

i was really impressed by the way people drove so politely.

ETA: I forgot stupid law outlawing pit bulls!

[T.A.M.]

What I'm being asked to provide is impossible to achieve in practice. There will always be sufficient wiggle room to claim any difference in cost and/or amount of treatment can be explained by other factors, even cases such as this one:



Fee for service provides an obvious temptation to exploit asymmetry of information.



In the UK it is required by law for the police to make audio recordings (http://www.icva.org.uk/site/downloads/PACE05/PACE_Chapter_E.pdf) of interviews with suspects. Video recordings (http://www.icva.org.uk/site/downloads/PACE05/PACE_Chapter_F.pdf) are currently optional.

Perhaps governments should try 'fee for arrests' remuneration for their police officers. What do you think might be the result of such a scheme?



I believe anyone is corruptible given the 'right' incentive(s).



Every group has a moral code. What makes doctors' moral code more robust than any other groups' moral code?



That does not mean what is being demanded is not being influenced by physicians.

I agree with you on almost every point actually. I think it is a matter of degree. How much, to what degree, does such tweaking of the system go on.

As for how the moral codes in "groups" might differ, you only have take the code of group A, and compare it with the CMA code of ethics to see.

TAM:)

[T.A.M.]

Do all treatments suggested by a physician result in the same remuneration to him/her?

If not then there is an incentive to recommend expensive treatments that are no better (as far as the patient is concerned) than cheaper alternatives.

An interesting fact is that as the number of GPs in an area increases, so does the demand for their services. E.g., figure 2 page 10 (http://www.buseco.monash.edu.au/centres/che/pubs/wp81.pdf).

Here in Canada, a physician, a GP, gets paid the same amount regardless of what he sees the patient for, and gets no positive financial incentive to send them to a specialist or for a procedure.

For any procedures I might do in clinic, the pay is actually so low, that I am better off referring them out for the procedure, as the time the procedure takes is not worth my effort. Despite that, I do them anyway, usually at the end of the day, so the time it takes does not interfere with my work day or my patient's wait time.

TAM:)

[paximperium]

Where I practice, the idea of Doctor Driven Demand is ridiculous, as there are not enough doctors to keep up with the demand as it already exists.

As someone who works at the County Hospital, we're the safety net of the community.

Business in booming. The ER's volume has doubled from over a year ago. We don't have have enough resources, the clinics are overfilled, the wait for a primary doctor is almost 2months long, the ORs are sometimes going through the night to clear the backlog in cases. It seems to be more a "patient driven demand".

I would be one of the first to criticize any physician in the community(and I do) who waste resources at this point, but I'm not seeing it. Most docs, even the private ones, are overwhelmed and have more than enough business at this point.

[Rolfe]

... the wait for a primary doctor is almost 2months long, the ORs are sometimes going through the night to clear the backlog in cases. ....


:eye-poppi

You're kidding! Americans keep telling us how they don't have waiting lists and we're in the dark ages because we might not get elective surgery the same week.

Here, we have to be able to see our GP within 48 hours, if necessary.

Sorry, I'm just really surprised because I thought that for all your system costs so much and excludes some people, when you were in nit it actually worked.

Rolfe.

[paximperium]

:eye-poppi

You're kidding! Americans keep telling us how they don't have waiting lists and we're in the dark ages because we might not get elective surgery the same week.

Here, we have to be able to see our GP within 48 hours, if necessary.

Sorry, I'm just really surprised because I thought that for all your system costs so much and excludes some people, when you were in nit it actually worked.

Rolfe.
This is for the uninsured which is what the County usually sees. If you have insurance it is different.

Oh, you can in and be seen within a week if you have a semi-emergent problem and you will definitely be treated for an emergency but elective stuff takes some time and to get a permanent Primary Doctor(not just who ever is available in the clinic) takes months.

[BillyJoe]

Do all treatments suggested by a physician result in the same remuneration to him/her?

As far as Australia is concerned, neither investigations nor treatments* suggested by a physician result in any remuneration to him. I can't imagine this happens anywhere unless the physician also owns the pharmacy or the pathology company.

*edit: I was thinking of drug treatments here, but this could also apply to physicians who remove skin lesions. This would, of course, result in remuneration to him. Off hand, I can't think of any other treatments that could be sensitive to the SID effect.

If not then there is an incentive to recommend expensive treatments that are no better (as far as the patient is concerned) than cheaper alternatives.Hmmm....do you know any physicians who also own the pharmacy or the pathology company. I would hope that this is outlawed because of concerns about conflict of interest.

An interesting fact is that as the number of GPs in an area increases, so does the demand for their services.If the area was undersupplied with GPs, then as new GPs came into the area, the number of services would increase. So, how do you know its not undersupply being satisfied rather than SID?

BJ


edit2: Here is an interesting quote from your last link:

...the existence of SID does not necessarily imply the need to regulate the medical market. If doctors are inducing services that are health promoting...it may be
judged unnecessary to regulate the sector...


Hmmm...I'm thinking that SID does not imply what you think it implies.
If SID includes services that are health promoting, we actually have no argument.

[BillyJoe]

Here, we have to be able to see our GP within 48 hours, if necessary.



Apparently capitation is coming to Australia. :)

Enrol with a GP and he has to attend to your every need at a price determined and paid by government.
I'm going to see if I can find a shonky one who'll split the proceeds, because the odds are excellent that I won't ever need to see him.

On the other hand, where do the chronics go? :confused:

BJ

[T.A.M.]

you can likely write off the "skin lesion" removal bit.

Here is Canada, to remove a skin lesion in your clinic, it takes about 20 minutes minimum. You walk in, talk briefly to patient. Get patient prepped, administer Xylocaine, wait 3-5 minutes for xylocaine to take, excise lesion, suture up lesion, dress it if needed, and discharge patient.

For your work you are paid about $15 more than a regular visit ($30.00). A grand total of $45. Now you take away 1/3rd for overhead (rental space, secretary, equipment, supplies), and another 1/3rd for taxes, and a GP takes home about $15 for the 20 minute procedure.

TAM:)

[T.A.M.]

Apparently capitation is coming to Australia. :)

Enrol with a GP and he has to attend to your every need at a price determined and paid by government.
I'm going to see if I can find a shonky one who'll split the proceeds, because the odds are excellent that I won't ever need to see him.

On the other hand, where do the chronics go? :confused:

BJ

They (the govt) have been trying to get this going here in Canada for years. Extremely opposed by most doctors for a variety of reasons.

1. Fixed salary just doesn't cut it for many.
2. Will lead to abuse, where first on the scene will select only the youngest, healthiest patients for their practice.
3. Where do the chronics, the elderly, the MMP (multiple medical problems) go?
4. Who sets your hours of work? Who sets the maximum # of patients before you close your practice? Can you be forced to do "on call"? Can you be forced to do house calls?

TAM:)

[BillyJoe]

They (the govt) have been trying to get this going here in Canada for years. Extremely opposed by most doctors for a variety of reasons.
Likewise the AMA over here.

1. Fixed salary just doesn't cut it for many.
Yeah, bummer hey, fixed salary but you're forced to do all the work no matter how much your patients demand of you.

2. Will lead to abuse, where first on the scene will select only the youngest, healthiest patients for their practice.
That was the point of my third sentence (well, I 'm not exactly young, but I'm healthy - 5 visits in half a life time aint bad!)

3. Where do the chronics, the elderly, the MMP (multiple medical problems) go?
Hey, you stole my last sentence.

4. Who sets your hours of work? Who sets the maximum # of patients before you close your practice? Can you be forced to do "on call"? Can you be forced to do house calls?
That, I believe, is the not so well hidden masterplan of our present Labor government. Well, you set your hours but you have to see all of the patients that are enrolled under your care. Close your practice? Are you kidding? The patients enrol with you. Yes, and meeting the needs of all the patients under your care obviously means doing all the on call and home visits.
Of course, the idea will be to introduce this in stages so there's not too much opposition all at once.

Want to migrate? :D

BJ

[BillyJoe]

Seriously, if I ever do need medical care, I don't want to be a patient of a doctor whose interest in his patients has been all but squeezed out of him by the overbearing actions of big brother government.

[Rolfe]

Could a British GP explain why these things don't seem to be a problem here? Or if they are, I never heard anyone talking about it.

Deetee, where are you?

Rolfe.

[T.A.M.]

Likewise the AMA over here.


Yeah, bummer hey, fixed salary but you're forced to do all the work no matter how much your patients demand of you.

It is a tough issue. Medicine, especially at the clinical level, is very much a mentor based system. As a result, we often admire greatly, and often imitate our mentors. This is good and bad. I have had great mentors, from a clinical/bedside manner pov, but they were also workhorses. The generation above mine and back further, saw medicine as a calling, something that took priority above EVERYTHING ELSE.

As a result, they buried themselves in their work at the sacrifice of their families, friends, and everything else.

That has changed with my generation. We now realize that medicine is a career, like any other in many ways. We now realize that Family and a life outside of medicine is just as important, if not more, then the career itself.

Why am I telling you all this? Because with this shift, comes a higher demand for MDs, simply because we are not willing to work the 90-100h weeks that our previous generation was. Of course there are still some who do, but they are few and far between.

Most in my generation are satisfied with a 50h work week. Most of us do not do house calls. The time it takes to get to a person's house, see them, etc... is just not worth it for most. Sounds selfish I know, but medicine is a business as much as a anything else.

For instance, in the time it takes me to do a housecall, and get paid the $80 it pays, I could see 6-8 patients at the clinic, paying $30 each. You do the math.

I am placing this long diatribe here, as it relates to the issue of patient demand and work load in Capitation versus Fee-For-Service (You run the show).

If it happens in the province I practice in, I will move...100%.


That was the point of my third sentence (well, I 'm not exactly young, but I'm healthy - 5 visits in half a life time aint bad!)


Hey, you stole my last sentence.

Patient selection will be the ultimate killer for Capitation. The argument is sound, and no one has provided a way to stop it, so I think it will be the nail that seals the Capitation Coffin.

As for your last sentence, Yes I stole it, it was good, Imitation is the most sincere form of flattery.



That, I believe, is the not so well hidden masterplan of our present Labor government. Well, you set your hours but you have to see all of the patients that are enrolled under your care. Close your practice? Are you kidding? The patients enrol with you. Yes, and meeting the needs of all the patients under your care obviously means doing all the on call and home visits.
Of course, the idea will be to introduce this in stages so there's not too much opposition all at once.

Want to migrate? :D

BJ

At present, nah, no plans to migrate. As for the masterplan, well I would say that the "Setting your own hours" thing is not as cut and dry. For instance, If I set my clinic to 9AM-4PM, and come 4PM there are 8 patients out in the waiting room, what do I do? Patients, and Govts know that Physicians are bound by their ethical code to not leave those patients unseen.

So ultimately, in that regard, you have no control over your hours. At least with Fee-For-Service there is the satisfaction of knowing that you are getting paid for those extra 8 patients. Now if their was some way to bill overtime for the hours you work, that might make some difference.


Seriously, if I ever do need medical care, I don't want to be a patient of a doctor whose interest in his patients has been all but squeezed out of him by the overbearing actions of big brother government.

That is the rub of it.

Capitation will leave some Docs (those who got into an area early and selected all of the young healthy patients for themselves) happy, and other docs VERY VERY BITTER.

TAM:)

[Ivor the Engineer]

As far as Australia is concerned, neither investigations nor treatments* suggested by a physician result in any remuneration to him. I can't imagine this happens anywhere unless the physician also owns the pharmacy or the pathology company.

*edit: I was thinking of drug treatments here, but this could also apply to physicians who remove skin lesions. This would, of course, result in remuneration to him. Off hand, I can't think of any other treatments that could be sensitive to the SID effect.

Page 26: (http://www.buseco.monash.edu.au/centres/che/pubs/wp81.pdf)

6 A Natural Experiment

Australia provides an interesting and unique laboratory for the examination of the relative importance of price and SID effects on patient demand. The perverse and idiosyncratic financing of health services results in a public sector in which hospital patients are treated without cost and a private sector in which, in return for the purchase of private health insurance, the patient is left with significant out of pocket expenses. In a simple market equilibrium public demand per capita would be expected to exceed private demand per capita. However, incentives facing doctors also differ. In the public hospital there is no financial benefit from the treatment of additional patients. In the private sector a full fee is earned. There is therefore no incentive for doctors to increase demand in the public sector and a strong incentive to increase it in the private sector.

In a recent study Richardson et al (1998) examined the treatment of patients after an emergency admission with a heart attack (acute myocardial infarction [AMI]). Various treatments are possible for AMI. The most expensive and recent of these include the diagnostic test, angiography, and the procedures collectively known as ‘revascularisation’, that is coronary artery bypass surgery, balloon angioplasty and stenting. Each of these four procedures attracts a significant fee. Differences in the rates of angiography and revascularisation for the Victorian population are shown in Table 5. In this, a percentage of patients receiving CARP (Coronary Artery Revascularisation Procedure) is shown in the first two columns and the likelihood of revascularisation in different hospital settings is shown in the subsequent columns in which the average likelihood of CARP for all AMI patients in Victoria is set equal to 100 in each year. Column entries show the likelihood of revascularisation in each setting after (indirect) age standardisation.12 Thus, in 1996 the likelihood of a private patient in a private hospital receiving CARP was 5.99 and 7.23 times greater for men and women admitted to private hospitals than the state average. The likelihood of public patients receiving revascularisation was 0.57 and 0.48 times the state average; that is, men and women were 10.5 and 15.1 times more likely to receive CARP as a private patient in a private hospital than as a public patient. It would require remarkably agile footwork to avoid the conclusion that these patterns were driven by physician judgement rather than patient preference.

Hmmm....do you know any physicians who also own the pharmacy or the pathology company. I would hope that this is outlawed because of concerns about conflict of interest.

Ever heard of private healthcare? Physician-owned hospitals?

If the area was undersupplied with GPs, then as new GPs came into the area, the number of services would increase. So, how do you know its not undersupply being satisfied rather than SID?

BJ

I don't.

Secondly, it is possible that GPs locate their practices in areas of high autonomous demand. It is for this reason that a serious statistical analysis of cross-sectional data must attempt to take account of reverse causation and endogenise the GP supply. The importance of reverse causation could, however, be overstated. Age/sex standardization does not reduce the variation in either the 1976 or 1996 data significantly. Price, income and socio-economic variation are also insufficient to explain a significant part of the variation.

edit2: Here is an interesting quote from your last link:

Hmmm...I'm thinking that SID does not imply what you think it implies.
If SID includes services that are health promoting, we actually have no argument.

That depends on the marginal cost and marginal utility of the service. E.g., using $1million worth of resources to extend a life 1 week would be a waste of resources (to give an absurd example).

[BillyJoe]

That has changed with my generation. We now realize that medicine is a career, like any other in many ways. We now realize that Family and a life outside of medicine is just as important, if not more, then the career itself.
Yes, it's obvious isn't it? But I wonder if patients see it that way. A political associate of my father (hey, it's actually embarrassing - look up the Australian DLP sometime :o) had a son who was so devoted to medicine that he never married. He did morning, afternoon, and evening sessions during the week and Saturday and Sunday mornings as well as being on call around the clock, and he never went on holidays. His patients absolutely loved him.

Most of us do not do house calls. The time it takes to get to a person's house, see them, etc... is just not worth it for most. Sounds selfish I know, but medicine is a business as much as a anything else.Yes and, taking the cue from your quote below, 6-8 other patients miss out on being seen that day. But what does a patient who is house-bound (eg elderly patient living alone, no car, or can't drive, or too sick) do when they are in need of medical care?

For instance, in the time it takes me to do a housecall, and get paid the $80 it pays, I could see 6-8 patients at the clinic, paying $30 each. You do the math.Am I reading you right that you are not alowed to charge a private fee for house visits.

Patient selection will be the ultimate killer for Capitation. The argument is sound, and no one has provided a way to stop it, so I think it will be the nail that seals the Capitation Coffin.How does it work in England then. But perhaps you're the wrong person to ask? Rolfe thinks Deetee might be able to inform us.

If I set my clinic to 9AM-4PM, and come 4PM there are 8 patients out in the waiting room, what do I do? Patients, and Govts know that Physicians are bound by their ethical code to not leave those patients unseen...So ultimately, in that regard, you have no control over your hours. At least with Fee-For-Service there is the satisfaction of knowing that you are getting paid for those extra 8 patients. Well, you have some control. At least you don't still have 8 patients come 6PM or 8PM :D. But, yes, I certainly see the downside of capitation for docs, and hence ultimately for patients. In Australia it is intended to only to GPs who seem to earn no more than a good tradesman. (A Specialist's degree, on the other hand, seems to be a licence to print money. But that's another story for another time).

BillyJoe.

[BillyJoe]

Page 26:
Ever heard of private healthcare? Physician-owned hospitals?

Yes, that is a study done in Victoria, Australia where I just happen to live, so I was actually interested to read most of it, including the bit you link to above. One problem, however, is that it uses terminology that it does not even try to define let alone reference.

Perhaps you can define "autonomous demand", "reverse causation", and "endogenising the supply" for me in the context of the study?

I have a problem with Specialist as I have just indicated above. But there is a control in place: Unless the patient is referred by a GP, the patient must bear the full cost of specialist intervention. Also, in Victoria, how many hospitals are owned by physicians? As far as I can tell, private hospitals are owned by businessmen, or medicos turned businessmen who no longer actually practise medicine. Do you know any different?

As for that specific study of the difference in treatment of Heart attack patients in private and public hospital settings (15 fold difference). How do you know that the treatment in the private hospital setting is not "best practice"? Because the authors of the study find it hard to believe? That study was in 1998 and it would be interesting and informative to see if the public system has moved significantly towards the private system in terms of managing heart attack victims since 1998. If it has, this would suggest that the private system was doing "best practice" long before the public system caught up - cost restraints and budgets could have held up adoption of best practice until the evidence for it could no longer be avoided. Perhaps only the private system had the money and the resources to test the hypotheses implied by these treatments and, once these hypotheses were confirmed, the public system followed suit.

Perhaps I'll ask you. Would you rather have Medicare save money by allowing part of your heart muscle to die, or would you rather Medicare spend a bit extra (okay, a fair bit extra*) to preserve your heart muscle?
*Of course the cost may be offset by possible savings of avoiding a second heart attack, avoiding treatment and hospitalisation for heart failure, and maintaining fitness for gainful employment.

The article doesn't mention what is the evidence-based best practice for management of heart attack, so how can they conclude that it is just SID. On the other hand, as I pointed out before, the article includes this statement:
"...the existence of SID does not necessarily imply the need to regulate the medical market. If doctors are inducing services that are health promoting...it may be judged unnecessary to regulate the sector..."
so, if SID includes services that are health promoting, SID may be actually be no argument at all against the medical profession.

I don't [know its not undersupply being satisfied rather than SID].Then, what exactly what is your argument :confused:

That depends on the marginal cost and marginal utility of the service. E.g., using $1million worth of resources to extend a life 1 week would be a waste of resources (to give an absurd example). Of course. But that means that, unless you know the answer to the question of "best practice" taking into account cost-effectiveness and what people are willing to pay to derive a certain benefit, how can you make a call on SID?

BillyJoe

[Skeptic Ginger]

Do humans respond to incentives?

Are physicians human?I don't believe any in the medical community here on the forum have claimed no health care providers are primarily motivated by financial reward. In fact, I'll go even further and say a few medical specialties are entered because they offer greater financial reward, not that everyone in those specialties is so inclined.

But what you seem to be missing is the fact most of us are motivated by professional rewards. That can be anything from being the top surgeon, a Nobel winner, a discoverer of cancer cures, to helping the poor around the world or teaching students. Being good at what you do is extremely rewarding, especially in the medical profession.

[T.A.M.]

Well said skeptigirl.

The rewards are many, the honors many. What other profession allows you the privilege of attending the final moments of a stranger's grandfather, the first moments of a newly born daughter? What other profession provides you with a glimpse of the deepest, and many times darkest, secrets within a man/woman.

I have smiled and felt a lump in my throat as I have lifted a newborn into the hands of a waiting mother. I have held the hand of an elderly woman until she drew her last breath. I have held back tears as I told a mother and sister that their son/brother was killed. Most in my profession have...and it is an honor to be allowed the privilege.

There is no profession like it on earth.

So ya, as I have said above, it is a career, but by far, it is, in my mind, the greatest career anyone could hope for. If it were simply about money, I wouldn't be working in Atlantic Canada, I assure you.

TAM:)

[Skeptic Ginger]

Well said skeptigirl.

The rewards are many, the honors many. What other profession allows you the privilege of attending the final moments of a stranger's grandfather, the first moments of a newly born daughter? ..Amazing you should bring up these examples. One of the earliest things I was awestruck with by my profession was thinking how amazing it was I had seen people born and die and how rare it was in our society to watch such important parts of our lives.

[BillyJoe]

Ivor,

You've heard from T.A.M. and Skeptigirl.
Now listen to your very own reference on SID:

http://www.buseco.monash.edu.au/centres/che/pubs/wp81.pdf

doctors exert greater effort when there is a need to do so.the existence of SID does not necessarily imply the need to regulate the medical market, if doctors are inducing services that are health promotingCasual observation strongly suggests that doctors firmly believe in the efficacy of their own treatments and, indeed, it would require a remarkable personality to believe that the training and practice of a lifetime did not result in the creation of highly valued servicesThe behaviour postulated here would be less likely to occur if the doctor’s only motivation was the maximization of profit...the majority..of doctors have...only limited interest in...profit maximization, but a major concern with the achievement of professional objectives through the provision of what is perceived to be valued and needed medical services.The general point is that there are multiple explanations for doctor behaviour that are consistent with demand shift if the dynamics of the market are combined with the assumption of weak profit maximization, belief in the efficacy of the services provided, and a professional commitment to ethical behaviour.

regards,
BillyJoe

[BillyJoe]

Ivor,

I'm going to do one more thing for you.

I'm going to tell you what that paper you referenced is all about. But first I'm going to give you the chance to tell me. I think it should take only a small paragraph. So, if you haven't actually read it, as I suspect (and I sincerely apologise if you have), hey, it's only 35 pages long!

Okay, I'm feeling generous today, so I'm going to make it easier for you. You can skip the 3 pages of acknowledgements at the start, the 8 pages on cross-sectional data in the middle (I'll explain why later), and the 9 pages of references and appendices at the end. That leaves only 15 pages.

Enjoy!

BillyJoe

[kellyb]

If that was the case then presumably more unnecessary procedures would be done in places where doctors were on performance related pay. Is there any evidence for this?

Yuri

There's this. It's more about unnecessary visits than procedures, though.

http://pediatrics.aappublications.org/cgi/content/abstract/80/3/344

Physician Reimbursement by Salary or Fee-for-Service: Effect on Physician Practice Behavior in a Randomized Prospective Study
Gerald B. Hickson MD1, William A. Altemeier MD1, and James M. Perrin MD1

1 From the Department of Pediatrics, Vanderbilt University, Nashville, Tennessee



We used a resident continuity clinic to compare prospectively the impact of salary v fee-for-service reimbursement on physician practice behavior. This model allowed randomization of physicians into salary and fee-for-service groups and separation of the effects of reimbursement from patient behavior. Physicians reimbursed by fee-for-services scheduled more visits per patient than did salaried physicians (3.69 visits v 2.83 visits, P < .01) and saw their patients more often (2.70 visits v 2.21 visits, P < .05) during the 9-month study. Almost all of this difference was because fee-for-service physicians saw more well patients than salaried physicians (1.42 visits and .99 visits per enrolled patient, respectively, P < .01). Evaluating visits by American Academy of Pediatrics' guidelines indicated that fee-for-service physicians saw more patients for well-childcare than salaried physicians because they missed fewer recommended ommended visits and scheduled visits in excess of those recommendations. Fee-for-service physicians also provided better continuity of care than salaried physicians by attending a larger percentage of all visits made by their patients (86.6% of visits v 78.3% of visits, P < .05), and by encouraging fewer emergency visits per enrolled patient

The effect is not huge, and I would guess it's more of a subconscious bias popping up from the incentive than "corruption".

I'm pretty sure this principal (physicians respond to financial incentives by altering clinical practice) is behind the P4P initiatives, isn't it?

[kellyb]

Do you know who she's reacting to?

Linda

Stuff like this Washington Times editorial, I bet:

http://www.washingtontimes.com/news/2009/feb/11/health-efficiency-can-be-deadly/

Secreted in the House version of the stimulus bill the President is trying to rush through Congress is the germ of a major overhaul of the American health care system. One provision causing increasing concern is the future role of the National Coordinator of Health Information Technology, who will be in charge of collecting and monitoring the health care being provided to every American.

The purpose of the database is to help increase health care "quality, safety and efficiency." The first two goals are commendable, but what does efficiency mean?

There is no telling what metrics will be used to define the efficiencies, but it is clear who will bear the brunt of these decisions. Those suffering the infirmities of age, surely, and also the physically and mentally disabled, whose health costs are great and whose ability to work productively in the future are low.

This notion is fully in the spirit of the partisans of efficiency but came from a program instituted in Hitler's Germany called Aktion T-4. Under this program, elderly people with incurable diseases, young children who were critically disabled, and others who were deemed non-productive, were euthanized. This was the Nazi version of efficiency, a pitiless expulsion of the "unproductive" members of society in the most expeditious way possible.




:rolleyes:

[GreyICE]

Stuff like this Washington Times editorial, I bet:

http://www.washingtontimes.com/news/2009/feb/11/health-efficiency-can-be-deadly/
:rolleyes:

Obama = Hitler.

Why obvious really. How did we ever miss it?

How does this editorial, which would pretty much qualify as blatant trolling on the internet, get published in a 'real paper?'

Oh that's right, the only man left talking about media responsibility is Jon Stewart.

[Ivor the Engineer]

I don't believe any in the medical community here on the forum have claimed no health care providers are primarily motivated by financial reward. In fact, I'll go even further and say a few medical specialties are entered because they offer greater financial reward, not that everyone in those specialties is so inclined.

But what you seem to be missing is the fact most of us are motivated by professional rewards. That can be anything from being the top surgeon, a Nobel winner, a discoverer of cancer cures, to helping the poor around the world or teaching students. Being good at what you do is extremely rewarding, especially in the medical profession.

I'm not missing anything at all:

Direct financial reward is not the only incentive for medical professionals to engage in SID.

It has already been mentioned that physicians in the US often perform tests they know are pointless to protect themselves from being sued (though this may also be used as a rationalisation to justify extracting more money from the patient:)). This would be SID to avoid a possible loss of money and public image. SID may also occur for internal rather than external payoffs. E.g., associating more care with better care.

The overarching priority for a medical professional is to be an advocate for what her patient wants, not what she wants. As soon as she lets her personal motivations (e.g., being the top surgeon, a Nobel winner, a discoverer of cancer cures, to helping the poor around the world or teaching students) interfere with her patient's treatment choices, SID will likely occur.

[Ivor the Engineer]

Ivor,

I'm going to do one more thing for you.

<snip>

And I'm going to tell you to stop with the patronising tone.

[fls]

Stuff like this Washington Times editorial, I bet:

http://www.washingtontimes.com/news/2009/feb/11/health-efficiency-can-be-deadly/

:rolleyes:

Wow.

Thanks. I got the impression that she was responding to something specific. She also seems to be responding to comments from physicians, as well.

Linda

[Skeptic Ginger]

I'm not missing anything at all:



[snip] As soon as she lets her personal motivations (e.g., being the top surgeon, a Nobel winner, a discoverer of cancer cures, to helping the poor around the world or teaching students) interfere with her patient's treatment choices, SID will likely occur.
Good grief, now you've twisted pride in doing a good job into a grab for personal fame.

Earth to Ivor, some of us consider what the patient wants IS a big part of doing a good job.

[the snipped part]The overarching priority for a medical professional is to be an advocate for what her patient wants, not what she wants.:id:

You should consider your own words here considering you have so much to say about what your personal preferences are for what the NHS should or shouldn't cover.

[Skeptic Ginger]

Wow.

Thanks. I got the impression that she was responding to something specific. She also seems to be responding to comments from physicians, as well.

LindaI looked for some other blog entries by Ms Begley and this one seemed analogous. The 3 comments reveal a lot.

Tuna Industry 1, Science 0 (http://blog.newsweek.com/blogs/labnotes/archive/2009/03/12/tuna-industry-1-science-0.aspx)

[balrog666]

More evidence that medical professionals (as a group) are excellent at gaming the system to maintain or increase their remuneration:

http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1069862


As opposed to every other profession?

:rolleyes:

[paximperium]

And I'm going to tell you to stop with the patronising tone.
Pot meet kettle.

[BillyJoe]

And I'm going to tell you to stop with the patronising tone.

Well, you must have clapped your hands with joy when you read that line. Now, instead of posting insubstantial replies to my posts amongst slabs of copy-and-pastes, you have an excuse to simply not answer at all.

Oh well, I suppose I should have put a smiley in there somewhere. :(

BJ

[Ivor the Engineer]

Good grief, now you've twisted pride in doing a good job into a grab for personal fame.

Earth to Ivor, some of us consider what the patient wants IS a big part of doing a good job.

I'm sure I read several posts (some of which were by physicians) which stated that many medical procedures are performed to avoid being sued by a patient. E.g.,

My anecdotal experience:
How much of this is

Cover my ass? 50%

Profit driven? 10%

Ignorance of current best practice? 40%


In many cases CYA is supplier induced demand.

You should consider your own words here considering you have so much to say about what your personal preferences are for what the NHS should or shouldn't cover.

As a member of society who contributes to the UK's NHS I am entitled to express an opinion* as to what services I think it should and should not cover. Do you disagree?


*Though I appreciate and am not bothered that no one particularly cares about what I think.:)

[BillyJoe]

Oh, and T.A.M., Paximperium, and Skeptigirl...

...don't you dare enjoy yourselves while you're helping all those patients. :D

[Ivor the Engineer]

As opposed to every other profession?

:rolleyes:

Physicians as a group are no worse or better than any other professional group at attempting to game the system in their favour. The primary difference is in the opportunity physicians have to do it compared to other professionals.

[paximperium]

I'm sure I read several posts (some of which were by physicians) which stated that many medical procedures are performed to avoid being sued by a patient. E.g.,
And that somehow equates to me not enjoying my job or caring about what my patient's want?

Well selective quoting and cherry picking is your forte after all.


In many cases CYA is supplier induced demand.
Repeatedly repeating this claim does not magically make it true.

[paximperium]

Physicians as a group are no worse or better than any other professional group at attempting to game the system in their favour. Congratulations, you've just proven that physicians are human...again and again and again...a fact that no one has an issue with at all.

The primary difference is in the opportunity physicians have to do it compared to other professionals.
Congratulations. You've made a repeated claim that has yet to magically become true.

[Dancing David]

Physicians as a group are no worse or better than any other professional group at attempting to game the system in their favour. The primary difference is in the opportunity physicians have to do it compared to other professionals.

More assertion of opinion, great Ivor, why don't you admit it. You can't substantiate this claim either.

[Ivor the Engineer]

And that somehow equates to me not enjoying my job or caring about what my patient's want?

<snip>

*Sigh*

No, it doesn't.

Repeatedly repeating this claim does not magically make it true.

How is CYA not supplier induced demand? I.e. do patients regularly come in and ask to be tested and/or treated for everything their physician can think of because they happen to be particularly litigious?

[Ivor the Engineer]

More assertion of opinion, great Ivor, why don't you admit it. You can't substantiate this claim either.

You are of course free to ignore the obvious conclusions of the evidence KellyB and I have presented and choose to believe a more warm and fuzzy interpretation.

[T.A.M.]

I think the clarification needed here is the impetus, or causative factor behind this so called PID. In the case of CYA, I guess technically it is Physician induced, and it is increasing "demand".

However, I think the jist of the topic, and what most here are taking from it, is that PID is a money/profit driven increase in physician services brought on by the providers themselves. Covering your ass is not, for the most part, profit/income driven, but rather is their because medicine is gray, not black and white, and despite all that we know, there are Zebra exceptions to every stable full of horses, so we do at times order tests on the off chance that if we do not, we may miss the zebra.

TAM:)

[Rolfe]

You know, lots of vets do work on a fee-per-service basis. And there definitely are some who will over-investigate and over-prescribe for financial reasons. And instruct their salaried assistants to do likewise. Some of them (probably most of them) try to excuse it as CYA, but that's justification, no more.

But you know what? Most vets aren't like that.

I'm fairly sure the medical profession is similar.

Rolfe.

[Dr. Imago]

Ivor,

Last night I ended-up taking an 89-year-old patient to the OR emergently for an infected wrist that need to be debrided.

Prior to taking him, when I did an physical exam in the Emergency Department, I noticed a Grade III/VI systolic ejection murmur at his right sternal border. I looked through his medical records, and there was no mention of a murmur as recently as this past December.

I spoke to the Orthopedic surgeon and informed him that I wanted to get an echocardiogram, something that hadn't been done on this patient since 1997, before we went to the operating room.

I had to call the cardiologist at home and have him come into the ED and do a limited echo. The patient had a body habitus that wasn't amenable to a great study, but in it I could see that he had good coaptation of his aortic valve despite a moderate to severe degree of annular calcification. We weren't able to quantify the degree of stenosis, but he didn't have a significant degree of ventricular hypertrophy or wall motion abnormality - despite an EKG that demonstrated Q-waves consistent with a prior MI in the inferior leads. Likewise, we were able to see that he didn't have any vegetations on any of his valves indicative of infective endocarditis.

Long story short?

I took this guy to the OR, induced general anesthesia, and he ultimately did fine. So, in a sense, it could be said ex post facto that this test was an additional charge to this patient, an 89-year-old, for a relatively minor procedure. He (or his insurance) is going to get a bill for a STAT echocardiogram in the ED. I didn't produce any additional income for myself, but I certainly added some money to the coffers of the Cardiology department.

So, did I "game the system"? If you think so, please explain to me what I did wrong and what I should've done instead. And, while you're doing that, imagine that this was your father or grandfather laying in that hospital bed.

Thanks!

~Dr. Imago

[Ivor the Engineer]

Dr. Imago,

From your description is sounds like you detected what may have been a sign of a condition which could have caused serious complications during the operation, so it seems reasonable that you investigated it further before proceeding.

Is your claim that a salaried physician would not have investigated the heart murmur further?

[Dr. Imago]

First off, I am a salaried physician. I get no additional "performance" incentive.

Secondly, many physicians may have taken that patient to the operating room without the echo. They might have blocked that arm. They might have done it under local. They might have done a whole host of other anesthetic techniques to avoid the complication.

The patient wanted to be "out" for the procedure. I heard a murmur. I insisted, having had one of my colleagues kill a patient a few weeks ago after inducing anesthesia on a patient with critical aortic stenosis, on the echocardiogram.

My assertion is that a lot of studies attempt to quantify the inscrutible. There is and always will be an individual practice variability. We all have our own forms of cognitive bias in a given clinical situation. To expect that we will all follow the same rules, and that somehow that is or should be predicated on whether or not someone gets an additional charge, is ridiculous.

I literally know hundreds of physicians professionally and personally. The ones that order unnecessary tests (and they are extremely rare) usually do so because they are nervous-nellies, not because they think they will get more money from an insurer. I'm a bit disappointed in you with your focus on physicians, when it is the private insurance business that is the real demon here. (Just look at what the top executives at Aetna make every year, in salary, bonuses, and stock options... I assure it is more than what 99.9% of physicians in the U.S. make).

So, I ordered what may have been by some considered to be an unnecessary test for the procedure undertaken. And, the results of that study didn't alter my anesthetic plan, although they could have.

I had no way of knowing that before I took that patient to the operating room and, if I'd killed him because of something I'd missed and could've prevented, I wouldn't have been able to live with myself.

This is the part of what we do that critics, like yourself, who believe we're out there trying to scam the public don't see. What's worse, is that you don't really have any solutions to what you perceive to be the problem either. You just like to cherry-pick studies that, in your own way, confirm your already preconceived notions and own form of cognitive bias.

~Dr. Imago

[kellyb]

When forming an opinion about national policies with regards to healthcare, I don't think it serves either patients or providers to deny that physicians are not immune to forming biases, consciously or not, based on compensation and incentives.
Third party payers know physician behavior can be influenced by both positive and negative financial incentives. That is the whole basis of P4P and the "never events" list.
And this matters for us all.

What do American MD's here think about this:

http://www.cms.hhs.gov/apps/media/press/release.asp?Counter=3041&intNumPerPage=10&checkDate=&checkKey=&srchType=1&numDays=3500&srchOpt=0&srchData=&srchOpt=0&srchData=&keywordType=All&chkNewsType=1%2C+2%2C+3%2C+4%2C+5&intPage=&showAll=&pYear=&year=&desc=&cboOrder=date

CMS is proposing to expand the list of conditions that need to be reported if present when a patient is first admitted and is seeking public comment on whether they should be added to the list in the final rule to be announced later this year. The list in the proposed rule includes:



Surgical site infections following certain elective procedures
Legionnaires’ disease (a type of pneumonia caused by a specific bacterium)
Extreme blood sugar derangement
Iatrogenic pneumothorax (collapse of the lung)
Delirium
Ventilator-associated pneumonia
Deep vein thrombosis/Pulmonary Embolism (formation/movement of a blood clot)
Staphylococcus aureus septicemia (bloodstream infection)
Clostridium difficile associated disease (a bacterium that causes severe diarrhea and more serious intestinal conditions such as colitis)


Beginning October 1, 2008, Medicare will no longer pay the hospital at a higher rate for the original eight conditions or any conditions added to the list in the final rule, if they were acquired during the hospital stay.

Could there not be unintended negative consequences (in addition to positive effects) of third party refusal to pay for some of those if, in fact, physicians respond to financial incentives?

[kellyb]

While this guy is a libertarian, I think the potential problems he sees are real.

http://covertrationingblog.com/general-rationing-issues/never-events-never-mind

If you guys are right, and physicians are uniquely immune among the human species to positive and negative financial incentives influencing behaviors, then it doesn't matter.
But if you are wrong, and reimbursements can have an effect upon your decision making process, then an awareness of this will serve us all well.

[Ivor the Engineer]

First off, I am a salaried physician. I get no additional "performance" incentive.

Then I don't see the significance of your anecdote.

<snip>

My assertion is that a lot of studies attempt to quantify the inscrutible. There is and always will be an individual practice variability. We all have our own forms of cognitive bias in a given clinical situation. To expect that we will all follow the same rules, and that somehow that is or should be predicated on whether or not someone gets an additional charge, is ridiculous.

I don't believe the difference in behaviour between salaried and fee-for-service physicians can reasonably be explained by individual practice variability.

I literally know hundreds of physicians professionally and personally. The ones that order unnecessary tests (and they are extremely rare) usually do so because they are nervous-nellies, not because they think they will get more money from an insurer. I'm a bit disappointed in you with your focus on physicians, when it is the private insurance business that is the real demon here. (Just look at what the top executives at Aetna make every year, in salary, bonuses, and stock options... I assure it is more than what 99.9% of physicians in the U.S. make).

Believe me, I've tried. I was derided and insulted in those threads as well.:)

So, I ordered what may have been by some considered to be an unnecessary test for the procedure undertaken. And, the results of that study didn't alter my anesthetic plan, although they could have.

I had no way of knowing that before I took that patient to the operating room and, if I'd killed him because of something I'd missed and could've prevented, I wouldn't have been able to live with myself.

This is the part of what we do that critics, like yourself, who believe we're out there trying to scam the public don't see. What's worse, is that you don't really have any solutions to what you perceive to be the problem either.

Two obvious solutions to the perverse incentives created by fee-for-service are salary and capitation, though these lead to different incentives which may be considered undesirable. I think, however, that these problems are easier to mitigate than those created by fee-for-service.

You just like to cherry-pick studies that, in your own way, confirm your already preconceived notions and own form of cognitive bias.

~Dr. Imago

I believe people respond to incentives. Is this an irrational belief?

[fls]

If you guys are right, and physicians are uniquely immune among the human species to positive and negative financial incentives influencing behavious, then it doesn't matter.

I don't think anyone is saying that physicians are uniquely immune. I think what is being pointed out is that there is very little opportunity for a change in behaviour to change financial renumeration, there are many other influences on behaviour, and attempting to indicate excess services is confounded by quite reasonable variations in need and practice.

But if you are wrong, and reimbursments can have an effect upon your decision making process, then an awareness of this will serve us all well.

I suspect you are way behind the curve on the issue of 'awareness'. This has been of interest to physicians for a lot longer than whenever it managed to hit the popular press.

Linda

[kellyb]

I don't think anyone is saying that physicians are uniquely immune. I think what is being pointed out is that there is very little opportunity for a change in behaviour to change financial renumeration, there are many other influences on behaviour, and attempting to indicate excess services is confounded by quite reasonable variations in need and practice.

Well, the randomized trial demonstrated that the effect of fee-for-service increasing visits is real. But the effect is small, and not particularly expensive, it appears. It's not something that bothers me or something I think is a key element in our skyrocketing healthcare costs.

I suspect you are way behind the curve on the issue of 'awareness'. This has been of interest to physicians for a lot longer than whenever it managed to hit the popular press.

Linda

Then why are the MDs on this thread trying to say that they're not influenced by reimbursements at all? Is it because everyone here is on salary, so the potential isn't even there? Or is the argument that only negative incentives can have an effect?

[Ivor the Engineer]

I don't think anyone is saying that physicians are uniquely immune. I think what is being pointed out is that there is very little opportunity for a change in behaviour to change financial renumeration, there are many other influences on behaviour, and attempting to indicate excess services is confounded by quite reasonable variations in need and practice.

<snip>

No, it is not.

Originally posted by KellyB:

http://pediatrics.aappublications.org/cgi/content/abstract/80/3/344

We used a resident continuity clinic to compare prospectively the impact of salary v fee-for-service reimbursement on physician practice behavior. This model allowed randomization of physicians into salary and fee-for-service groups and separation of the effects of reimbursement from patient behavior. Physicians reimbursed by fee-for-services scheduled more visits per patient than did salaried physicians (3.69 visits v 2.83 visits, P < .01) and saw their patients more often (2.70 visits v 2.21 visits, P < .05) during the 9-month study. Almost all of this difference was because fee-for-service physicians saw more well patients than salaried physicians (1.42 visits and .99 visits per enrolled patient, respectively, P < .01). Evaluating visits by American Academy of Pediatrics' guidelines indicated that fee-for-service physicians saw more patients for well-childcare than salaried physicians because they missed fewer recommended ommended visits and scheduled visits in excess of those recommendations.

[fls]

Then why are the MDs on this thread trying to say that they're not influenced by reimbursements at all? Is it because everyone here is on salary, so the potential isn't even there? Or is the argument that only negative incentives can have an effect?

Are you suggesting that they are only saying this because they were unaware of the issue until people like you brought it to their attention?

Linda

[kellyb]

No, it is not.

Originally posted by KellyB:

http://pediatrics.aappublications.org/cgi/content/abstract/80/3/344

And I don't think those docs that were influenced to schedule more visits are greedy, evil people. I bet there was a good reason for all of those extra visits. It's just "good reasons" the salaried physicians weren't subconsciously motivated to think of.

[Ivor the Engineer]

Well, the randomized trial demonstrated that the effect of fee-for-service increasing visits is real. But the effect is small, and not particularly expensive, it appears. It's not something that bothers me or something I think is a key element in our skyrocketing healthcare costs.

<snip>

Is 43% more visits per well patient small?

[kellyb]

Are you suggesting that they are only saying this because they were unaware of the issue until people like you brought it to their attention?

Linda

Can you not see how it would appear that MDs in this thread are in denial about the fact that physicians respond to financial incentives?
Back on page one Yuri asked:


If that was the case then presumably more unnecessary procedures would be done in places where doctors were on performance related pay. Is there any evidence for this?

Yuri

And the concensus was "Absolutely not, you heathen!"

[kellyb]

Is 43% more visits per well patient small?

I'll let someone else answer that. Small vs. large are relative.
Visits aren't that expensive, though.

[Rolfe]

You know, lots of vets do work on a fee-per-service basis. And there definitely are some who will over-investigate and over-prescribe for financial reasons. And instruct their salaried assistants to do likewise. Some of them (probably most of them) try to excuse it as CYA, but that's justification, no more.

But you know what? Most vets aren't like that.


The Today programme on ITV (8 to 8.30) just spent half an hour saying exactly that.

Rolfe.

[Ivor the Engineer]

The Today programme on ITV (8 to 8.30) just spent half an hour saying exactly that.

Rolfe.

Then why are vets so bloody expensive?

[kellyb]

The Today programme on ITV (8 to 8.30) just spent half an hour saying exactly that.

Rolfe.

I think most of the effect that shows up in the studies is probably not the result of unethical money grubbers (like the "bad vets" you know, who are rare), but rather a lack of extra compensation effectively muting the "more care is better care" bias.

[T.A.M.]

It is not as easy as:

Salaried = good
FFS = bad

Here are the advantages and problems I see with both (and I have been both).

Salaried:

Advantages:
- patient care is not negatively impacted by demands on physician time.
- Physicians get the benefits of set hours, health benefits, and paid vacation.

Disadvantages:
- Physicians have NO INCENTIVE to see any more patients then THEY DEEM reasonable.
- With less patients per day seeing the salaried physician, more physicians will be needed for a given area.

FFS:

Advantages:
- Physicians, driven by the bottom dollar, will see more patients per day, and work longer hours. You will need fewer physicians for a given area to do the same work.
- Physicians get to set their own hours, take vacation at their convenience, come and go as they please.

Disadvantages:
- Less time per patient, as a result of caseload, will dictate either (A) multiple visits for people with many different medical problems, or (B) a brush over of each problem in a single visit.
- In some cases, PID will insure that some percentage of visits (though I think relatively small) might be deemed redundant, or over cautious in nature.

I am sure there are other issues, but the above is what jumps out at me.

examples of the extremely bad for each...

1. I knew a SALARIED pediatrician who would see no more than 6 (SIX) patients in a 4 hour half day.

2. I knew a FFS Physician who would brag that some days (granted 10-12h days) he would see over 100 (one hundred) patients.

TAM:)

[paximperium]

1. I knew a SALARIED pediatrician who would see no more than 6 (SIX) patients in a 4 hour half day.

2. I knew a FFS Physician who would brag that some days (granted 10-12h days) he would see over 100 (one hundred) patients.

TAM:)
There are a few mixed systems that I believe are a compromise between both systems.

Some groups have a base salary with a percentage of the salary tied to performance or RVUs. Some will tie bonuses onto the productivity as well. Our ER group does this, we have base salary but a percentage of our salary and bonuses are tied to the productivity.

This allows for productive docs to be incentivized to see more patients effectively and chart better but if you are a slower and less productive doc and are happy to move at your pace(to a minimum degree of course), you get paid less.

This waters down both the pros and cons of FFS and salaried but I think it works well for our group.

[paximperium]

Oh yeah, here is a New England Journal article on the basic on physician compensation in the US and discusses the pros and cons.
http://www.nejmjobs.org/career-resources/physician-compensation-basics.aspx

[T.A.M.]

There are a few mixed systems that I believe are a compromise between both systems.

Some groups have a base salary with a percentage of the salary tied to performance or RVUs. Some will tie bonuses onto the productivity as well. Our ER group does this, we have base salary but a percentage of our salary and bonuses are tied to the productivity.

This allows for productive docs to be incentivized to see more patients effectively and chart better but if you are a slower and less productive doc and are happy to move at your pace(to a minimum degree of course), you get paid less.

This waters down both the pros and cons of FFS and salaried but I think it works well for our group.

I agree it isn't a bad compromise. Like I said, I have worked both sides of this fence.

I found the Salaried position left me with too little control. The medical board controlled when you worked. They knew they had you by the kahunas, so they rarely bothered to find locums to fill in gaps, rather they made you and your colleagues work it out. Vacation time allocation was a nightmare. As well, I found myself angry with my colleagues, who would only see 6-8 patients in a half day, while I still saw 15-20.

Fee For Service, while I agree I have to work faster, and sometimes split up visits for patients, offers myself A LOT more flexibility, and control.

TAM:)

[paximperium]

As well, I found myself angry with my colleagues, who would only see 6-8 patients in a half day, while I still saw 15-20.

Bah, work and medical ethics are overrated. Be a slacker.

[T.A.M.]

Oh yeah, here is a New England Journal article on the basic on physician compensation in the US and discusses the pros and cons.
http://www.nejmjobs.org/career-resources/physician-compensation-basics.aspx

good article.

TAM:)

[T.A.M.]

Bah, work and medical ethics are overrated. Be a slacker.

lol...it was tempting.

TAM;)

[fls]

Can you not see how it would appear that MDs in this thread are in denial about the fact that physicians respond to financial incentives?
Back on page one Yuri asked:

And the concensus was "Absolutely not, you heathen!"

Since that is very much not the response that Yuri received, the answer to your questions is simply that you are not listening to what people are saying.

Linda

[Ivor the Engineer]

All the companies I've worked for have had a really effective (and rarely used) incentive scheme for salaried employees who don't pull their weight as agreed in their contracts of employment. It's called "the sack".

[Ivor the Engineer]

I agree it isn't a bad compromise. Like I said, I have worked both sides of this fence.

I found the Salaried position left me with too little control. The medical board controlled when you worked. They knew they had you by the kahunas, so they rarely bothered to find locums to fill in gaps, rather they made you and your colleagues work it out. Vacation time allocation was a nightmare. As well, I found myself angry with my colleagues, who would only see 6-8 patients in a half day, while I still saw 15-20.

Fee For Service, while I agree I have to work faster, and sometimes split up visits for patients, offers myself A LOT more flexibility, and control.

TAM:)

Obviously I will want to see five or six randomised studies showing this effect before I even consider it to be plausible. After all, I'm sure employers responding to an incentive to exploit their employees is very rare.:)

[paximperium]

All the companies I've worked for have had a really effective (and rarely used) incentive scheme for salaried employees who don't pull their weight as agreed in their contracts of employment. It's called "the sack".
And if the contract says you need to see a minimum of 12 patients a day but they are 20 waiting? Apply that to 1000doctors under contract at a hospital.

[kellyb]

Since that is very much not the response that Yuri received, the answer to your questions is simply that you are not listening to what people are saying.

Linda

You're right. It was the response Ivor recieved for answering "yes" and presenting evidence.

[T.A.M.]

All the companies I've worked for have had a really effective (and rarely used) incentive scheme for salaried employees who don't pull their weight as agreed in their contracts of employment. It's called "the sack".

ah yes, but here is the thing.

In areas of North America, RURAL areas in particular, the salaried doctor has that covered. If they were to "sack" him, then who would they find to replace him? These areas offer very little in the way of modern amenities for the young urbanite doc (of which most graduates are). If they sack the pediatrician, they will be left with either (A) neither one at all, or (B) extra workload added to the 1-2 that might be left. Even if they find a candidate, who do you think the candidate will talk to before making the final move to the area? You think the disgruntled remaining docs, or the "sacked" one will have positive things to say?

You see, in order to get many docs to work in rural areas, the employers already sacrifice much. Sure, they can demand that the doc work from 8 til 5, but they would not dare set a number to what that doc feels is a "safe" number of patients to see in that time period. They would not dare ask a doc to go faster than his skills would safely allow...he knows this, they know it.

Is this horrible, yes, but it exists, and I was using it as an example of the extreme case.

TAM:)

[T.A.M.]

Obviously I will want to see five or six randomised studies showing this effect before I even consider it to be plausible. After all, I'm sure employers responding to an incentive to exploit their employees is very rare.:)

lol...

Yes it is anecdotal evidence, but I presented it as nothing more.

TAM:D

[Ivor the Engineer]

And if the contract says you need to see a minimum of 12 patients a day but they are 20 waiting? Apply that to 1000doctors under contract at a hospital.

Then the hospital needs more doctors and/or the terms of the doctors employment needs to be renegotiated.

The other 8 patients getting to see a constantly tired, overworked doctor, making him/her more prone to mistakes, is not a good long-term solution to a staffing shortage.

[paximperium]

Then the hospital needs more doctors and/or the terms of the doctors employment needs to be renegotiated.

The other 8 patients getting to see a constantly tired, overworked doctor, making him/her more prone to mistakes, is not a good long-term solution to a staffing shortage.
What if they are not overworked?
Some of the docs could easily see 20 patients a day but a couple are only capable of 16 but are really really good with the families and elderly while a rare few could see up to 30.

Why should the most productive docs see more patients?
Do you fire the slower docs who are very good with their patients?
Who decides how many patients a doc must see?

[Ivor the Engineer]

ah yes, but here is the thing.

In areas of North America, RURAL areas in particular, the salaried doctor has that covered. If they were to "sack" him, then who would they find to replace him? These areas offer very little in the way of modern amenities for the young urbanite doc (of which most graduates are). If they sack the pediatrician, they will be left with either (A) neither one at all, or (B) extra workload added to the 1-2 that might be left. Even if they find a candidate, who do you think the candidate will talk to before making the final move to the area? You think the disgruntled remaining docs, or the "sacked" one will have positive things to say?

You see, in order to get many docs to work in rural areas, the employers already sacrifice much. Sure, they can demand that the doc work from 8 til 5, but they would not dare set a number to what that doc feels is a "safe" number of patients to see in that time period. They would not dare ask a doc to go faster than his skills would safely allow...he knows this, they know it.

Is this horrible, yes, but it exists, and I was using it as an example of the extreme case.

TAM:)

Perhaps the employer could offer physicians a higher salary, better holidays, etc. to work in less glamorous regions/specialties?

E.g., the civil service in the UK has "London pay" to compensate employees who work in the capital for their increased cost of living compared to other regions of the UK.

[paximperium]

Perhaps the employer could offer physicians a higher salary, better holidays, etc. to work in less glamorous regions/specialties?
They do. If I decide to pick up a job in rural Kentucky, my salary would be approx 40% higher with lower malpractice and a huge chunk of my student loans paid off but they still can't get those positions filled.

[T.A.M.]

What if they are not overworked?
Some of the docs could easily see 20 patients a day but a couple are only capable of 16 but are really really good with the families and elderly while a rare few could see up to 30.

Why should the most productive docs see more patients?
Do you fire the slower docs who are very good with their patients?
Who decides how many patients a doc must see?

exactly. As I mentioned, it is a can of worms the health boards often will not dare dive into. If they try to set a "minimum" number to be seen, then they are asking for an "overworked" argument if anything goes wrong with patient care. Then who is to blame for the "overworked" doc...well the big bad board who set the guideline. Sounds ridiculous, but it is true...it happens.

As well, you have to look at the fact that in many rural areas, doctors are at a premium.

It is easy to say "well just hire more doctors" but the areas I am talking about can barely keep the few docs they have. Many docs, fine docs, will as a result, work longer hours, seeing more patients than they would like, because they are taught - patients first.

Some docs, unfortunately, will realize all to well their worth, and the demand for their services, and will realize that they can do as they wish, with respect to # patients seen, because the boards would rather except this, then do without any physician at all, and the wrath of the community as a result....what happens, is the wait list to see the doc, in that case, is several WEEKS long.

TAM:)

[Ivor the Engineer]

What if they are not overworked?
Some of the docs could easily see 20 patients a day but a couple are only capable of 16 but are really really good with the families and elderly while a rare few could see up to 30.

Why should the most productive docs see more patients?

Because their salaries would be increased at their next performance appraisal.

Do you fire the slower docs who are very good with their patients?

Not if they are meeting the patient throughput they agreed to.

Who decides how many patients a doc must see?

The doctor's manager.

[Ivor the Engineer]

They do. If I decide to pick up a job in rural Kentucky, my salary would be approx 40% higher with lower malpractice and a huge chunk of my student loans paid off but they still can't get those positions filled.

Why not?

[T.A.M.]

Perhaps the employer could offer physicians a higher salary, better holidays, etc. to work in less glamorous regions/specialties?

E.g., the civil service in the UK has "London pay" to compensate employees who work in the capital for their increased cost of living compared to other regions of the UK.

I agree, and many of these things are offered, but this is often only enough to keep someone there for a year or two. As well, these incentives are not always what they seem.

For instance, you get holiday time, yes, but what if when you go to take your holidays, they cannot find a locum to replace you? If you are one of two doctors in that region, do you go on your 2 week vacation, and leave your colleague on 24/7 call for 2 weeks?

What about that financial incentive? Lots of good it will do you when you live in the middle of freaking nowhere, with nothing to spend it on.

I have lived in areas where the nearest Coffee shop was 150 miles away, the nearest Walmart the same.

Incentives help, but they are not even close to a cure all.

TAM:)

[T.A.M.]

Because their salaries would be increased at their next performance appraisal.



Not if they are meeting the patient throughput they agreed to.



The doctor's manager.

In Canada, there is no "doctor manager". There is an executive that runs a health care board. There is a hospital CEO who runs the entire hospital.

Canada, as a nation, has been battling with this for decades, and still has not come to a consensus.

TAM:)

[Ivor the Engineer]

<snip>

Some docs, unfortunately, will realize all to well their worth, and the demand for their services, and will realize that they can do as they wish, with respect to # patients seen, because the boards would rather except this, then do without any physician at all, and the wrath of the community as a result....what happens, is the wait list to see the doc, in that case, is several WEEKS long.

TAM:)

We had a similar problem with coal miners in the UK.

It did not end well for the miners.

[T.A.M.]

We had a similar problem with coal miners in the UK.

It did not end well for the miners.

yes, and a closed coal mine will wreak havoc with the local community, but what does a coal mining company care?

It is different when you are dealing with a govt institution (the hospital) and when you are dealing with PEOPLES LIVES, and who will heal/help/save them.

TRUST ME.

TAM:)

[fls]

You're right. It was the response Ivor recieved for answering "yes" and presenting evidence.

That makes sense. It is my impression that Ivor isn't any better at listening than you.

Linda

[kellyb]

That makes sense. It is my impression that Ivor isn't any better at listening than you.

Linda

Well you're a poopyhead.
HA! Take THAT!

[Ivor the Engineer]

That makes sense. It is my impression that Ivor isn't any better at listening than you.

Linda

Did you say something?

[fls]

Did you say something?

I SAID, "the COVER is GLISTENING with DEW."

Linda

[Ivor the Engineer]

yes, and a closed coal mine will wreak havoc with the local community, but what does a coal mining company care?

It is different when you are dealing with a govt institution (the hospital) and when you are dealing with PEOPLES LIVES, and who will heal/help/save them.

TRUST ME.

TAM:)

In this case the government just pays whatever price to a few locum doctors to provide a basic service until those striking have been softened up and the public hate them for letting baby Charley die of a chest infection.

[fls]

Well you're a poopyhead.
HA! Take THAT!

Well, there has been some interesting and useful information presented in this thread from people who have knowledge and experience in the area in question. It would be a shame to squander the opportunity.

Linda

[paximperium]

No comment.
In this case the government just pays whatever price to a few locum doctors to provide a basic service until those striking have been softened up and the public hate them for letting baby Charley die of a chest infection.
I just felt like quoting Ivor's own compassionate words.

[Skeptic Ginger]

Can you not see how it would appear that MDs in this thread are in denial about the fact that physicians respond to financial incentives?
....To reinforce what Linda said, this is false.

Health care providers are motivated by a mix of incentives, and individual billing practice ethics vary as they do in any other profession, was the answer I gave and read.

[Skeptic Ginger]

Is 43% more visits per well patient small?It could be if the % of well patient visits amounted to a tiny fraction of the patients seen.

[fls]

No comment.

I just felt like quoting Ivor's own compassionate words.

Has anyone here ever participated in a doctor's strike?

Linda

[Skeptic Ginger]

You're right. It was the response Ivor recieved for answering "yes" and presenting evidence.No, it was not. It was the response to Ivor drawing a conclusion based on a very narrow interpretation of a study on a single practice.

[Skeptic Ginger]

Has anyone here ever participated in a doctor's strike?

LindaI've never even participated in a nurse's strike. Half my career we were "professionals" and striking was unprofessional, and by the time real unions moved into the nursing profession, I was in non-contract positions.

[T.A.M.]

Doctor's Strikes are not very useful. The govt realizes that our ethics bind us to provide Emergency services even when on strike (like nurses) which renders our bargaining power almost useless. With Essential/Emergency Services provided for, the govt can wait out any group of health care providers.

TAM:)

[paximperium]

Doctor's Strikes are not very useful. The govt realizes that our ethics bind us to provide Emergency services even when on strike (like nurses) which renders our bargaining power almost useless. With Essential/Emergency Services provided for, the govt can wait out any group of health care providers.

TAM:)
Not the mention there aren't any doctor's unions in the US of any significant strength not to mention all the different specialties have completely different needs. Unionizing doctors is like herding cats

I can barely remember a doctor's strike in the US...the first one in the entire history of the US was in 1991 in NYC and I can't think of any recent ones.

[kellyb]

Well, there has been some interesting and useful information presented in this thread from people who have knowledge and experience in the area in question. It would be a shame to squander the opportunity.

Linda

Yes, I know you're fond of paternalistic attitudes. Patients have knowledge and experience on being on the receiving end of various incentive-induced physician behaviors.

I would think a discussion on how to set reasonable limits on the influence of third party payers on a physician's clinical judgment would be mutually beneficial, but perhaps you're right, and these things are best left to be sorted out among the third party payers who pay all of our healthcare-related bills and incomes.

We should leave the "doctor manipulating policies" discussions to the doctor manipulating experts.

You're still a poopyhead, though.

[paximperium]

Patients have knowledge and experience on being on the receiving end of various incentive-induced physician behaviors. Sure. It is anecdotal but it definitely has some uses in finding the underlying problems involved...it becomes an issue when people seem to never be able to see past their anecdotes and base all their conclusions on their own personal experience.

I would think a discussion on how to set reasonable limits on the influence of third party payers on a physician's clinical judgment would be mutually beneficial, <snipped useless strawman>So why don't you and Ivor actually do so?

We should leave the "doctor manipulating policies" discussions to the doctor manipulating experts.
That may very well be for the best. People who don't even seem to be able to get past their biases, actually listen to opposing opinion and actually have a productive discussion aren't very useful.

[Skeptic Ginger]

Have I told you how cute your avatar is, paxi?

[paximperium]

Have I told you how cute your avatar is, paxi?
Feed me.

[Skeptic Ginger]

Farmer Mallard, for all your Duck food requirements! (http://www.flickr.com/photos/misty69/2517915929/)

[kellyb]

So why don't you and Ivor actually do so?

I'm actually trying to. From my POV, I want to preserve the traditional patient/provider relationship as well as can be reasonable. I'm sort of picky about docs, but the ones who I like, I love. I trust their clinical judgment. I don't want them being manipulated by third party payers via incentives, be they positive or negative.

That may very well be for the best. People who don't even seem to be able to get past their biases, actually listen to opposing opinion and actually have a productive discussion aren't very useful.

My main dog in this race is my abhorrence with the art of coercing doctors to do what vested-interest laced guidelines demand. I think good doctors should be truly free to follow their clinical judgment. It should not cut into their paycheck if they see that a certain patient needs a treatment approach that deviates from the usual guidelines.

For me, as a patient, when looking at healthcare policy...I see a need to acknowledge that both positive and negative incentives can be used to influence physician behavior.
I have a small baby, and when I gave birth to her, my doc "let" me only do periodic (every 30 minutes or 1 hour for 15 or 30 minutes at a time) electronic monitoring, for example. He and I both knew the evidence supported this option as "as safe as" continuous monitoring. For me, the benefit of being able to wander around the room during labor was enormous. I have no idea if he would have made more money insisting that I do continuous monitoring because of CYA reasons. But I would definitely prefer that it not cost him something to have "allowed" me that option.

I think most docs are in medicine for altruistic reasons. But I think they are still human, and open bias from incentives and manipulation from their bosses like any other profession.

In the US, healthcare is really in a state of crisis. I think we have to acknowledge all the forces at play, and one of them (though far from the largest) is individual doctors' desire to stay afloat (in the case of PCPs) or make as much money as possible (on the other extreme end of specialists).

[kellyb]

Sure. It is anecdotal but it definitely has some uses in finding the underlying problems involved...it becomes an issue when people seem to never be able to see past their anecdotes and base all their conclusions on their own personal experience.

To get to the first point lastly...

My problems with MDs stems from various decisions coming from insurance companies, like the "6 minutes per patient" rules.
HALF of our combined income goes to medical insurance for our family. Half of our income. Absurdly hurried visits make me irritated.
But I know this is the result of a much larger problem that involves doctor reimbursement from insurance companies.

[BillyJoe]

My problems with MDs stems from various decisions coming from insurance companies, like the "6 minutes per patient" rules.
The "6 minutes per patient" rule?
Is ther really such a rule??
Here in Australia there certainily is not, although there are "bulk-billing" practices that rely on quick throughput to make up the difference between the private fee and the "bulk-billing" government fee, that are referred to as "6 minute medicine". There are not many though.

HALF of our combined income goes to medical insurance for our family. Half of our income.
Half you income???
Come to Australia! :)

[BillyJoe]

I want to preserve the traditional patient/provider relationship as well as can be reasonable. I'm sort of picky about docs, but the ones who I like, I love. I trust their clinical judgment.
It is often said that everyone thinks all doctors are crap...
...except their very own doc, who it just absolutely magnificent. :D

My main dog in this race is my abhorrence with the art of coercing doctors to do what vested-interest laced guidelines demand.Well, the guidelines, I would hope, are evidence-based.
Are they not?

I think good doctors should be truly free to follow their clinical judgmentGood doctors follow evidence-based guidelines but use their clinical judgement as to how to apply them to the particular patient in front of them. If they deviate from the guidelines (and this is allowed by the very word "guideline"), they must have good reasons for doing so.

It should not cut into their paycheck if they see that a certain patient needs a treatment approach that deviates from the usual guidelines.Does that really happen?

I think most docs are in medicine for altruistic reasons. But I think they are still human, and open bias from incentives and manipulation from their bosses like any other profession.Yes, doctors are human. No one is denying that. But Ivor is making more of this than it deserves. And all the studies he quotes are open to interpretation. That study he quoted from Victoria, for example, doesn't say what he says it says. He only makes it sound that way by selective quoting.

And I would think that the entrance requirements into medical school would weed out the "unfit" and, in that sense, doctors are likely to be more caring and compassionate than the average in our society.

In the US, healthcare is really in a state of crisis.You are not wrong. The largest per capita on health of any first world country and the least equitable.

[Rolfe]

I agree, and many of these things are offered, but this is often only enough to keep someone there for a year or two. As well, these incentives are not always what they seem.

For instance, you get holiday time, yes, but what if when you go to take your holidays, they cannot find a locum to replace you? If you are one of two doctors in that region, do you go on your 2 week vacation, and leave your colleague on 24/7 call for 2 weeks?

What about that financial incentive? Lots of good it will do you when you live in the middle of freaking nowhere, with nothing to spend it on.

I have lived in areas where the nearest Coffee shop was 150 miles away, the nearest Walmart the same.

Incentives help, but they are not even close to a cure all.

TAM:)


I know it's not as bad, but compatre this story I noticed in the paper a couple of days ago.

Just what the doctor ordered (http://www.theherald.co.uk/search/display.var.2495459.0.600mile_move_to_the_highland s_is_just_what_the_doctor_ordered.php)

A doctor is moving almost 600 miles to care for only 265 people in a remote Highland community after beating off applications from around the world for the part-time post.

Dr Mark Darbyshire, 34, will next month quit his job as a GP in Chepstow, South Wales, for the wilds of the Wester Ross peninsula of Applecross, which is currently finding fame in BBC TV series, Monty Hall's Great Escape.

Dr Darbyshire said he had no regrets about taking up the job after the local community drummed up interest in the vacant post by advertising it in outdoors magazines and on its own website.One of the hopeful candidates was even willing to commute between Scotland and his home in the US. [....]

When he moves to Wester Ross with his partner and two dogs, Dr Darbyshire will share the workload and £70,000 salary with the current long-serving GP Dr Janice Cargill - who provides out-of-hours cover. Until now she has been the only doctor in the area and has been on call 24 hours a day for up to six weeks at a time. [....]


Seems to have been plenty of interest in the post. Mind you, Applecross isn't 150 miles from a coffee shop, and how hard can it be, with only 265 patients on your list?

Rolfe.

[Dancing David]

Obviously I will want to see five or six randomised studies showing this effect before I even consider it to be plausible. After all, I'm sure employers responding to an incentive to exploit their employees is very rare.:)

Unlike your assertions which are not from 5-6 randomised studies.

Sorry, exploitation of salaried employees is common. In much of the US there is NO implied contract, I work in Illinois. Illinois is a 'right to work state', it means there is no implied contract, they can change the terms of your employeement at any time. And if you don't like it, there is the door.
When I worked for mental health agencies (1990-2000, 2003-2005) or for domestic violence (2000-2003) there was no compensation for over time. Period, and you were required to work it as needed. We were allowed to 'flex' meaning if your supervisor approved (and sometimes they did not) then you could take it off as straight time, but often you could not. So they increase your case load, and you no longer have anytime to do paperwork during the work day, That means an hour to an hour and a half each day, doing paper work at home. All without compensation.

So if they say, 'you have to staff the shelter' and you work another eight hour shift, that is what you do. if they say, 'that is flex' then you say 'okay', if they say 'that is not flex' then you say 'okay'.

This is also a common corporate practice, especially for salaried employees.

[Ivor the Engineer]

<snip>

And I would think that the entrance requirements into medical school would weed out the "unfit" and, in that sense, doctors are likely to be more caring and compassionate than the average in our society.

<snip>

What entry requirements to medical school make you believe doctors are likely to be more caring and compassionate than the average person in their society?

Given that there are far fewer places in medical schools than people applying for them, why would the resulting competition select for the more caring and compassionate people?

It seems one of the main motivations doctors get is interacting with and being thanked by the people they help.

Most professionals are helping other people, yet few need the gratification of interacting with them.

[fls]

Doctor's Strikes are not very useful. The govt realizes that our ethics bind us to provide Emergency services even when on strike (like nurses) which renders our bargaining power almost useless. With Essential/Emergency Services provided for, the govt can wait out any group of health care providers.

TAM:)

I participated in a doctor's strike when I was in Canada, and it was successful.

At the time I was at the university hospital. The physicians attending on the clinical teaching units were subject to the same fee schedule as specialists working in the community, even though the work that we did was very different in amount and kind from that of a community internist.* The bulk of the work was done by my section (General Internal Medicine), and while we wouldn't have minded more pay, our real problem was getting any other sub-specialist physicians to participate in the schedule. Because of the way that they were renumerated, it represented a huge pay cut for a sub-specialist to take on a 2-week stint on the hospital service vs. a 2-week stink on their hospital consult service. We took our complaints to the department of health - the work we were performing was far in excess of those who were paid the same amount and there were serious and unsustainable staff shortages due to inequalities in renumeration - but they wouldn't even come to the table and talk to us since, as far as they could tell, the services paid for were commensurate with what was needed. So we simply informed them that if what they were paying for was adequate, we were going to simply stop performing those services they had deemed unnecessary by virtue of making them not worthy of renumeration. This meant that we would no longer free up hospital beds by managing certain patients as outpatients (which required visits in excess of the once per week we could charge for), we no longer transferred patients from surgical wards to medical wards if their care became complicated (as renumeration was based on length on time in hospital regardless of whether the length was due to complications vs. babysitting for rehab or nursing home placement), we no longer accepted patients for admission who had already been seen by a specialist (the attending physician would not receive any renumeration for their complete history/physical/evaluation), etc.

It lasted for less than two days, I suspect mostly because of the effect on the surgical wards - it seems that people listen to surgeons, I wish I knew why. Anyway, they agreed to sit down and take another look at the fee schedule and as a result we moved to block funding rather than fee-for-service. But it's true that we were very reluctant to take that step and we really wouldn't have held out for very long.

Linda

*I used to fly in to smaller communities to provide consultation services and I was often asked to see hospital patients and ICU patients, as well. The typical hospital patient was similar to one of my more stable outpatients, and the typical ICU patient would be similar to one of my not-very-sick hospital inpatients.

[fls]

Yes, I know you're fond of paternalistic attitudes.

That's another good example.

I said: People with knowledge and experience have provided useful and interesting information.

You heard: People should be sub-ordinate to authority figures.

Are authority figures the only people with knowledge and experience? Does the act of carefully considering information mean you are sub-ordinate?

I would think a discussion on how to set reasonable limits on the influence of third party payers on a physician's clinical judgment would be mutually beneficial, but perhaps you're right, and these things are best left to be sorted out among the third party payers who pay all of our healthcare-related bills and incomes.

Another good example.

I said: It would be shame to squander the opportunity.

You heard: We should squander the opportunity by avoiding discussion.

I think I've figured it out, though.

We should leave the "doctor manipulating policies" discussions to the doctor manipulating experts.

Yes, it is clearly unreasonable to attempt to understand ways we can maximize outcomes and efficiency, and to make the attempt represents unwarranted manipulation of the physician-patient relationship. Instead, physicians should be free to figure out how best to line the coffers of some git they don't know at great personal and professional expense.

Linda

[Ivor the Engineer]

In Canada, there is no "doctor manager". There is an executive that runs a health care board. There is a hospital CEO who runs the entire hospital.

Canada, as a nation, has been battling with this for decades, and still has not come to a consensus.

TAM:)

That sounds like a really poor organisational structure. Why do you think it has persisted for so long?

[Ivor the Engineer]

That's another good example.

I said: People with knowledge and experience have provided useful and interesting information.

You heard: People should be sub-ordinate to authority figures.

Are authority figures the only people with knowledge and experience? Does the act of carefully considering information mean you are sub-ordinate?

<snip>

Perhaps I missed it, but other that anecdotes, KellyB and I are the only people to have provided any useful and interesting information.

Or do anecdotes trump data sets when the issue is close to your heart?

[fls]

Perhaps I missed it, but other that anecdotes, KellyB and I are the only people to have provided any useful and interesting information.

Or do anecdotes trump data sets when the issue is close to your heart?

Yes.

Linda

[Ivor the Engineer]

Linda said: "Yes."

Ivor heard: "**** off."

:D

[fls]

Linda said: "Yes."

Ivor heard: "**** off."

:D

I rest my case.

Linda

[kellyb]

Linda said: "Yes."

Ivor heard: "**** off."

:D

Apparently we do share the same hearing disability, Ivor.
:D

[Ivor the Engineer]

I rest my case.

Linda

Do you think there's an under supply of physicians?

If so, what do you think are the causes and how may they be mitigated?

(I'm listening:))

[fls]

Do you think there's an under supply of physicians?

Yes.

If so, what do you think are the causes and how may they be mitigated?

(I'm listening:))

More sex.

Linda

[Ivor the Engineer]

Do you have any serious answers to my questions, or am I beneath contempt?

[JJM]

{snip} More sex.

LindaIt is refreshing to see someone use the word "sex" since "gender" is overused by the "politically correct" crowd.

[Professor Yaffle]

Is more sex the cause or the proposed method of mitigating the problem?

[GreyICE]

Do you have any serious answers to my questions, or am I beneath contempt?

False dichotomy - one who is not 'beneath contempt' may ask questions that another person might not think are worthy of answer. By attempting to make the question personal, you force a person to either 'be mean' to you, or address your question, which they did not feel was particularly worthy of address in any respect - potentially because it was an emotion-based question, one designed to derail the conversation, or simply stunningly irrelevant.

Since this debate tactic is fundamentally both dishonest and stupid (dishonest since it leverages a logical fallacy into the 'poor victim' stance, stupid since it is so easily identified that only one fundamentally damaged would either believe it effective or find it likely to be), it might cause one to lower one's opinion of the person using it several notches.

[Ivor the Engineer]

Is more sex the cause or the proposed method of mitigating the problem?

Exactly what I was thinking.

What puzzles me is why doctors believe it is necessary to do 48+ hr. weeks to become competent. E.g.,

http://esciencenews.com/articles/2008/08/01/working.time.regulations.are.failing.doctors.and.p atients

Recent changes to working regulations in the UK are seriously damaging the working life and education of junior doctors and patients are also suffering, warn senior doctors on BMJ.com today. The British government must relax the regulations of the European Working Time Directive (EWTD) or it could spell disaster for medicine in the UK, say the authors.

"British medicine is highly respected worldwide because of the training provided and the breadth of experience and clinical expertise of most consultants and GPs", write Hugh Cairns and colleagues from King's College Hospital in London. But the EWTD is threatening this reputation by having a negative effect on medical training and taking doctors away from direct patient care. No amount of teaching can substitute for this practical experience, they add.

Introduced to improve workers' safety and protection, the directive changed the maximum working week to 56 hours in 2007, with a planned further reduction to 48 hours in 2009, and a minimum requirement of 11 hours rest in any 24 hour period.

According to the authors, these changes have posed considerable problems for medicine in the UK because of the need for junior medical staff to work long hours to fulfil training requirements and to provide a 24 hour service to patients.

:boggled:

[Ivor the Engineer]

False dichotomy - one who is not 'beneath contempt' may ask questions that another person might not think are worthy of answer. By attempting to make the question personal, you force a person to either 'be mean' to you, or address your question, which they did not feel was particularly worthy of address in any respect - potentially because it was an emotion-based question, one designed to derail the conversation, or simply stunningly irrelevant.

Since this debate tactic is fundamentally both dishonest and stupid (dishonest since it leverages a logical fallacy into the 'poor victim' stance, stupid since it is so easily identified that only one fundamentally damaged would either believe it effective or find it likely to be), it might cause one to lower one's opinion of the person using it several notches.

In Linda's case I don't think that's possible, though obviously I'm still trying.;)

[kellyb]

Well, the guidelines, I would hope, are evidence-based.
Are they not?


Well, the people developing the guidelines would say they are. Individual doctors might disagree about some of them:

http://jama.ama-assn.org/cgi/content/short/301/8/868

Most current articles called "guidelines" are actually expert consensus reports. It is not surprising, then, that the article by Tricoci et al2 in this issue of JAMA demonstrates that revisions of the American College of Cardiology (ACC)/American Heart Association (AHA) guidelines have shifted to more class II recommendations (conflicting evidence and/or divergence of opinion about the usefulness/efficacy of a procedure or treatment) and that 48% of the time, these recommendations are based on the lowest level of evidence (level C: expert opinion, case studies, or . . . [Full Text of this Article]






Good doctors follow evidence-based guidelines but use their clinical judgement as to how to apply them to the particular patient in front of them. If they deviate from the guidelines (and this is allowed by the very word "guideline"), they must have good reasons for doing so.

Does that really happen?



I'll refer you again to that NEJM editorial (this time the first part)

In 1990, the Institute of Medicine proposed guideline development to reduce inappropriate health care variation by assisting patient and practitioner decisions.1 Unfortunately, too many current guidelines have become marketing and opinion-based pieces, delivering directive rather than assistive statements.

And if guideline adherence is used to evaluate P4P measures, then yes, it can happen.

[fls]

Do you have any serious answers to my questions, or am I beneath contempt?

One uses 'and' to combine two independent ideas.

Linda

[Deetee]

Drive by:
Children at risk through lack of training for doctors and nurses (http://www.telegraph.co.uk/health/healthnews/4980086/Children-at-risk-through-lack-of-training-for-doctors-and-nurses-report-warns.html).

When appointed to a consultant position in the UK, I had experienced about 14 years of postgraduate training (excluding research time). One of my early posts entailed a 104-hour week.
Trainees today will become consultants after as little as 5 or 6 years of training/experience (currently at 56hpw but dropping to 48hpw soon.)

[fls]

Is more sex the cause or the proposed method of mitigating the problem?

I was thinking of the latter, but I suppose the former cannot be ruled-out.

Linda

[Ivor the Engineer]

One uses 'and' to combine two independent ideas.

Linda

Providing a flippant answer to my questions was contemptuous behaviour:

http://en.wikipedia.org/wiki/Contempt

Contempt is an intense feeling or attitude of regarding someone or something as inferior, base, or worthless—it is similar to scorn. Contempt is also defined as the state of being despised or dishonored; disgrace, and an open disrespect or willful disobedience of the authority of a court of law or legislative body.[1] One example of contempt could be seen in the character Ebenezer Scrooge from the Charles Dickens book A Christmas Carol. Scrooge was cold hearted, hating everything about Christmas and looked down upon everyone around him, especially the poor. The word originated in 1393, from the Latin word contemptus meaning “scorn.” It is the past participle of contemnere and from com- intens. prefix + temnere “to slight, scorn.” The origin is uncertain. Contemptuous appeared in 1529.[2]

Robert C. Solomon places contempt on the same continuum as resentment and anger, and he argues that the differences between the three emotions are that[3] resentment is directed toward a higher status individual; anger is directed toward an equal status individual; and contempt is directed toward a lower status individual. Contempt is often brought about by a combination of anger and disgust.[4] [5]

Now enough of this nonsense! I'm finding this thread interesting.

[Ivor the Engineer]

Drive by:
Children at risk through lack of training for doctors and nurses (http://www.telegraph.co.uk/health/healthnews/4980086/Children-at-risk-through-lack-of-training-for-doctors-and-nurses-report-warns.html).

When appointed to a consultant position in the UK, I had experienced about 14 years of postgraduate training (excluding research time). One of my early posts entailed a 104-hour week.
Trainees today will become consultants after as little as 5 or 6 years of training/experience (currently at 56hpw but dropping to 48hpw soon.)

Given that hospitals operate all day every day, could you (or someone else) explain why it is so difficult to fit training of junior staff into a 48 hour week?

[T.A.M.]

What entry requirements to medical school make you believe doctors are likely to be more caring and compassionate than the average person in their society?

Given that there are far fewer places in medical schools than people applying for them, why would the resulting competition select for the more caring and compassionate people?

It seems one of the main motivations doctors get is interacting with and being thanked by the people they help.

Most professionals are helping other people, yet few need the gratification of interacting with them.

1. The entry into medical school is a complex, multi-factoral one. Is it perfect? Not by a long shot. You still have the occasional one go completely off the rales...murderers, pedophiles, they occasionally happen. However, I think that trying to seek out "compassion" in a candidate is something that we strive for when selecting medical school candidates. Whether it be through the type of volunteer work that they do, or the answers to particular questions in the interview, it is looked for.

2. Because there are more people then places, there will naturally be a tendency towards the "best" of the bunch, for sure, but that is not a question answered purely with academic prowess. In my class we had english majors, music majors, teachers, engineers. Yes the bulk of the students were science (Biochem, Biology, Nursing) majors, but that is to be expected. As well, the academic average and MCAT scores are only two of many factors, and not neccesarily the most important.

3. I would say that many things motivate people to become physicians. Challenge, Curiosity, Altruism, Money, Respect, and yes, Gratitude. I suspect the need for gratitude is not a major factor by a long shot, although I would be interested in reading a study that proves me wrong on that one.

4. Your comments, to me, sound tinged with a combination of bitterness and annoyance.

TAM:)

[Professor Yaffle]

Given that hospitals operate all day every day, could you (or someone else) explain why it is so difficult to fit training of junior staff into a 48 hour week?

I think the point is that they have less experience per year if they are only working half the number of hours. So if you are reducing the hours, you should increase the years of training. But then it's not exactly a good idea to work people so hard that they are half asleep and making mistakes because of sleep deprivation. I think there is a genuine problem, but also a resistance born more of machismo from some older doctors. If they went through that hell in order to get where they are, then so should younger doctors. Like some sort of bizarre initiation rite.

[T.A.M.]

I participated in a doctor's strike when I was in Canada, and it was successful.

At the time I was at the university hospital. The physicians attending on the clinical teaching units were subject to the same fee schedule as specialists working in the community, even though the work that we did was very different in amount and kind from that of a community internist.* The bulk of the work was done by my section (General Internal Medicine), and while we wouldn't have minded more pay, our real problem was getting any other sub-specialist physicians to participate in the schedule. Because of the way that they were renumerated, it represented a huge pay cut for a sub-specialist to take on a 2-week stint on the hospital service vs. a 2-week stink on their hospital consult service. We took our complaints to the department of health - the work we were performing was far in excess of those who were paid the same amount and there were serious and unsustainable staff shortages due to inequalities in renumeration - but they wouldn't even come to the table and talk to us since, as far as they could tell, the services paid for were commensurate with what was needed. So we simply informed them that if what they were paying for was adequate, we were going to simply stop performing those services they had deemed unnecessary by virtue of making them not worthy of renumeration. This meant that we would no longer free up hospital beds by managing certain patients as outpatients (which required visits in excess of the once per week we could charge for), we no longer transferred patients from surgical wards to medical wards if their care became complicated (as renumeration was based on length on time in hospital regardless of whether the length was due to complications vs. babysitting for rehab or nursing home placement), we no longer accepted patients for admission who had already been seen by a specialist (the attending physician would not receive any renumeration for their complete history/physical/evaluation), etc.

It lasted for less than two days, I suspect mostly because of the effect on the surgical wards - it seems that people listen to surgeons, I wish I knew why. Anyway, they agreed to sit down and take another look at the fee schedule and as a result we moved to block funding rather than fee-for-service. But it's true that we were very reluctant to take that step and we really wouldn't have held out for very long.

Linda

*I used to fly in to smaller communities to provide consultation services and I was often asked to see hospital patients and ICU patients, as well. The typical hospital patient was similar to one of my more stable outpatients, and the typical ICU patient would be similar to one of my not-very-sick hospital inpatients.

It seems your striking power was exceptional. For us physicians striking is so rare, that it is hard to have enough incidents to make a valid comment on their usefulness. I have seen, unfortunately, nursing strikes go on much longer than they should have, because the govt waited them out, knowing they had to provide essential services.

TAM:)

[Professor Yaffle]

1. The entry into medical school is a complex, multi-factoral one. Is it perfect? Not by a long shot. You still have the occasional one go completely off the rales...murderers, pedophiles, they occasionally happen. However, I think that trying to seek out "compassion" in a candidate is something that we strive for when selecting medical school candidates. Whether it be through the type of volunteer work that they do, or the answers to particular questions in the interview, it is looked for.

2. Because there are more people then places, there will naturally be a tendency towards the "best" of the bunch, for sure, but that is not a question answered purely with academic prowess. In my class we had english majors, music majors, teachers, engineers. Yes the bulk of the students were science (Biochem, Biology, Nursing) majors, but that is to be expected. As well, the academic average and MCAT scores are only two of many factors, and not neccesarily the most important.

3. I would say that many things motivate people to become physicians. Challenge, Curiosity, Altruism, Money, Respect, and yes, Gratitude. I suspect the need for gratitude is not a major factor by a long shot, although I would be interested in reading a study that proves me wrong on that one.

4. Your comments, to me, sound tinged with a combination of bitterness and annoyance.

TAM:)

On point 2, going by my sister's experience about 20 years ago, at that time one of the selection criteria was making sure nobody too working class got in.

[T.A.M.]

That sounds like a really poor organisational structure. Why do you think it has persisted for so long?

That is a good question. A lack of privatization may be part. Govt burocracy is likely another. The power of Physicians within the work force, and the history of policing their own may be another, but I am sure there are many reasons I am not hitting right now.

TAM:)

[T.A.M.]

Do you think there's an under supply of physicians?

If so, what do you think are the causes and how may they be mitigated?

(I'm listening:))

Not a simple answer. I think there is an extreme under supply of physicians in rural areas, and an adequate or perhaps slight under supply in urban areas.

Causes/Mitigating factors are many, but as I see them, are:

1. You can put the doc in the rural, but you cannot put the rural into the doc. By this I mean you can put a physician in a rural environment, and he will function, but you cannot force him to love rural life, and so for most they leave when they get tired of it.

2. Too few positions at medical schools. Some of this is self regulating, some of it is the cost to educate them.

3. Here in Canada, some of the problem is an exodus to the USA. The average pay per visit in Canada is about $30-$35. I have a physician friend in the USA who says the average pay for a visit there (where he works) is $115.

TAM:)

[T.A.M.]

Exactly what I was thinking.

What puzzles me is why doctors believe it is necessary to do 48+ hr. weeks to become competent. E.g.,

http://esciencenews.com/articles/2008/08/01/working.time.regulations.are.failing.doctors.and.p atients



:boggled:

Interesting. Some of it is tradition. Some of it is to prepare you for the potential hours you may have to work when you finish. Some of it is pure love of torture.

TAM;)

[paximperium]

I think the point is that they have less experience per year if they are only working half the number of hours. So if you are reducing the hours, you should increase the years of training. But then it's not exactly a good idea to work people so hard that they are half asleep and making mistakes because of sleep deprivation. I think there is a genuine problem, but also a resistance born more of machismo from some older doctors. If they went through that hell in order to get where they are, then so should younger doctors. Like some sort of bizarre initiation rite.
I do find it amusing that UK docs are complaining about a 48hour work week. When I started residency, I regular went through a 100 work week and the surgeons regularly went higher. The 80hour max work week rule came to my hospital half way through my residency and it was such a major change.

48hours a week is not enough for certain specialties and I see signs that a 80hour work week may well not be enough. I think it is barely enough for pediatricians, ER docs and General Internists, but for a Surgeon, even with 5-6years of residency, I'm seeing some of new grads lack certain skills that was once expected from the older generation.

[T.A.M.]

On point 2, going by my sister's experience about 20 years ago, at that time one of the selection criteria was making sure nobody too working class got in.

lol...

Well I entered medical school 15 years ago, and while I was not privy to their entry criteria then, I can tell you that no such criteria exists at the med school I graduated from now, AFAIK.

TAM:)

[Professor Yaffle]

lol...

Well I entered medical school 15 years ago, and while I was not privy to their entry criteria then, I can tell you that no such criteria exists at the med school I graduated from now, AFAIK.

TAM:)

First question at my sister's interview for medical school: "So, why on earth would the daughter of a TV repairman (said in a sneering voice)want to become a doctor?"

[Ivor the Engineer]

<snip>

I'm seeing some of new grads lack certain skills that was once expected from the older generation.

Could you give some examples please?

[fls]

Providing a flippant answer to my questions was contemptuous behaviour:

Right, 'cuz you simply assumed the outcome - that my response was non-serious and that it was so because I have contempt for you - in the same way that one assumes that changes in practice represents provision of excess services or that the presence of conflict of interest creates biased guidelines. It's of interest and useful (I assume) to uncouple those assumptions, at least occasionally.

Linda

[paximperium]

Could you give some examples please?
Why should I?

[paximperium]

First question at my sister's interview for medical school: "So, why on earth would the daughter of a TV repairman (said in a sneering voice)want to become a doctor?"
As a member of the Elite Physician's Cabal, I am very interested the answer.

Plebeians and peasants should know their place :p

[fls]

It seems your striking power was exceptional. For us physicians striking is so rare, that it is hard to have enough incidents to make a valid comment on their usefulness. I have seen, unfortunately, nursing strikes go on much longer than they should have, because the govt waited them out, knowing they had to provide essential services.

TAM:)

Yes, I've been through several nursing strikes and they do tend to be messy. I've seen threat of strike by physicians a few times, but it was doubtful that the threat would be acted upon. Looking back on my experience with the department of health, it seems that the main influence comes about when positions cannot be filled because of poor terms.

Linda