Up Down and Sideways

CRIMS - Community and Rural Internists: An Endangered Species

Bet you didn't realize that these once plentiful and admired people are on the endangered list. In British Columbia, the community/rural internist is the person who takes on every problem that is slippery and hard to grasp. Problems that might fall to a sub specialist also are taken on, since sub specialists tend to confine their activities to larger centres. The internists get patients ready for surgery, run the intensive care units, organize chemotherapy and do a host of other things that other specialists rely on. No internists and you may not have a surgical program.

Across the province hospitals are struggling as internists are unable to provide year 'round call coverage. According to HealthMatchBC, there are 29 permanent positions going begging today in British Columbia alone. The kicker is that last year we only graduated 38 general internists in the entire country.

That kind of arithmetic isn't encouraging. Unless we some up with some solutions, and soon, we will face a crisis of care. Here are some thoughts, and I'd welcome yours as well.

• Increase the supply of younger internists by:
  • Improving payment
  • Lobbying the provincial government to increase residency positions for general internists
  • Providing debt relief to general internists working in community hospitals
  • Providing the same debt relief to sub specialist internists who agree to work on call as generalists
  • Making subspecialty practice attractive to those who will work on call as generalists
  • Recruiting foreign medical graduates
  • Increasing the prestige of the discipline by providing leadership roles to general internists.
• Keep established internists practicing by:
  • Providing clinic space in or near the hospital at reduced rates
  • Providing enhance training opportunities to allow established internists to upgrade their skills
  • Training hospitalists to do many of the tasks presently covered by general internists at night - for example, ventilator management or insertion of lines
  • Enhanced use of telehealth technology which could provide centralized medical advice for remote intensive care units.

Keep in mind that new internists are going to take four years to train following medical school. We don't have time to procrastinate.

What are your thoughts?

Let's Talk Quality - Part II

In my last post I spoke about the difference between pay for performance (P4P) as opposed to pay for outcomes. There is a difference, so it's worth spending some time looking at them.

P4P tries to raise all boats to the same level. In British Columbia, family physicians are paid for ensuring that their patients are followed according to certain guidelines. So diabetic patients for example would need to have certain tests like a Haemoglobin A1c done every three months.

Of course, most of us, if we are smart should be following guidelines, so in essence the doctors are being paid for showing their homework. That takes time which is one reason why many physicians resent having to log into a government site to file their work. It is also clerical work, which is something that most doctors are not tempermentally inclined towards. This could be overcome by having electronic medical records automatically do the reporting.

From a management point of view, this does provide some indication of how many doctors are showing their work, but it's a fair bet that many others are doing this but not reporting. There are other problems. There is no direct link to patient outcomes for one, and for another, guidelines tend to ossify - and slavish adherence to them discourages innovation. Finally, these guidelines can drive costs upwards, especially when we look at diagnostic services like labs and imaging.

To use an analogy used by Michael Porter and Elizabeth Olmstead Teisberg in their book Redefining Health Care, most of us don't care how our cars are repaired or how long it took to repair them. We just want the things to work well when they come back from the shop. Most don't care whether our cars were filled with synthetic or mineral oil. And frankly most patients only care about feeling better - and they'd like to get that way with the least possible effort.

Enter pay for outcomes. Physicians could be paid according to the risk adjusted outcomes they acheive. The paying agency wouldn't care how those results were acheived, nor would it put roadblocks in the way. Things like restrictive formularies would be dispensed with, guidelines would be published but not enforced and innovation would be encouraged. We wouldn't care if the work was done by a physician, a nurse, or a mechanic, as long as the outcomes were good.

So how would we do this? Exactly what do we mean by an outcome? Those details are important. We can easily reward the wrong behaviour if we don't get it right. Fortunately in BC we have some time. The next Physician Master Agreementbetween the BCMA and the Province of British Columbia won't be signed until 2012.

Let's consider who we should pay. We could pay individual doctors. That would have the advantage of not requiring any significant changes in infrastructure, but comes with some disadvantages as well. It ignores the fact that many individuals contribute to an outcome. If we were to reward groups of doctors, we would be giving them an incentive to work and play well together.

Newsflash: that's not how we've been trained. We've been trained to excel individually and to distrust the conclusions raised by others. That training has been re-inforced by the court system. Unfortunately, none of this is in the patient's best interest. Patients complain about having to tell their story over and over again.

So let's assume that we encourage physicians to form into incorporated networks. These networks could be at the community level, the hospital level or both. At the hospital level, the network could consist of a tertiary care group that would include the surgeons, internists, radiologists and pathologists who contribute to an outcome. In the community it might include family physicians and the consultants who support them.

Ideally, we would want to report outcomes publicly. Network A gets these results for a particular condition, as opposed to network B. I'd take this a step further and have the health authorities (all six of them in BC) report their results. And the Medical Services Plan should benchmark it's results against other paying agencies in Canada and the USA.

Right now, I'm not sure what the outcome indicators should be. In my own specialty, we might want to look at days missed from school because of asthma as being a good indicator of asthma care. Cardiac networks might want to look at the percentage of their patients who return to work.

We also need to consider what should trigger the payment. Would we reward only the top 80% of physicians and leave the 20% at the bottom with a goose egg, or should we consider rewarding only those who acheive a certain target?

I look forward to your thoughts on this idea. Let's six hat it- what is good about this, what is bad, how can we make it better, what data do we need, and what is your gut reaction?

Let's Talk Quality - Part One

When I got started in medicine, I felt that quality of care meant getting good outcomes. Then someone pointed out to me that most patients get better despite our efforts and that we are often wasteful in our pursuit of good outcomes. Process seemed important at that point, leading me to work on paediatric care pathways. But neither good process associated with poor outcomes nor poor process associated with good outcomes is ideal. One harms patients while the other harms both the people caring for patients and the people paying for the care.

Obviously what we need is both good process and good outcomes. But how do we achieve that in a system that pays physicians fee for service and pays health authorities a fixed amount to meet the expectations set by government?

It won't be a quick process, but there are things that can be done to move it along. We need to encourage physicians to learn about quality. We need to pay them for improving quality. Eventually we need to pay physicians a bonus based on outcomes. Nothing I've suggested here is new.

I have suggested to my professional association, the BCMA, that we work to make these things happen. One good start would be to pay physicians to be quality champions within their health authorities. Based on one champion per 25 hospital beds, with a budget of $70,000 per project, the cost for the Province of British Columbia would be $21 million.

That sounds like a lot of money, but if the quality literature is to be believed, quality efforts actually save money. If we take the time to train physicians about quality, we should see both better outcomes and lower costs. The Pittsburgh Regional Health Initiative has demonstrated this using Toyota Production System based methods.

Pittsburgh has developed Perfecting Patient Care University, a four day program that teaches participants how to use Toyota based methods. All champions would be required to attend along with a non physician clinician with influence in the area the project is intended to address.

We wouldn't expect every champion to succeed but we would expect to see a fair number of physicians to develop an excellent track record of improving results. There would be obvious benefits to the health authorities and to patients, but perhaps more importantly, it would give physicians the tools needed to improve their own private fee for service practices.

Using the metric of one champion per 25 beds, we could expect to educate 300 physicians in these methods.  That would amount to approximately three percent of the doctors in the province. We would expect to see some knowledge transfer however, since no one works in a vacuum. We would also expect that some physicians would drop out after one project, making room for others to learn.

The quality champion idea is outlined well in a book by Naida Grunden called The Pittsburgh Way. It's excellent reading.

Once we have physician champions trained, we will be on our way to equipping physicians to enter a payment for outcomes process. This is something quite different from traditional pay for performance, and will be the topic of my next post.

What do you think? I'm interested in your ideas.

 

 

Hello, I'm Jon and I'm a Recovering Paediatrician

The last day in the office has come and gone. After three years as a general practitioner and 17 years as a general consulting paediatrician, I am no longer in the office practice of medicine. I am on my way to becoming a full time medical bureaucrat. It's a big change, and it makes me nervous.

 

One of the nicest things about this past 17 years has been working with my wife in the office. She's a nurse; her insight and common sense have had an impact on almost every aspect of what we've done. We built two practices - first in Kamloops where we spent 11 years, then in Comox.

 

For the most part, it has been a happy practice. I think of my patients and how they've become a part of my life. The baby boy I resuscitated in 2004 gave my grand-daughter her first (non-family) kiss two years later. Then there's the mother of a baby with congenital chylothorax. I resuscitated her infant in the delivery room with high pressure ventilation and then with bilateral chest tubes. We sent the baby off to a tertiary center within hours of delivery. But she recognized me two years later in a donut shop and came over to say thank you.

 

I think of all the kids I saw with learning and behaviour problems. Some did well, others not so well. I remember attending the high school graduation of one of my cancer patients. Then there were the children who didn't do well. Kids with inoperable heart disease and metastatic cancer plus one lovely girl with polyarteritis. Their funerals taught me some humility. But they also taught me that medicine is rarely about curing and is always about caring. How we care, and how we show we care will be fodder for another post, but caring will always be the most important medical value for me.

 

It was a real mixed up day today. I felt as if I was abandoning my patients. One boy was in tears. So was another child's Mom. And then there were the good moments, with gifts received (chocolate, drawings) and memories exchanged. A girl who I had looked after with bronchiolitis as an infant presented today with psoriasis. A girl referred for ADHD looked as if she were more depressed than inattentive. Our receptionist left to get home before darkness fell - and that was a pretty choked up feeling.

 

Finally, the last patient went out the door - a lovely kid with CP. My wife and I were alone in the office with our thoughts and memories. We will miss this work. I know I will miss it a lot. I know that I will want to continue seeing babies, children and youth as part of my professional life. I've been doing it for so long that it's a part of my fabric. I'm Jon, and I'm a recovering paediatrician. I look forward to a few relapses.

 

Regional Hospital

Here in beautiful North Vancouver Island we have a problem. The Vancouver Island Health Authority (VIHA) wants to spend money on us for a new regional hospital. The problem we have is that most people are in favour as long as it remains in their own community.

Initially, VIHA paid a consulting firm to meet with stakeholders and find the best location for this brand new hospital. The solution arrived at was to place the hospital halfway between the two communities of Comox and Campbell River. VIHA looked at her new baby proudly, but found that no one would admit to being the father. And that was a problem, because the municipalities of the north are responsible for footing 40% of the cost. If they don't agree, VIHA doesn't get a hospital. More importantly, neither do the people who live here.

So, the municipalities decided that the best thing to do was to have the doctors decide. They appointed two doctors each from the Comox Valley and Campbell River to come up with an answer. Not surprisingly, they couldn't agree. None of them wanted to move.

We now have two well dug in camps. One insists that VIHA refurbish the old hospitals in the Comox Valley and Campbell River. The other insists that a regional hospital is required to save health care in the north.

I would probably support the first group (enhanced status quo) if we were delivering great care to our population. The facts however suggest otherwise. Surgical call is split between the two hospitals. We end up transferring patients to the other community's hospital if we don't have an appropriate surgeon on call. Sometimes, we'll have an orthopaedic surgeon on in one hospital and a general surgeon on in the other. This doesn't work well for trauma patients who may need both types of surgeon to get them out of trouble.

The other problem has to do with critical mass. We don't have the numbers of physicians in each specialty to sustain the call schedule. We are facing a manpower crisis when the baby boomer docs retire. Thirty percent of internists, 38% of orthopaedic surgeons and 33% of general surgeons in this province have been out of medical school thirty years or more. The docs coming to replace them will not be willing to work on call every other day. 

There is also the economic problem to consider. Hospitals pay their workers well. Campbell River in particular relies on its hospital as an employer. It is losing its pulp mill, having previously lost a sawmill. Municipal politicians aren't likely to agree to losing another major employer.

All of this is by way of setting the scene. What can be done to get out of the impasse and to deliver the care that the residents of the north deserve. Well, at one level, we may be going about the problem backwards. It would make more sense to ask the physicians and nurses in these two communities, in consultation with VIHA to talk about what services we should be able to deliver here. Then VIHA should go with its planning staff to the municipalities to discuss how we could do that. The physicians should not be part of that discussion.

If I were the Czar, we would have a single hospital with two campuses, one in each community. One campus would be responsible for inpatient care and would house all on-call services. The other would be a state of the art ambulatory care centre providing teaching clinics for the medical school, day surgery, endoscopy and diagnostic facilities. It would be win-win for all communities. Too bad I'm not the Czar. 

Patient or Client?

KevinMD talks about how the nursing literature tends to use the word client, instead of patient. There is nothing more likely to provoke a reaction from a physician than the “c” word. Nurses believe that “client” implies a respect of the individual’s autonomy, while physicians believe that “patient” suggests a caring relationship.

The etymology of the two words may provide some insights. Client derives from the Latin cliens, meaning “to lean”. Thus you have inclinations, clinometers and clients. A client may be a consumer of a professional service, but it may also be one who is under the protection of another.

Patient derives from the Latin pati, meaning “to suffer”. So a patient is one who suffers and is therefore deserving of compassion and care.

Of course, whether one is deserving of compassion and care or under your protection may be a very fine point indeed. To that extent, the patient – client debate seems to be more about defining professional cultures than a real concern for the person at the centre of the discussion – patient or client depending on your point of view.

 

 

Horsethieves

My father is a born again politician. He was on the phones in the last Nova Scotia provincial election trying to get the New Democratic Party's vote out. He tells this story of one of the conversations he had. After introducing himself and his affiliation, he asked the woman on the other end of the telephone if she would vote for the NDP.

 

“No” she said, “my mother, father and grandparents were Liberals, and I’m a Liberal too”.

 

Dad, being Dad couldn’t let it go. “If your mother, father and grandparents were horse thieves, would you be a horse thief too?”

 

“No”, she replied, “I’d be a Conservative”.

 

How’s that for a snappy comeback?

Steven Harper makes me URL

Well, it isn't going to write itself, is it? I've been wanting to write for a while, but keep getting stuck in the mechanics of making the blog look pretty. No more. Steven has inspired me to write. He has raised me from my complacency, provoked my indignation and generally pissed me off. Thank you Steven.

This article by Rex Murphy and this one by yarnharlot sum up the situation nicely but I want to add my thoughts. Steven has shown that he can't work or play well with others. That he despises the respresentatives of the 63% of Canadians who didn't vote Conservative. That he is constitutionally incapable of running a minority government and for that reason alone, can't be trusted with a majority - which amazingly enough he could earn with only 40% of the votes.

Not only that, but in his zeal to appear patriotic, he has offended an entire province. For an intelligent man who claims to love his country, that is an awfully stupid and unpatriotic thing to do.

It's hard to say if the Coalition will hold itself together, but I can't think of anything more Canadian than seeing these opposition politicians putting aside their differences for their love of country. Even the Bloc Quebecois, which is not part of the coalition, and which only represents the interests of one province is willing to make Parliament work. Very likely the Bloc has its own motivation, but at this point its support benefits the country.

Steven's reckless contempt for Canadians has to be punished, either by his own party or by the country at large. I'm not holding my breath though.