Open Payments: Will Transparency Hurt Or Help Patients?

Today, I was interviewed on CBS This Morning about whether the government’s Open Payments website should be delayed. This is part of the Physician Payment Sunshine Act that will provide public access to payments made to physicians by pharmaceutical and medical device companies.

Over the years, I have become increasingly concerned about the harmful effects of financial conflicts of interest on patient care. Dozens of studies have shown that financial relationships between doctors and drug/medical device companies influence physician prescription practices.

My research on patient-centered care also shows that patients are concerned about these potential conflicts of interest and how they may affect their care. Our patients deserve to know how their doctors are paid and whether this may affect them. The Sunshine Act will provide much-needed, critical tools for increasing transparency and accountability, and will help exert pressure to prevent inappropriate financial relationships between doctors and industry in the future.

The Open Payments website that will display the payments to doctors has already been delayed by more than a year. Now, in light of some technical problems, physician groups including the American Medical Association are arguing that there should be another six-month waiting period. While it is important to provide doctors an opportunity to review and dispute payments to them, this should not delay timely release of physician payments data to the public.

The American Medical Association argues that inaccurate information could undermine trust. If physicians want to improve trust, they can take a proactive approach and begin conversations with patients. They can send out an email or letter clarifying their affiliations with drug companies. They can participate in Who’s My Doctor and explain their philosophy publicly, online. They can have one-on-one conversations with those who have questions. Such openness will only improve the doctor-patient relationship, improve trust, and increase accountability.

For those doctors who truly are ashamed of their payment history, perhaps they can reevaluate their financial relationships. As former Supreme Court Justice William O. Douglas said, “Sunlight is the best disinfectant.” The sunlight is available now. Physicians and patients alike should embrace it, now.

Parts of this post were part of an open letter I sent to Ms. Marilyn Tavenner, CMS administrator, on May 27^th 2014 with the subject of “Revision of a currently approved collection; Title of Information Collection: Registration, Attestation, Dispute & Resolution, Assumptions Document and Data Retention Requirements for Open Payments (CMS-10495).”

From NYC and the Leonard Lopate Show

This week, I had the honor of speaking with Leonard Lopate, the award-winning host of National Public Radio's WYNC show.

Among the topics, we spoke about:
* What is cookbook medicine and why aren't checklists always good?
* What happens when doctors don't listen? 
* Why is getting a diagnosis so important?
* How can patients help doctors help them?
* Is malpractice a big problem?
* How will the Accountable Care Act shape the future of medicine?

How to Get Better Health Care From Your Doctor

We received many comments from listeners. Among those posted is one from Ellen from Upper Manhattan:

"I have no problem helping a doctor be as good as she/he can be with me. The anger we feel at doctors comes directly from our fear of helplessness in a vital aspect of our lives.... For me, the antidote is empowering and caring about myself."

What do you think? I'd love to hear your thoughts!

Care for the Neglected 20%

In this week’s “Shots” on NPR, I wrote about the barriers to care faced by patients with disabilities. Some of these barriers can be directly attributed to the lack of education healthcare providers receive about caring for people with disabilities.

Doctors' Ignorance Stands In the Way of Care For the Disabled

I was shocked to learn that though nearly 20% of the American population have a physical or mental disability that causes significant life impairment, studies show that less than 20% of medical schools have curriculum that discuss the needs of patients with disabilities. More than half of medical school deans report that their students are not competent to treat people with disabilities.

As someone who grew up with a severe and often debilitating stutter (see TEDxFoggyBottom talk where I discussed this in depth), caring for people with disabilities is a topic very personal to me. As a child, I had to visit the doctor several times a month for asthma attacks. When I had trouble getting out my words, doctors would ask my parents if I were mentally retarded. Sometimes, they initiated far more aggressive treatment because they thought my stutter was from difficulty breathing.

When I was a medical student, I recall an attending physician ordering a head CT on a patient who had a severe stutter just to make sure he wasn’t having a stroke. Had he listened to the patient for a few more minutes, he would have found out that this was how the patient always spoke, and that he was there for a completely unrelated issue. This is just one of many examples of how lack of understanding and training present a significant barrier to care.

In response to the NPR article, some readers have written about the burgeoning field of Physical Medicine and Rehabilitation. This is a much-needed specialty in medicine—but all doctors, nurses, and other healthcare providers need to be educated about how to take care of 20% of our patients.

I’d love to hear from you. What can we do to better educate healthcare professionals? Are there other areas that are neglected in medical training?

Does Your Doctor’s Gender Affect Your Care?

My patient, a 40-year old woman named Sally, broke into a wide grin when she saw me enter the room. 

"Are you my doctor?" she asked. I nodded and started to introduce myself, but she cut me off. "I'm so glad that I have a woman doctor! I think women are much better than men."

That's in stark contrast to the previous patient I had seen just before Sally. Frank, a 72-year old man, looked at me askance and asked me if I was sure I wasn't his nurse. His wife explained (nicely) that they preferred a male doctor. 

These preferences don't always abide by gender or age divisions, either; plenty of female patients have said they prefer male doctors, and vice versa.

A new study from the University of Montreal finds that there may be real differences between the care provided between female and male doctors. Female doctors are more likely to follow evidence-based guidelines, and they score higher on care and quality, according to the study. Other research has found that female doctors tend to show greater empathy and are perceived as being better listeners. 

Some researchers have hypothesized that the differences are cultural and rooted in our upbringing. From an early age, girls tend to serve as confidantes to their friends, which may then result in greater attention to listening in the clinical context.

At the same time, I have worked with many men who display great empathy and care deeply about their patients. I also know of female doctors who don't hold up to the traditional gender stereotypes and don't like to spend time listening. 

In selecting a doctor, gender is one component. For some people (like Sally and Frank), it may matter a lot, in which case it should certainly help guide your choice of doctor. Other people just want to find someone who they can trust; they aren't as concerned whether their doctor is male or female.

So how can you identify a good doctor? Here are some characteristics to look for—regardless of gender:

Your doctor should listen to you: Research shows that 80 percent of diagnoses can be made just by listening to your story. Listening leads to better care, and your doctor should make an effort to hear you out and learn about you.

Your doctor should view your relationship as a partnership: Today's medical care is not about the doctor telling you what to do; rather, your doctor should involve you in your care as an equal partner. He or she should actively involve you in every step of the decision-making process about your treatment. 

Your doctor should be willing to ask for help: There is so much information on diagnostics and treatments—one person cannot possibly know everything. A good doctor is one who isn't afraid to admit that he or she doesn't know everything. Asking for help doesn't mean your doctor is incompetent; rather, it should increase your faith in his or her abilities and humility.

Your doctor needs to be available: It's unrealistic to expect that your doctor will be at your beck and call 24/7; however, before you leave your doctor's office, he or she should communicate to you how you can get help if necessary. Make sure you understand your follow-up plan. Are there any specific signs or symptoms you should watch out for? What should you do if something new or worse happens? 

You should feel comfortable with your doctor: This is perhaps the most important of all. If you do not feel at ease with your doctor, you might not share critical information, and important pieces of the puzzle might be missed. That's the most compelling argument for choosing a doctor of a particular gender—and only you can decide whether that's a characteristic that matters a lot to you.

One of my heroes, the Nobel prize-winner, humanist, and cardiologist Dr. Bernard Lown, talks about how a doctor is someone who should always make you feel better after having seen them. You go to your doctor because you want to feel better. You should find someone—female or male—who helps you accomplish this goal.

This article was previously published in Women's Health Magazine (posted here with their permission).

To the Doctors: A Response (Part 1 of 2)

Last week, KevinMD published my article calling for participation in the new transparency campaign, Who’s My Doctor, on his highly trafficked website. Medscape also highlighted the campaign in an report. The articles drew many responses, including from some doctors who were not thrilled with the concept of transparency.

My next two blogs will report the five major themes and direct quotes, and my responses.

First is Theme 1.  If you don’t want to read the (rather entertaining) quotes, here’s the general idea: “Doctors need drug companies. We’re not influenced by them. They just pay for lunches, and I need to eat. Bedsides, it’s not my patients’ business what I do.”

“If I get some pizza from a drug rep, I'm not going to use that med for every patient regardless of need, and I don't think the patient needs to know that.”

“Do people really think I will change how I treat my patients if I am given a pen or a pizza, GOD forbid, a lunch? This whole thing is insulting to physicians and shortsighted.”

“I don’t have money or time to buy my lunch. Drug companies know that. I get food and learn some stuff, so what’s wrong with that?”

“Drug manufacturers will not uncommonly provide lunch in my office so that I can have time to discuss their medications. It is quality time because, unlike many rude physicians that I've heard about, I personally am there talking with them, instead of hidden back in my office just consuming the food.”

"I see all representatives equally and have no endearment to any one product.”

“I happen to, once a month, go to a staff meeting where a drug rep has brought in takeout food which I eat while internally rolling my eyes at their sales spiel.”

“Is the lunch that they provide me and my staff an 'association' by the NEJM's study (I had quoted a New England of Journal Medicine study that 94% of doctors have some affiliation with a drug or medical device company)? Probably. Is it inappropriate? Absolutely not. It is essential that I get the best for my patients. The lunch means that I get to eat that day while still doing that.”

“I implore all physicians to defend the freedoms of the American way of life and to do everything possible to defend the individual patient. If helping an individual patient involves learning about a new medication from a Pharmaceutical Representative, then never be ashamed to do it. Take advantage of all options, as that is the American way. Your patients deserve it.”

“The USA is still a free market society and sometimes that's how business is conducted.”

“Maybe Dr. Winn (sic) needs to move to Russia or Cuba where she can practice her style of medicine!”

Dozens of studies have shown that even small gifts affect physicians’ prescribing habits, and that doctors suffer from the “you but not me” phenomenon—where we believe our own prescription habits aren’t affected (which implies that pharma is somehow wasting their marketing efforts, a contention we know is not true).

Some have raised the point that drug reps are helpful for educational purposes, or that they need the lunch to get through their day. As a physician who invested over 14 years of my life in medical training, I find it offensive and disingenuous for doctors to say that we are interacting with drug reps "for our education". There are many free, impartial sources of information to learn evidence-based guidelines on new protocols and treatments. Drug companies are beholden not to providers, or patients, but to their stakeholders, and we as professionals (making plenty of money to buy our own lunches!), and we need to uphold our professional duties to do what's best for patients.

(For more information, there has been excellent work done in this field. See information about Healthy Skepticism, No Free Lunch, American Medical Student Association, Dr. Peter Mansfield, Dr. Joel Lexchin, Dr. Marcial Angell, Dr. Ben Goldacre, among others.)

All that said, there *might* be a difference between doctors accepting money to be a “key opinion leader” for a drug and leading a multi-site clinical trial. There are multiple websites where doctors’ affiliations with drug companies are already out in the open: ProPublica has a website, and also Accountable Care Act will have a public website in Oct 2014. Who’s My Doctor allows doctors the opportunity to explain the degree of interaction with drug companies. If you as a doctor think that your interaction with drug companies is good for you and your patients, then you have a chance to explain why.

Ultimately, the goal is not to point fingers and say that doctors who associate with drug companies (or that have investments or other specific revenue streams) are bad, but rather that our patients should know about it. Perhaps it could even be seen as a good thing that, as an oncologist, you lead large pharmaceutical-funded research studies. We need this transparency. Just as doctors disclose our conflicts of interest to each other in journals and conferences, we should disclose them to patients.

Finally, there is the issue of whether our patients should know what we are doing. The next question answers this from the standpoint of social accountability, but here’s some food for thought directly on the question of drug-company sponsorship: if doctors are taking money for something that we are ashamed of letting their patients know about perhaps it’s not something they should be doing.

Theme #2: Doctors aren’t accountable to society. We are just private citizens conducting business.

“When I became a physician, I don't recall taking an oath of poverty… Why the heck should anyone know about my investments?”

“I find it an invasion of my privacy to disclose where my income comes from. My patients don't disclose their incomes to me.”

“I'm not a public servant.”

"Maybe we can talk about accountability when all my debt has been paid off.”

“Anything that I obtained from the US taxpayers for funding of my medical education was paid back in spades."

“The individual's right of privacy is in the constitution. The "sunshine act" violates this right. Therefore the "sunshine act" is unconstitutional.”

I cite from an article for the Lancet that some colleagues and I wrote about social accountability in medicine:

“Service is the highest calling for all health professionals and, upon beginning our studies, each of us enters into social contract between our profession and the public to serve in the public’s best interest. Using physicians as a specific example, the World Health Organization defines social accountability in training as ‘the obligation to direct their education, research and service of activities towards addressing the priority health concerns of the community, region and/or nation that they have a mandate to serve.’”

Here is an excellent article about the role of physician-as-citizen.

If we are to use an economic argument, though medical students face heavy debt, our medical education is still heavily subsidized by taxpayers. Every student interviewing for medical school understands that our job is to be socially accountable to our patients and our society. They choose to enter medicine willingly, and to take the debt and our obligation willingly. We swear a Hippocratic Oath where we place patients as our first priority.

I argue that it very much is our patients’ business how we get paid, because it affects their healthcare directly.

In addition, even if you don’t believe that doctors are public servants and are just responsible to themselves, remember that disclosure is standard business practice, i.e. lawyers have to disclose their conflicts to every potential client.

Questions and comments? Please post below; I’d love to hear from you! Also, please visit our new website (open while under construction): www.whosmydoctor.com and our Facebook page.

Where to Begin the Conversation on Overdiagnosis

One of the many takeaways from the recent Preventing Overdiagnosis Conference is that it’s hard for doctors to tell their patients that too much care is bad.

For so long, the rhetoric has been about the danger of too little care. Newspapers brim with stories of death from missed diagnosis and lack of access to care. TV shows glorify the detective-doctor who doesn’t give up and persists on ordering test after test in order to solve an esoteric case.

Over the last decade, there is mounting evidence illustrating the harms of overdiagnosis and overtreatment. Risk factors have been turned into diseases, and diseases are being created for the purpose of selling medications. Dartmouth’s Dr. Lisa Schwartz told the story of how GlaxoSmithKline created a new disease entity—restless leg syndrome—to find a new use of an existing medication that was going off patent. American Cancer Society’s Chief Medical Officer Dr. Otis Brawley discussed how hospitals offer “free” screening tests knowing that they will lead to false positives, thus creating a market for further testing and more care.

Who is to blamed for “selling sickness”? No doubt, big pharma and hospital corporations are culpable. They feed into patients’ fears. Maybe your doctor hasn’t heard of this “new” disease. Maybe she has financial incentives to prescribe you the rival medication. Why not take control of your health, and heed the advertisements to “ask your doctor about” the latest medication and the full-body CT scan?

There is another party that is just as guilty in the crime of disease mongering. It is doctors who are complicit with drug companies by speaking about “new” diseases and prescribing unnecessary medications. It is doctors who are complicit with hospitals by ordering unnecessary tests. It is doctors who instilled in our patients the blind faith in technology and the boundless optimism in treatments.

Combating overdiagnosis must begin with doctors acknowledging that we are part of the problem. The foundation of medical care is trust, and this trust is being eroded by financial incentives and conflicts of interest. We need to address this and reassure our patients that we are fully on their side.

Just as our profession stepped up to address critical issues such as access to care and medical error, we must have the courage to admit our contribution to the growing health threat of too much care. This will not be easy—but we must have the courage to reinstill trust, and do what’s right by our patients and our society.

****

This article previously appeared in and reposted with permission from British Medical Journal's blog.

"Don’t Just Do Something, Stand There!"

My last blog post discussed why medicine is so intolerant of uncertainty and inaction, and how this has resulted in a culture of overtesting and overtreatment.

All of us as patients and doctors are at fault for feeding into this system of waste and harm. However, there are some active voices of resistance. Here are some examples:

Dr. Jerome Groopman, internist and author of the excellent book, How Doctors Think, writes about how he teaches medical students to “don’t just do something—stand there.” Very few situations in medicine require immediate action. It may be uncomfortable to apply the tincture of time as a treatment, and many doctors find it easier to order a test than to discuss the pros and cons of the test with a patient.

However, we need to remember our first principle, primum non nocere: first do no harm. Dr. Abraham Verghese writes about the importance of restraint and self-awareness in his novel, Cutting For Stone. Here is the protagonist, a doctor himself, speaking about his father:

My father, for whose skills as a surgeon I have the deepest respect, says, "The operation with the best outcome is the one you decide not to do." Knowing when not to operate, knowing when I am in over my head, knowing when to call for the assistance of a surgeon of my father's caliber--that kind of talent, that kind of "brilliance," goes unheralded.

Doctors: think carefully. Engage in thoughtful discussion with your patient, and decide together what’s best for him. Remember that no testing and no treatment may be the best course of action.

If you have to do something, consider a novel treatment that Dr. Aaron Stupple coins “a listening infusion.” During his internship, Dr. Stupple faced resistance when he questioned his supervisors on the necessity of costly tests and invasive treatments. As the most junior person on the team, he couldn’t override their decisions, but he could add his own treatment. He made it a routine to visit patients and talk to them, often staying hours after everyone else to finish his “listening infusion”. He didn’t obtain more test results, but somehow he knew more about his patients than anyone else. He didn’t give them a pill, but somehow his patients felt better at the end of the day.

This is what doctoring should be about. A recent study of resident doctors found that only 12% of their time was spent interacting with patients, versus 40% interacting with the computer. The doctor may find everything about a person’s laboratory tests, but nothing about her family or values. “Personalized medicine” and “patient-centered care” are hot buzzwords, but it’s not just about finding someone’s DNA and redoing the waiting room area. Improving medical care must begin with personalizing care to the patient and listening to her story.

We must bring back the art of medicine and the art of healing, and treat all of our patients with a “listening infusion”. Then, “don’t just do something—stand there”! Changing any deeply-entrenched culture is hard, but it can happen: one doctor at a time, one patient at a time.

Rebranding “Patients” as “Healthcare Consumers”: Tread with Extreme Caution

On Monday, I had the privilege of serving as the keynote speaker for an excellent conference in Boston. Empowering Healthcare Consumers: a Community Conversation brought together an impressive array of people to discuss how to improve healthcare through empowerment. In attendance were over 150 community leaders, clinicians, hospital administrators, insurers, advocacy group leaders, and patients.

Patients—or I mean healthcare consumers? The conference organizers specifically requested that I use the terminology of “healthcare consumer” rather than “patient” in my presentation. Several of the speakers before me made the point eloquently as to why: “patient” has the connotation of passivity, and people need to be active to take charge of their health. We need to be savvy consumers and do our own research into the cost and quality of healthcare, much the same way we would if we were shopping for a new car.

The new language made me uneasy. Don’t get me wrong; I am all for people being empowered in their healthcare (I write a blog and published a book on this), and for transparency and availability of information to make informed choices. However, I also believe that healthcare is a human right. A patient deserves healthcare as a right. But does a consumer?

Those of us in favor of universal access to care argue that healthcare is not a commodity like cars and TVs. Using the language of people being consumers could undermine this fundamental tenet. If you are shopping for healthcare in the same way you shop for your car or TV, this implies that you buy what you can. (Can’t afford a new Lexus? Buy a used Toyota. Maybe wait a year.) This doesn’t—and shouldn’t—work for healthcare. (Need heart surgery? Choosing the “discount” surgeon, or waiting a year, don’t sound like good choices.) Those who can’t afford healthcare are priced out of it, and healthcare is no longer a public good, like public education and clean water.

I also worry about effects of rebranding on the physician-patient relationship. What happens when the doctor becomes the hired consultant of the savvy shopper patient? Perhaps the doctor will be more responsive to consumer demands—but perhaps this doctor will also feel more obligated to give the consumer exactly what he wants, including unnecessary tests and harmful procedures. And will these physicians still retain their sense of social responsibility, when healthcare is reduced from societal obligation to personal choice?

An extreme version of patient-as-consumer can be found in China, where people routinely pay their doctors under the table as promise to receive better care, and patients—even those dying of stroke and heart attack—are turned away from hospitals if they cannot pay upfront for their treatments. The physician-patient relationship has broken down so much that doctors have been murdered by angry patient families.

In such a system where it’s every man for himself, it’s hard to convince people that healthcare is something we all have to safeguard. We already live in a society where many believe that more is better—at least when it comes to ourselves. When making healthcare decisions, few take into account the cost to society. Yet, healthcare is not a limitless commodity. There are efforts underway to think of the escalating cost of healthcare as we do global warming; these efforts will not work if we adopt the language of consumerism.

So what is to be done? Here’s a suggestion. Instead of throwing out the word “patient”, change what it means. Encourage people to become the educated, empowered patient, even, dare I say, the pushy patient. This is the patient who will make individualized choices about her health as an active and equal partner with her doctor. This is the patient who will ensure the best possible care for herself and, in so doing, catalyze reform of our healthcare system to one that values informed decision-making and reaffirms health as a basic right.

12 Ways to Stay Safe in Hospitals

Hospitals can save you, but they can also harm you. In my last two articles, I discussed recent research that shows how medical errors affect one in three hospitalized patients, and the 10 types of errors that happen.

So how can you stay safe in hospitals? Follow these 12 life-saving tips:

#1. Never go alone. Always bring someone else—a trusted family member or friend—with you. That person will be your primary advocate, and can serve as an extra set of eyes and ears to help make sure you are safe. (This tip applies to routine doctors’ appointments too; always bring your advocate with you.)

#2. Determine, in advance, the goals of the hospitalization. Before you go to the hospital, ask your doctor why you need to be hospitalized. Is it necessary, or is outpatient care possible? What is the goal of the hospital stay? How often will that goal be assessed? Can you choose which hospital to go to, and when you should go? Rarely is the need for hospitalization so emergent that you can’t get these answers and discuss them with your doctor in advance.

#3. Prepare. Bring all the things you would normally bring with you to a doctor’s appointment, including a list of your medical problems and allergies. Don’t assume that the hospital will have your records. It’s very important to bring all the pill bottles that you take so that there will be no mistake about what dosage and how often you take your medications. Keep your main doctor’s phone number and your advocate’s phone number handy (though your advocate should be going with you to the hospital).

#4. Meet your care team. Find out who is in charge of your care: is it your regular doctor or a hospitalist doctor? Introduce yourself to her, and to your primary nurse. Meet the patient care tech, the nursing assistant, and the other members of your healthcare team. Tell them about yourself, and find about them. The more they get to know you as a person now, the more they will help to answer your questions later. Your advocate should also get to know your care team.

#5. Know who to call for help and how. Who will be the night-duty doctor and nurse, and how can you reach them? If you are in trouble, or if your advocate sees you’re in trouble, how will you get help? Many hospitals have a “rapid response team” or a “code team” that come to assist in emergency situations. Can your advocate activate this team himself?

#6. Ask about every test done. Don’t just consent to tests. They all have risks, so ask about them. Why is your blood drawn every morning—what is the purpose? Why are you getting the CT scan? You should discuss every test with your doctor in advance of doing them, and have a thoughtful discussion about risks, benefits, and alternatives.

#7. Ask about every treatment offered. If you’re being started on a new medication, ask about what it is, what the risks are, what the alternatives are, and why you need it. If you’re told you need a procedure, make sure you discuss it with your doctor.

#8. Keep a record of your hospital stay. Your advocate may need to help you with keeping a careful record. This includes your tests (make a note of what you get done and ask about the result), medications (write down when each medication is given and double-check it’s correct), and providers who come to see you (write down names of specialists and their recommendations). A detailed record helps to prevent mistakes, coordinate your care, and keep you on track.

#9. Attend bedside rounds. Doctors and nurses usually have rounds at least once a day to discuss their patients. Find out when rounds happen and ask if you and your advocate can attend. This is your time to find out what’s going on with your care. Prepare questions to ask during rounds.

#10. Know your daily plan. Rounds are a good time to ask about what is happening that day. Are you doing more tests? More treatments? Are you on track, or did something unexpected happen? When can you expect to go home?

#11. Keep your eye on infection control. If someone comes into your room, ask him to wash their hands. If someone is doing a procedure on you, ask her to follow an infection control checklist. Hospital-acquired infections kill 100,000 people every year, and you can help prevent them.

#12. If something isn’t right, speak up immediately. Remember that it’s your body and you know yourself the best. Get help if you develop new or worsening symptoms. Empower the person you’re with to speak up for you if you can’t.

All of these tips may sound like a lot of work, and you may be wondering why it’s your job to do all of this. After all, aren’t you the patient, the person who is feeling unwell and seeking help? By and large, doctors and nurses are well-meaning, and most of the time, the system is working well and you will get good care. However, mistakes do happen—and you and your advocate can help prevent medical error. Follow the tips above to make sure that you are safe and well during every hospital stay.