Don’t Make Me Gag

By Steven Lewis

Would you commit in writing not to slag your physician on the internet? A US company called Medical Justice (MJ) is hawking a waiver form that gets patients to foreswear anonymous posts to doctor rating websites. I'm your doctor, you're my patient. If you have problems with me or my staff, tell us, tell your friends and family, tell anyone you want through the usual channels. But put it in writing that you won't post it to the internet.

The internet is a pretty big windmill to tilt against, but MJ claims 1000 doctors have signed on. The pitch is that the muzzle pact protects doctors from anonymously posted and inaccurate portrayals of their courtesy, promptness, morals, and clinical skills. The lawyer in the MJ website video recounts the story of an anonymous post implying that a physician was a child molester. Though the post was a malicious plant from a competitor, not a patient, apparently US law exempts Internet Service Providers from liability in such cases, and they cannot be compelled to remove the alleged defamation.

This is ugly and outrageous stuff. But the proposed remedy is ethically objectionable in principle and foolish in practice. The flaws are as follows.

First, Medical Justice argues that rating doctors is not the same as rating barbecues. This is formally true: I cannot libel the barbecue, and in any case the barbecue doesn't care. (The manufacturers do, but somehow they have not yet demanded censorship in return for the privilege of purchasing their goods.) MJ goes on to describe the doctor-patient relationship as a precious union of equals whose sanctity and trust are violated by the specter of anonymous rating. This is patent nonsense: there is a major power imbalance between the parties. The rating sites are popular precisely because the vast majority of patients don’t have the nerve to challenge their doctors face-to-face and fear the consequences if they do so.

Second, the internet free-for-all has been with us for a decade, and it has created an endless stream of opinion, advice, and rating. Of course it is full of garbage, lies, rantings and ravings. It is also a treasure trove of facts and shrewd observations that skewer privilege and reveal truths absent from the increasingly concentrated mainstream media. The bees have burst from the hive and there is no getting them back inside. There is no better advertisement for doctor rating sites than the attempt of doctors to suppress them.

Third, like Othello and Lear, MJ mistakes a friend for an enemy. Most people think better of their doctors than their doctors' performance warrants. The overwhelming proportion of assessments on www.ratemds.com are positive. An avalanche of evaluative literature shows that overall physician performance is in fact mediocre by the standards of evidence-based practice. Misprescribing is rampant, it takes weeks to get an appointment, adverse events abound in hospitals, and mental health problems are underdiagnosed and ineffectively treated. Physicians come off far better on the web-based rating sites than in scientific practice profiles. They should be demanding patient ratings, not proscribing them.

Fourth, the public can learn something from the ratings. Themes tend to repeat in both the critical and laudatory commentary. When 8 patients tell you that doctor X prescribes penicillin for everything, I doubt they’re lying. When 20 of 40 assessments of doctor Y mention misdiagnosis, I’d bet the farm that there’s a lot of misdiagnosis going on. When every one of 32 posters says Dr. Z cares, listens, and explains, I believe that of Dr. Z. Many of the postings are balanced, nuanced, and thorough. The critics in particular tend to give reasons for their judgments. Some are scathing and even cruel, but the savage commentary is usually reserved for those who have committed truly barbaric acts.

Fifth, physicians should welcome the feedback, especially if it is anonymous. Patients are disinclined to ruffle their doctors' sensibilities. I like my family doctor, Mick Jutras of Saskatoon, as do 29 of 32 raters here. He is intelligent, thoughtful, and a good communicator. I did not change my mind because one patient wrote, “He sucks. Totally ignorant. Rude.” But I have never had the jam to tell him that same-day access should be the norm*, that the lab test result communications are erratic, or that it is perplexing that Toyota summons my car for screening but his highly automated practice doesn’t invite me for the tests that are supposed to be so vital to my well-being. (My optometrist and dentist pester me relentlessly.) Nor has he ever surveyed me. Both he and I have let him down on the quality improvement front. If I thought he and his partners would read the internet ratings carefully and recognize that the negative feedback is the wellspring of improvement, I’d log on and write.

MJ claims to be in favour of objective physician rating systems, meaning, no doubt, rating systems that they control or endorse. Their real fear is that patients will pay more attention to each other than to the insiders’ guild. Don’t pay attention to the unwashed who have the gall to write about a condescending ass who interrupts after 20 seconds and can’t tell a virus from a bacterium. We’ll do the rating and ranking of our own.

But what about malicious content? Yes, it's a problem, and potentially harmful to the innocent. There are remedies aside from squashing your patients' freedom of expression. The rating sites open their doors to physician comments and rebuttals. Smart ones, like Saskatoon urologist and medical blogger extraordinaire Kishore Visvanathan, have actually embraced the concept and the technology as a learning tool. Patients can respond to others’ posts. Site surfers should be invited to report suspicious content to the administrators or directly to their doctors.

Above all, keep some perspective. False positive opinions far outnumber false negatives. A patient bent on vengeance has many ways to sully a reputation. And the public are not idiots: if they are at all open-minded about the merits of a doctor, they will read all of the posts and judge on the basis of the body of evidence presented.

If I ran a doctor rating site, I would add a new category: has your physician ever asked you to sign a MJ-type gag order? If the answer is yes, go elsewhere if you can.
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* Except for the time we were both at a fundraiser with excellent and abundant alcohol

My Evening with the Future

Steven Lewis

Throw away the crystal ball and spend an hour with Google Health: the future will be right in front of you. Providers who prefer the pedestal to parity and see themselves as traffic cops on the health information highway are in for the shock of their lives.

I intended to compare the on-line personal health records of both Google and Microsoft, but I couldn’t convince Microsoft that I was Phyllis Diller from Scottsdale AZ (you have to be a US resident to sign up). Google let me in, and in a few minutes I had my own record. Well, not quite my own. (Health record privacy purists, skip the next paragraph.)

Touch wood, I’m a healthy guy. I don’t have any chronic conditions (unless you count seasonal hay fever, a cat allergy and a severe reaction to sopranos), have never had surgery, take no prescription drugs, and, having read too much quality and outcomes research, am a bit of a fatalist. There will be no colorectal cancer screening bazooka shoved up my behind unless I get to watch a video of my doctor smiling happily through the procedure. With so little data to enter, I made stuff up – gave myself type 2 diabetes, angina, arthritis, and added 25 pounds – to test the ingenuity of the architecture.

Hello Frank Gehry. The software leads you through a consumer’s garden of neurotic delights – and I mean that in a good sense. You can input your own remarks and notes, set permissions for access, amend or delete entries. You can second guess the diagnosis or advice you got from your doctor in the seven minutes he spent with you. You can get drug price and therapeutic equivalence comparisons – your own reference based pricing program is at your fingertips. You can catch contraindicated drug combinations. You can learn your odds of falling prey to various health breakdowns by linking your profile to web-based risk calculators. You are handed the key to a cornucopia of safe information injection sites tailored to your profile.

But, dammit, this is America, and in America nothing good happens unless money changes hands. Some of the featured partner sites offer free advice, but they’ll also sell you drugs or other products. Others are more brazenly mercenary: at the Cleveland Clinic site it’s cash for counsel. Want a second medical opinion from MyConsult? That’ll be $565, and it’s not insured. The web site supplies a sample report so you can see what you’re likely to get: mainly of a summary of what the patient sent in, and a 3 paragraph opinion. I figure a good senior resident could knock one off in half an hour, an hour tops. Bargain-hunters can score a nutritional consult about your gout (honest) for a mere $95, or 2 sessions on high blood pressure for $165.

Perhaps you’re more inclined to Blueprint for Wellness, which offers a package of 29 lab tests, a wellness questionnaire, and a personal wellness report for $134. TrialX.org will match your condition to a database of 25,000 clinical trials and help you find clinical investigators expert in your condition – all free. It’s essentially a dating service for researchers and a potentially vast pool of trial recruits.

To those of us of a certain age for whom a long distance call was a special and costly luxury, this is all a bit disorienting, even creepy. Google has an incentive to choose its partners carefully – it doesn’t want to jeopardize its carefully cultivated we’re-not-like-the-other-megacorps image. No filter is foolproof, and no interaction is risk-free. Nonetheless, the methodologically innocent are far better off with Google as the quality control overseer than heading off solo into a cyberspace full of charlatans.

Still, there are reasons to pause and reflect. Will the model undermine the doctor-patient relationship? Will it fuel an even greater obsession with tests and assessments, luring millions more to the already-vast army of the worried well? What happens if providers act on inaccurate or misleading patient-created information? What jurisprudence will arise from the inevitable litigation when something goes wrong?

Yeah, whatever. Quibble all you want; it’s here, it’s growing, there will be no pausing and precious little reflecting. It’s a predictable workaround, an evening up of the odds against Fortress Healthcare that keeps patients in the dark and puts a firewall between them and their health record. Some enlightened health care organizations, such as Group Health Cooperative in Seattle, put patients at the centre of their e-health strategies. How strangely foreign to the Canadian Way.

Canada’s e-health leaders can either ignore it or embrace it. Ignoring it risks dooming the provider-oriented, paternalistic plans to rapid obsolescence. They should take what’s good about it – joint production and ownership of health information, the potential to create networks of trustworthy information sites, the linkage to self-management tools tailored to individual profiles, the fantastic communications capacity – and revamp their e-health plans, fast.

The democratization of knowledge and the desire to be treated like an adult in health care transactions are irresistible forces. It’s a near-miracle that Canadians for the most part continue to put up with the arrogance, inconvenience, secrecy, and error build into the existing system. We could have seen this coming a decade ago, but we are too often a nation of deer in a world of headlights. Google and Microsoft have set off the alarm. Pushing the sleep button won’t cut it much longer.

Pay for Performance: The Wrong Time, the Wrong Place?

Steven Lewis

It sounds like such a good idea: don’t pay people to show up and scurry about, pay them for proven performance. It’s the new Big Thing in health care financing. As usual, the Brits have pursued it most vigorously. Some Canadian health care executives get bonuses for achieving certain targets. The US Medicare plan has quit reimbursing hospitals for the costs of dealing with avoidable mishaps such as falls and bed sores. Health care cheques should come with performance strings attached. About time, right?

Well, yes, if your overlook the P4P track record. Renowned British health economist Alan Maynard found lots to be cautious about in his review of experiences to date. The Hay Group believes that even 5% to 10% of income at risk is insufficient to produce a significant effect, let alone the 1% to 2% typically on the table in such arrangements. In the UK, the vaunted GP bonus schemes – which can add tens of thousands of pounds to physician incomes – have turned into base pay. The average GP practice scores 95% of the bonus-triggering points available and virtually all get 90% or more. But the number of complaints per practice – one reasonable measure of satisfaction – varies considerably.

On examination, the very essence of P4P is troubling. It is a profoundly pessimistic concept of what makes people tick in health care: we can’t rely on organizational culture, professionalism, devotion to public service, or commitment to excellence to get the desired results, so let’s just concede that it’s all about the money. Managers and practitioners are hardened cynics for whom pecunia vincit omnia -- cash conquers all. So let’s tell them what to accomplish, ring the economic bell and watch the Pavlovian throng stampede to improvement via the cash-stuffed trough.

Dishearteningly, P4P writ large becomes a self-fulfilling prophesy. Adopt its assumptions and fund or pay accordingly and you will indeed turn civilized people into econocentric shadows of their selves. Set up the game and people will learn the rules and play accordingly. Moreover, the game will inevitably lack sophistication, because to dole out the rewards, the goals must be clear and simple; the results easily measurable and immediate; and the reach modest (no one will play if it’s too hard to win). All nuance and complexity are obliterated by the basic algebra of the payout. So it’s hardly any wonder that British GPs are walking away with the dough. Ask not for what the bell tolls – it tolls for fee.

But what if we’re just learning, and eventually get it right, particularly if we learn from our masters in the private sector? You’re doubtless as inspired as I am by the corporate CEOs with incomes almost entirely driven by the value of their (occasionally back-dated) stock options and the quarterly earnings statements. They sure knew how to tally up the performance points. You get what you pay for, and the denizens of Wall Street decided to pay for scams so absurd that they make the Nigerian please-be-my-agent-for-millions howler look like Protestant-ethic capitalism at its sober best. IKEA CEO Anders Dahlvig refuses to take his company public precisely to avoid the tyranny of get-rich-quickism that makes a virtue of impatience and myopia and rewards Ponzi schemes over substance. But he never claimed to be as smart as the guys who ran Lehman Brothers.

For the hundredth time in a seemingly infinite series, the world is learning two key lessons: you don’t get something for nothing, and appealing to baser instincts will improve neither humans nor their achievements. Health care is a uniquely fraught enterprise that deals with uncertainty, vulnerability, tragedy, hope, and trust. Of course it involves great amounts of money and to which neither individuals nor organizations can be indifferent. Health care takes place in a messy world, not a monastery. But money is a resource for achieving other ends, and if it defines us or crowds out nobler preoccupations, the means become the end, the aperture narrows, and the golden calf beckons.

Doesn’t it seem odd that we would have to coin the notion of “pay for performance” in the first place? What the hell else are we paying for? When did “doing one’s job” uncouple from “doing one’s job well”? Suggesting that ordinary performance – not spectacular, but merely satisfactory, like being nice to your patients or doing Pap tests at the recommended interval – deserves a bonus debases the entire enterprise. It creates a cultural norm in which lousy performance is the natural state and the passable is redefined as extraordinary. It dumbs performance down and leaves out the hard parts.

Show me a P4P system that rewards first class care of the frail elderly, life-enhancing management of multiple chronic conditions, reduced need for surgery fifteen years from now, or ending one’s career with sunny disposition and compassion intact, and I’m all ears. But in my preferred world, the first dollar and the last pay for excellence across the board, an ethos of care, devotion to the public good, and the perpetual search for knowledge. Pay individuals well and fund organizations fairly. Settle the money issues swiftly so all can focus on what the money is supposed to achieve. Do this well and we’ll have pay for performance – not as cause-and-effect, but as a harmonious feature of a thriving culture.

Providers who practice to chase income targets and dangled bonuses are different from providers who want a reasonable income to pursue their callings out of love for what they do and a drive to serve people better. For those who crave the buzz of the financial transaction, there is a vast world beyond health care to explore. Health care that takes its cues from the rantings of the Chicago School and the MBA culture imperils its values and its practitioners. If those twin intellectual frauds can take down an economy, they can easily corrupt health care. Health care culture needs more than a behaviourist tweak and tuck. The worst imaginable outcome would be that P4P as currently conceived actually worked as intended, for that would prove just how far we have fallen.

A Westjet Health Care System?

Steven Lewis

I fly a lot - too much actually; I am chagrined by my carbon footprint. Most of my flights are on Air Canada (AC), indisputably an international class, full-service airline. You can go pretty much anywhere in the world on AC or its Star Alliance partners. You can pick your fare, frills, seat, and class. I've been an Elite AC member for about 15 years, so I get to wait for my flights in swanky lounges with free food, booze, newspapers, magazines, and business centres. I get free flights from the Aeroplan miles I accumulate and an annual stack of upgrade certificates. I get a special number to call if I need to change a reservation or seek help. Cool, eh?

But I fly Westjet (WJ) whenever I can, and would happily abandon AC altogether if WJ decided to go after the Saskatoon-to-wherever (especially Toronto) business traveler markets. Why? What would lead me to turn my back on the airline that gives me all this stuff, and what accounts for the almost giddy affection for the one that doesn't? Here's my hypothesis: it's because Canada's airlines are akin to the health system we have (AC) and the health system we need (WJ). Here's how.

What do I need? Business class to Kuala Lumpur? Single malt scotch in the lounge? Special meal? AC can do it. WJ? No can do. AC is pretty good at tertiary air care; WJ is the primary care airline. Most travel needs are primary: a reasonably priced ticket, leave on time, decent legroom, a modern aircraft. My own travel life is, well, pedestrian: Calgary, Vancouver, Toronto, Ottawa, Winnipeg (quit smirking - I like Winnipeg). WJ gives me a Boeing 737 with good overhead luggage capacity and a quiet ride - every time, all the time. AC gives me cramped Bombardiers that force passengers to compete for comically little carry-on baggage room. Advantage: WJ for the basic journeys; AC for the continental transplant operation.

What happens when there's a problem? Planes break down and weather mocks schedules. The test of an airline is not when things are ticky-boo; it's when misery descends. AC appears to believe that keeping the passengers in the dark about why the flight is delayed is reassuring, and that parcelling out the delays in two hour increments is comforting. "The 2 o'clock flight that was to leave at 4 is now departing at 6. We can't tell you which gate." WJ makes it a point to tell you what's happening. Call AC with a problem and you almost feel the blame-the-passenger vibes as the agent leafs through the policy manual to confirm your non-entitlements. WJ seems to want to help. AC has done some nice things for me, but WJ has performed truly heroic feasts of creative problem-solving and in one case was generous beyond the call of duty. Advantage: WJ on both comportment and delivery.

Surprise, it's a service industry. Aviation is incredibly safe. Planes of equal size are pretty much interchangeable. The highway up there is the same for everyone and an airport is an airport. WJ offers no business class, no hot meals, no fancy lounges, no air miles of its own. It pursues advantage by other means: the attitude of its people and their capacity to solve problems. Their entire ethos is built around the customer. I used to think the "AC attitude" was the inevitable result of an aging workforce fatigued by the wear and tear of a zillion flights and alienated by repeated labour strife and restructuring. Likewise I was sure that the happy-faced, fun-loving, energetic WJ honeymoon would end.

Well, WJ is a decade old and still no sign of passive aggression; not all their employees are fresh-faced kids. AC actually tries, but there is too much ennui and complexity . Their own agents can't figure out their absurd aeroplan mileage redemption rules and its website produces some legendarily idiotic itineraries. Small wonder they can't reliably produce quality service in the crunch. Pleasantness and can-do are hard-wired into WJ's DNA: I once bought a ticket from a WJ baggage service agent. WJ gives you more while giving you less. It has chosen the right quality indicators. Advantage: WJ.

Simple, reliable, effective, pleasant: whether from an airline or from health care, that's what we need most of the time. And where simple won't cut it, more than ever we need reliable, effective, and pleasant. AC is besotted with complexity and covets the overseas, long-haul market segment. You can tell it doesn't really care about most domestic routes outside the big cities. Though they try their best, it's clear the employees have no great love for the corporation they work for.

AC is to air travel what our acute care-obsessed, high-tech-envy health care system is to health. It's great that we can find the cystic fibrosis gene and separate Siamese twins but not so good that chronic disease management is a national catastrophe. The vast majority of people don't need glitzy miracles; we need sound, evidence-based, timely, respectful, and well-communicated primary health care from a team dedicated to getting it right.

In the end it's about culture, that maddeningly elusive notion that signals what an organization or system is about. The truly successful put the customers first and pay attention to the workforce and the workplace. They get the fundamentals right and understand where their bread is buttered. WJ has mastered primary air care; it makes money where AC bleeds red ink. Health care, take a lesson.

A Man for All Sections: Physicians, Heed Thy Hobbes

Steven Lewis

I dunno, maybe it's the season, but I feel especially moved by the plight of doctors at the bottom of the medical politics food chain. Ontario emergency room docs are just the latest in a long line of disgruntled groups crying foul over the agreement negotiated by their medical association. That agreement got the support of 79% of Ontario doctors, but most ER docs said no. Now they're mobilizing to pursue distributive justice by other means.

Unfairness in the relative income distribution of physicians is not an occasional aberration, a minor side effect of an otherwise exemplary allocation process. It is the inevitable outcome of a fierce competition within a guild that does most of its bare-knuckled work behind closed doors. Fee schedules are complex and no well-intentioned amateurs - the kinds who sit at the table on behalf of their peers - can possibly master the game with equal panache. Over time, power shifts and accretes, some groups gain the upper hand, and income disparities proliferate. There are winners and losers - all relative of course, since every full-time physician's income is at least upper-middle class. Provincial medical associations are the certified bargaining agents for all doctors - even for doctors who choose not to join. In general, the association and the government negotiate a total amount of money for physician compensation, and most of the details get worked out by the doctors themselves. Sometimes the government targets a top-up here, a fee code adjustment there, but overall, the physician categories - called sections - duke it out for shares of the booty. The mystery is not the injustices that follow, but why habitually shafted specialties, from primary care to rheumatology to geriatrics, stay with the medical herd. We outsiders don't really know - the doctors don't air their reasoning to outsiders - but we can speculate. First, they are a profession, and professions love nothing more than self-regulation and self-management। They might prefer the irritations of internal decisions to the prospect of subjecting the guild to external scrutiny and meddlesome guidance. Who ya gonna trust: your peers, or the bureaucrats? We are a band of brothers (and sisters), are we not? We look after our own - imperfectly, but we get you. Stay with us, and we'll harder for you next time. To continue reading please click here.