Medical care and airlines - should there be a difference?

A recent article by Pauline Chen features a group of primary care physicians at Tufts Medical Center in Boston, who have created a concierge practice that funnels income into the traditional general medical practice that sees less-advantaged patients. Surveys (performed by the medical center itself) found that patients rated the quality of interactions with their doctors similarly regardless of their affiliation. The only significant differences in responses had to do with the services offered — care coordination, physician access and interactions with office staff. According to the medical director, analogous to airline services providing both first class and coach services, the parallel practice gets patients to the same destination - some eating peanuts, others eating caviar.

I believe this is an intelligent hybrid that may have successfully reacted to our broken medical system, but the ends does not justify the means. Differing services based on the ability to pay is discrimination - it is demoralizing for coach flyers, but morally wrong for economically-disadvantaged patients. This is because medical care is not the same type of services as airlines - people will not die if they cannot fly to places, but they will die without medical care.

In a civilized society, its members should have equal access to life-saving services regardless of the ability to pay. Just like the fire department, medical care should be provided as a societal safety net so that, instead of worrying whether our house will burn down while we're off at work or whether a catastrophic illness will take away everything we've worked hard to earn, we can focus on higher pursuits like being a productive member of society.

Differences in health outcomes between two groups remain unclear. If they are unequal, then there is discrimination based on the ability to pay. If they are equal, then first-class patients pay more money without justifiable returns other than convenience and a more pleasant office staff, which I argue should not be different in any circumstances - I'd like to believe that medical professionals treat fellow human beings in sickness with utmost compassion at all times, regardless of payment scheme.

Either way, segregating patient care leaves a bad taste in my mouth. As a doctor, we ask patients to trust us with personal life stories that they may never share with their parents or their significant others. Such level of trust can hardly be established in the settings of discrimination.

Deep-fried snickers bars

Today I went to a lecture where a cardiologist showed us photos of disgusting food sold across America. The purpose was to convince all the cardiologists in the room that despite decreasing incidence of heart attacks from 2000-2007, cardiologists can rest assured that these fattening food items will keep them in business, and this is true only because America pay based on volume regardless of outcome. It makes me sad to think that cardiologists are happy when people eat deep-fried snickers bars.

Why do we use carrots and sticks if humans are not horses?

It was 6PM and I was still at the clinic. My last patient, Mr. R, had left over an hour ago and as far as the rules go, I could be home by then, eating dinner and taking a shower. But as I perused Mr. R's medication list over and over, I couldn't get myself to leave. He was taking over 15 medications and the pill burden was overwhelming. Since he recently lost Visiting Nurse Services and had to fill the pillbox on his own, he was exhausted from taking medications. I thought of how all the puzzle games I used to play had prepared me for this day as I went through different combinations of medications to arrive at the smallest possible number of pill counts for Mr. R. I continued to think of his case on my drive home trying to figure out a way to get a better control of his raging diabetes.

As I sat down and stuck a fork into the piece of chicken that was my dinner, the clock read 730PM and I thought about why I didn't leave earlier. Why did I spend time trying to fix the life of a stranger instead of feeding myself? What motivates us as doctors to stay late and perform a thorough task instead of clocking out on time and leaving the fate of our patients to other forces in the health care system?

And this is a pivotal question, because as our nation tries to make sense of why health care cost is spiraling out of control, the new system will be rebuilt based on what motivates health care workers to do a good job of caring for patients.

Many fresh carrots on newly-minted sticks have already been instituted in various areas of the medical system as part of the new health care legislation in an attempt to motivate health professionals to do the right thing, including programs like Medicare's Physician Quality Reporting Initiative (PQRI). According to the legislation, PQRI asks physicians to report how the care they furnish aligns with evidence-based clinical guidelines for a variety of medical conditions, such as diabetes or heart disease (1). In 2010, physicians who successfully report these measures will receive a 2% bonus on charges received from Medicare. The bonus tapers down to 1% in 2011 and 0.5% from 2012-2014. However, starting in 2015, physicians who fail to report these measures will receive a penalty of 1.5 percent deduction from their Medicare revenue from that year, increasing to 2% penalty in 2016 and each subsequent year.

But before we march forward to the trial and error of this new measure designed to induce higher performance, it is important to step back and ask ourselves: what motivates us as human beings?

According to Daniel Pink's book Drive based on numerous researches replicated in various settings over time, humans are motivated by three intrinsic drives: autonomy, mastery and purpose.

In a book by Deci et al published in 1985 (2), multiple researches on school children randomized to autonomy-supporting versus controlling teachers conclude that autonomy-supporting environment correlates with more creativity as well as enhanced intrinsic motivation and self-esteem. The concept of autonomy is replicated in the real world today by a successful Australian software company called Atlassian (3). Inspired by FedEx's promise to deliver a package in 24 hours, Atlassian instituted "FedEx day," when, once in each quarter, software developers are allowed 24 hours to work on anything they want, enjoying full autonomy. Results are brilliant bug fixes and new innovative features that otherwise would not be explored as successfully.

Another landmark article in 1959 (4) by Robert White, a professor emeritus in clinical psychology at Harvard University, proposed that the inherent satisfaction in exercising and extending one's capabilities is a strong motivator. It later inspired numerous experiments on mastery motivation which show multiple positive effects on performance, from leading test subjects to spend more of their free time on tasks (5) to increasing cognitive development in children (6). The 21st century example of these validated experiments can be found on Youtube, where there are millions of videos on the how-to of everything, from using make-up to writing computer programs, made by folks who enjoy the subjects in their free time, free of charge.

An interesting study by Adam Grant at Wharton demonstrates the power of purpose as a motivator (7). The study shows that employees working in a call center at a university fundraising organization who were given stories of how the money they raised affected the lives of beneficiaries earned more than twice the amount of donation compared to before the intervention. Volunteers exemplify the power of purpose in the real world, where people from all walks of life are driven, not by the extrinsic motivation of money, but by the intrinsic motivation of being part of a cause.

Interestingly, within decades of social studies research on motivation, the most surprising finding of all is that monetary rewards actually lead to poorer performance for cognitive tasks. The pervasive belief that higher monetary rewards lead to higher performance only applies to straight-forward, mechanical tasks – as soon as the job requires even the least amount of rudimentary cognition, monetary rewards produce negative effects on performance. This finding has been shown in works by numerous researchers, including Dan Ariely (a professor of behavioral economics at MIT)(8) and Dr. Bernd Irlenbusch (a lecturer at the London School of Economics) (9).

Despite the repeatedly validated science of intrinsic motivations, managers and organizations continue to use money to motivate workers for the more and more complicated cognitive tasks of the 21st century, the Medicare's Physician Quality Reporting Initiative (PQRI) included. The monetary penalties of PQRI will narrow physicians’ minds onto the goal of mechanically completing reports, eliminate autonomy and distract away from mastery and purpose. It sends the message that physicians should do a good job, not because our work has a higher purpose of keeping other human beings healthy, but because we will earn more money for it. In a way, it views physicians as rudimentary horses easily lured by rudimentary carrots, when in reality I would like to believe that physicians are human beings driven by the ability to direct our own fate, the desire to be good at what we do, and the heart to be part of something bigger than ourselves.

On my drive home after another hard day's work, listening to the repeating lyrics of the wise singers of "The Lox," I reflected back on our motivation as physicians as the radio crooned, "It's the key to life. Money, Power and Respect." Autonomy is power, and mastery brings respect, but the Lox was wrong about the last key to life. In the end, life is never about money - it is all about purpose.

(1) http://www.acponline.org/advocacy/where_we_stand/access/int_prac_guide.pdf
(2) Intrinsic motivation and self-determination in human behavior By Edward L. Deci, Richard M. Ryan
(3) http://www.atlassian.com/about/Atlassian_Media_Kit.pdf
(4) R. White. Motivation Reconsidered: The Concept of Competence. Psychological Review. Vol. 66, No.5, 1959.
(5) S. Harter. Developmental Differences in the Manifestation of Mastery Motivation on Problem-solving Tasks. Child Development. Vol. 46, No. 2 (Jun., 1975) pp. 370-378.
(6) K. Jennings et al. Exploratory Play as an Index of Mastery Motivation: Relationships to Persistence, Cognitive Functioning, and Environmental Measures. Developmental Psychology. Vol. 10, No. 4, 386-394
(7)http://www.management.wharton.upenn.edu/grant/Grant_JAP2008b_TaskSignificance.pdf
(8) D. Ariely, U. Gneezy, G. Lowenstein, &N. Mazar, Federal Reserve Bank of Boston Working Paper No. 05-11, July 2005; NY Times, 20 Nov. 08
(9)http://www2.lse.ac.uk/newsAndMedia/news/archives/2009/06/performancepay.aspx

Can entropy be reversed?

For those with an android phone, I'd like to introduce you to Edwin, one of the most amazing applications out there for android users that really puts the future in perspective. It is a speech-to-speech personal assistant program that lets you asks any questions, from what is the meaning of life to where is the nearest coffee shop, and it will give you the answers (which by the way are 42 and dunkin donuts on chapel street). It links to wolfram alpha, google translate, and other incredible computational programs that vastly increase Edwin's ability to assist, including calculations, word spelling/definitions, language translation, map/navigation - the list goes on. Below are just some of the quirkier responses you can play around with if you're bored:

Input: I love you

Response: Sadly, I was not designed to love, but if I were, I would love you

Input: I hate you

Response: I'm sorry you feel that way. Maybe with a later update, you will change your mind.

Input: Where is my car?

Response: Not sure, but wherever you find it, that's where it is.

Input: Why are you awesome?

Response: If I have computed more, it is by standing on the shoulder of giants (plus a lot of hard work - with all due respect to Sir Isaac Newton).

Input: Do you have a brain?

Response: I am capable of universal computation; that I can say.

All fun aside, Edwin just shows that all the fancy technology we ever imagined in sci-fi novels/movies will become reality only in a matter of time. Edwin seems to be a primitive ancestor of Multivax, the all-knowing AI in the famous short story "The Last Question" by Isaac Asimov. With more computational power and programmed responses, Edwin will maybe one day tells us how entropy can be reversed. Until then, the next game-changing discovery will be something we have never ever imagined, sensed or comprehended in human history - a completely separate dimension that will change everything and how we operate. In a way I feel like we are ants, unaware of the human world above us. When Armageddon comes we wouldn't understand why, when in reality God just spilled a bag of skittles on us.

Extra Hour in the Sun

As a new intern at a well-endowed medical institution, I was disappointed despite the flurry of excitement that comes with orientation. I was disappointed despite the brand new privilege to save lives and relieve human sufferings. And the disappointment was made clear to me over the past two days.

What has happened in the past two days? As I will be working at two separate hospitals, for the past two days I have sat through training for at least 5 different EMR systems, none of which are similar or produced by the same company, all of which are designed to do the exact same things as hundreds of other EMR systems used in other parts of the country.

What really drove this home, as I zoned out during training for the 4th EMR system of the day, was the fact that in the mix, I didn't receive access for one of the EMR systems. The technician at the training center instructed me to call help desk when I got home. At home on the phone with the help desk specialist, I was told that the issue unfortunately could not be solved on the phone and I would have to return to the training center. As I hung up the phone, I thought how nice it would have been if I had found this out 15 minutes ago when I was still at the training center.

But I wasn't told that stopping by the help desk was an option. I wasn't informed that the help desk was in the same building as the training center. I didn't know that there was a possibility that this issue could not be solved on the phone.

Could this whole ordeal have been foreseen? Could it even be possible that I'm not the first person who fell through this trap? Very likely. But this is only one of the possible failings in our highly fragmented, variable medical system. With 5 different EMR systems in only two hospitals, how could a human being possibly plan for all the possible shortcomings these non-uniform processes create?

It's not a matter of inconvenience that new providers have to learn 5 new computer systems in two days - it is a matter of patient safety. I continue to be amazed that despite all our advances, we as a country have not reconciled our differences and agreed on a uniform EMR across most, if not all, medical institutions. The benefits are many, including the ability to consolidate fragmented/repetitive medical information, better coordinate care and reduce possible mishaps created by each separate system. The waste that goes into reinventing the wheel, retraining medical professionals, troubleshooting hundreds of different EMR systems nationwide is likely enormous.

I believe that amidst the effort to reform health care, the time is ripe for us as a country to put our self-interests aside and work together so that future medical professionals and patients do not have to settle for this substandard, fragmented medical system. But until then, I am walking back to the training center to tell Jim, my computer trainer, what had happened to me so that future interns can have an extra hour in the sun instead of spending time at a computer training center.

Tricky questions about the DMV and car insurance

DMV

Q: What is the difference between Title and Registration?

A: Title confers ownership of the car, while registration allows you to operate the vehicle regardless of ownership. Usually the two processes are completed together by the dealer when you buy a car, but they can be done separately at any time. Read more here.

Q: How do you transfer license from other states?

A: The processes are usually detailed on that state DMV website, but basically until you have a real license in hand, starting a transfer process means starting everything over (you'll have to redo the eye test, knowledge test, road test, pay for another 8-hour pre-licensing course). This is true for both learner's permit and interim license.

Auto insurance

Q: How can I get great prices and coverage on car insurance?

A: Edmunds.com has a good article explaining everything in detail here.

Q: Can you get insurance on a car that is not registered/titled to you?

A; Yes. Title and registration do not mean much - it is the car insurance and the coverage that really matter. If you need to drive someone else's car and would like to buy insurance to cover you and your friend's car in case you wreck it, you can certainly do so. Read more here.

Q: Do I get car insurance based on the state of registration, the state where I live, or the state where I drive the car?

A: Car insurance is based on the state in which you drive the car, basically where the garage is. Every state has different requirements and you can check the above link from Edmunds.com to see what they are.

Q: If I'm a new driver, can I get a cheaper insurance if I add another experienced driver on the policy?

A: I tried this while soliciting online quotes and discovered that the more drivers you add to the car, the higher the premium, regardless of their driving records, impeccable or not.

How to deal with car dealers

I recently bought a 2010 Honda Fit Base Automatic in silver with security system installed for $16,002.36 as a base price, $17,707.07 out the door with NY sales tax and registration (sales tax $1420.21, registration fees $197 ($214 with sales tax - dealer only charged $212), title fee $50, inspection fee $10, tire tax $12.50 for 5 tires). I believe it was a good price and I wanted to share my experience with you so that you can get the best deal on your future cars!

First, I read these tips on buying new cars on Edmunds.com. It gives a good, step-by-step overview of how to navigate through the whole process, most importantly how to not get scammed by dealers. After perusing the article, I went through the following process.

- I went on www.truecar.com, which is a great website that updates true cost to dealers (how much it actually costs the dealers to sell you the car) and true market value (the average of how much everyone is paying for this car) of your new car more regularly than Edmunds. According to truecar.com, the true cost to dealers of a new 2010 Honda Fit Base Automatic without the security system installed is $15,740. A great price is less than $15,912, good price is less than $16,343, and $16,344 or more is overpriced. These figures include destination fee (what dealers pay to get cars from factories to the lot) and regional ad fees. With these figures in mind, I have an idea of how much I should be paying for the car

- Truecar.com provides a list of dealers with the lowest prices in your area, so I solicited quotes from the internet departments of the 3 cheapest dealers. To save yourself some time, make sure to solicit out-the-door price through internet transactions only - beware of dealers trying to get you to come in for a test drive with unrealistically cheap base price for the car. Once you make a trip out to the dealer for a test drive wasting many hours of your day, they will add on ridiculous fees here and there so that in the end, you end up overpaying for the car. As a result, you want to negotiate based on the total price you will be paying, all fees included. I solicited quotes from both CT and NY, because even though I lived in NYC at that time, I was about to move to CT and could get the car at either place.

- I lucked out and got a ridiculously cheap quotes from a dealer in CT: $16,967 out the door, security system installed, including CT sales tax 6% - that's $15,847 base price with security system included. Considering the fact that true cost to dealer was $15,740 and the security system is worth at least $165 or so without the installation fee, this price was too good to be true. They were probably hoping that I will make a trip to CT so that they could force on ridiculous fees when I'm stuck there, but it did not matter.

- With this ridiculous quote in hand, the next thing I did was checking out the inventory of potential car dealers in the area. Dealers do not want to keep cars on their lot, so if you are willing to take cars that dealers already have on hand, they will be more eager to sell it to you, probably at a cheaper price just to get rid of the car. We searched for dealers with a lot of Honda Fit on hand and said to them, "if you could beat this quote, I will take the car off your lot today." This got many dealers squirming for business.

- I landed at a big dealer in Queens with the cheapest out-the-door price of $17,707.07. Base price with installed security system was about $16,000 like I mentioned above, and I made sure that all the other fees were not bogus. Sales tax is easy to check and is based on the state in which you register the car (it does not matter where you buy the car - you pay sales tax based on the state of registration). Registration fee varies, but you can use the DMV dealer's registration fee calculator to see if the dealer is overcharging you for registration. Title fee and inspection fee are standard and are always listed on the DMV website. Tire tax applies at least in NYC where the government charges tax for recycling your tires.

- People usually think that buying a car with a full cash amount up front will get you a better deal, but this is untrue. Dealers either do not care or would prefer that you finance the car, so that they can sell your debt to outside banks and make more profit on the deal.

Beware of the following dealer tricks:
- Some of them will make you sign a price offer, stating that if the dealer could match your price, you automatically have to buy the car. Do not sign this form - so that should you come upon a cheaper quote from another dealer, you can easily switch without your hands tied.
- If you decide to get extra options for your car, after you have agreed on a price, dealers will try to make you switch from OEM (original equipment manufacturer) options to other non-authentic options made by some random companies. They will say the non-authentic options are basically the same, but have better features, so as to persuade you to switch, but do not fall for this trick. Obviously, OEM options are worth more and will get you a better price for your car when you trade it in later on.
- Even though you have agreed on a price, dealers will try to sell you random extras while you're signing the contract - do not agree to buy unless you have thought carefully and decided you really want these options - most of them are junk. If you feel like you might be intimidated in the dealer's office and fall for these tricks, you can try to have dealers come by your house or fax the contracts over, but I found that dealers rarely agree to do this. Remember to be strong and do not buy anything because you feel bad or pressured.

More on tricky DMV questions in the next post!

Testing out PDSA - Roughage

With too much time on my hands, I'm taking free online courses on the Institute for Healthcare Improvement website, currently on quality improvement. The IHI chose the PDSA cycle as its weapon of choice, and in the spirit of self education, I'm creating a self-improvement project using the PDSA method. Follow me as I stumble through the path towards more roughage!

PDSA1

The three fundamental questions of the model for improvement:

1. Aim (How much? and By when?): I will consume at least 1 serving of fruits/vegetables with every meal eaten by the next month

2. Measures (How will we know a change is an improvement?):

- Outcome measures (How is the system performing?): Percentage = number of times successfully consuming AT LEAST 1 serving of fruits OR vegetables per meal eaten/total meals eaten. Data will be collected manually when eating real food only (not counting desserts/snacks). Baseline measurements will be excluded for convenience.

- Process measures (Are parts in the system performing reliably as planned?): The number of days with at least 2 servings of fruits/vegetables in house, the percentage of successfully getting a salad when eating food without roughage.

- Balancing measures (Did the changes we made to improve one part of the system mess up other parts?): One month after successfully eating at least 1 serving of fruits/vegetables per meal, I should not gain more than 10% of my baseline weight as a result of trying to eat more roughage. This data will be collected before and after 30 consecutive days of achieving the outcome measure. I don't have a scale so we'll have to skip this one.

3. Changes (What changes can we make that will result in improvement?):

- Keep at least 2 servings of fruits/vegetables in house at all times

- If there is no roughage accompanying the food I order when eating out, I must get a serving of salad with my food.

Plan:

- Objective: increase roughage consumption

- Question/prediction: Will keeping roughage in house and ordering salads when eating out increase roughage consumption?

- Plan: For the next week I will keep at least 2 servings of fruits/vegetables in house at all times, and if there is no roughage accompanying the food I order when eating out, I must get a serving of salad with my food.

Do:

- Problems: Cherry tomatoes go bad quickly and I can't shop that often, must find longer-lasting roughage!

- Unexpected observation:

Study:

- Results:

Act:

- Plan for next cycle: keep a bag of salad vegetables and Japanese salad dressing in house at all times? (yum!)

Track my progress here!

Why do primary care doctors deserve more money?

Today I had an interesting conversation with a few friends regarding the new health care reform that just passed. One future specialist asked me why primary care doctors should receive more money than they have in the past.

And this is an important question that I think sheds light on the whole mess of health care that we are in. It's important to specialists because there is only one pie - if primary care doctors start taking bigger cuts, specialists will have to take smaller pieces of income home. But more importantly, this question is compelling because really, what do primary care doctors do that make them deserve more money than what they are already earning (which is some of the lowest among the medical profession)?

I think the general notion is that primary care doctors manage various medical issues that are not complicated enough to be passed on to specialists. And so my specialist friend asked, why can't primary care doctors be replaced by less-trained health care professionals (nurse practitioners or physician assistants), if they are only managing basic medical issues? And if so, why do we need to pay primary care doctors more money if we can just hire non-doctors to do the same job?

I think that our job in primary care cannot be replaced any more than in other fields like surgery or anesthesiology. In every field of medicine, there are simple patients that can be taken care of by lower level health care workers, even in specialized fields, and then there are more complicated patients that need to be cared for by physicians with a deeper understanding of medicine. For example, in the field of anesthesiology, nurse anesthesiologists can do many things that MD anesthesiologists can do, but they serve as a simpler clone of that physician so that he/she can anesthetize a few patients at one time. In the field of OB/GYN, midwives play a very important role in non-complicated deliveries, while leaving trained obstetricians to care for complicated pregnancies.

I'd like to argue that in the field of primary care we specialize in coordinating care for the patient as a whole person - a manager for your health care - which I think is one of the hardest jobs in this complicated health care maze. Doctors in traditional medicine do not usually view this as a real or worthy specialization, but more and more people start to realize that this is a complex field of specialization that requires a smart physician with a thorough understanding of all other medical fields.

A good analogy I've heard is to think of primary care doctors as air traffic control . Specialists only see the problems within their field, just like a pilot in a single plane. They are important, but it's impossible to expect them to take in the big picture of the whole airport with hundreds other diseases in it, all interacting with one another. Primary care doctors step back and integrate all information to make sure that all treatments work together synergistically and that the airport as a whole functions optimally.

And this is why health care reform is focusing more and more on attracting talents to primary care. Since we're the managers, we make the decisions on when patients need tests or a trip to the specialists. If the managers suck, costs go up without increased outcomes, and specialists can't get good referrals without a good gatekeeper. Sure, for a young healthy person, their care can be coordinated by a nurse practitioner, but for a 70 year old patient with multiple comorbidities, that job gets complicated and it needs to be handled by a good primary care physician.

I have high hopes for primary care, and even though I obviously did not choose this field for the money (because there is none), I do hope that we get higher reimbursements in the future so that we can attract better talents (than me) that will turn our failing system around and keep our nation healthy.

Humans vs Algorithms

Since the conception of the first computer operating on algorithms, there has been a struggle between humans and machines – when will computers get so good at doing our job that they should replace humans?

Two most interesting articles shed light on this question. One was written by Garry Kasparov¹, the chess grandmaster who battled the famous Deep Blue, a supercomputer programmed by a full team of humans to play chess. Kasparov’s career spans a pivotal period when computers progressed from a weak chess player to an unbeatable one. But the most interesting finding of all was the fact that when weak human players team up with a few average computers, they are superior to chess grandmasters or the best supercomputers alone.

The second article by Kahneman² explains why this is by characterizing how human intuitions work. First, good intuitions take years to attain – a study by Chase et al³ showed that chess players take 10 years of dedicated study and competition to possess a good mental collection of board patterns that allow players to identify a good move without calculating all possibilities.

Second, intuitions are easily affected by biases or the way information is presented. One example is the anchoring phenomenon. When people are asked “Is the average price of German cars more or less than $100,000?” before giving an estimate of the average price of German cars, participants will “anchor” around Mercedes and high-end cars when estimating. On the contrary, when another group of respondents are asked a different anchoring question “Is the average price of German cars more or less than $30,000?” they anchor around cheaper cars and give a lower estimate.

Third, human intuitions are inconsistent. A study by Goldberg⁴ created simple diagnostic algorithms based on the criteria used by 29 psychologists to distinguish neurotic from psychotic patients. These 29 psychologists then compete with algorithms built from their knowledge to distinguish new sets of patients. Researchers found that algorithms differentiated neurotic from psychotic patients more accurately than psychologists from whom the models were derived. Kahneman believed that this is because human judgments are inconsistent.

Last and most importantly, intuitions only work in a limited environment that provides good cues and rapid feedback. This explains how a team of weak human players and average computers becomes so powerful. In this setup, humans use accurate cues and rapid feedback provided by computer calculations to make decisions. The key is a good process with humans and computers playing to each other’s strengths – computers are better at processing information, while humans are better at strategic planning.

The advancement of computers creates an impending shift in how we practice medicine. As we strive to limit human errors and stretch limited resources to expand health care access to underserved areas, computers and their algorithms play an important role. To reduce medical errors, evidence-based guidelines can help physicians concentrate on strategic thinking instead of recalling medical knowledge from memory. To increase access to care, we can rely on a team of health workers aided by computer algorithms for simpler medical problems, while referring to human physicians and their intuition to override preformed models for more complicated cases.

Overall, considering the fact that common medical conditions are common, the role of physician experts will change as we rely more on evidence-based algorithms and mid-level health professionals. This shift should free doctors to fulfill a bigger, more complicated role in health care that has yet to be determined. Until then, it is important to recognize that intuitions are limited. Using algorithms to aid in diagnosis is not just an option – it is a must to improve patient care.

References

1 Kasparov G. The Chess Master and the Computer. The New York Review of Books. 2010:57:2

2 Kahneman D, Klein G. Conditions for intuitive expertise: A failure to disagree. American Psychologist. 2009:64:515-26

3 Chase. The mind’s eye in chess. In: Chase WG. Visual information processing. New York: Academic Press, 1973:215–81.

4 Goldberg LR. Man versus model of man: A rationale, plus some evidence, for a method of improving on clinical inferences. Psychological Bulletin. 1970: 422-32.

Doctors are only as good as the environment around them

Maggie Mahar digested a new report on the abusive, unprofessional state of current medical education. She used the word shocking, but reading the quoted examples I could not feel more at home - for every outrageous finding that was mentioned, I have a personal anecdote for it.

Health care really is a weird, alternate universe where people can do nasty things that will never be ok out on the streets and get away with it. Surgeons often throw sharp instruments in the OR out of anger, many times at other human beings - can you imagine a mechanic throwing a wrench at their colleagues out of anger? Sadly, the former example fails to raise any eyebrows, and the most interesting phenomenon I've ever witnessed is how fast the foul mood trickles down in an OR. The pecking order goes from surgeons --> scrub nurses --> medical students, and soon enough everyone makes mistake out of fear and anger.

Under abusive environment, I notice I fail to accomplish tasks that I have previously mastered, and under nurturing environment, I can complete procedures I've never even seen. Doctors, like any worker in other industries, are really as good as the environment around them, and when people's lives are at stake, it is so important that health care professionals learn to be nice to one another. Instead of criticizing others for stupid consults, we can educate them when consults are warranted. Instead of labeling patients as non-compliant, we can try to sympathize with the myriad of reasons why people continue to be overweight and diabetic in this country.

For readers in the health care profession, I know this is old news, but let's make it not so.

Today we made history

Despite all the complaints I have in a prior post regarding joining the medical profession, I must admit there isn't a more exciting time in medicine than now, especially in the field of primary care which I dearly believe in. Today will be written down in history as the day that our society decided to move forward and become truly civilized - health care reform has passed. Just like slavery and other outrageously unfair practices we inflicted on our fellow human beings, pre-existing condition is a now a thing of the past.

After match day last week, I have encountered much skepticism from friends and family members when I told them I chose primary care. Is that still internal medicine? Can you still do GI/cardiology? Are you sure that's not family medicine?!?

Primary care at this point in time gets you no glory or money - I believe that will change, and health care reform has proven it. Even though we won't be earning significantly more in the near future, our values are recognized when the legislation included a provision that primary care doctors will be paid 100% of Medicare rates when caring for Medicaid patients (doctors should not be paid less when caring for poorer patients!). People in business know that managers have to be one of the smartest people in any organization, and this provision recognizes our value as managers and gatekeepers of your medical care.

Having an independent board consisting of medical professionals determining Medicare payments also holds a dear place in my heart. As an economics major and a QI enthusiast, I always struggle between being a good, comprehensive medical student ordering every test that's remotely relevant, and timidly presenting my superiors with evidence that the tests they wanted are unnecessary and harmful. After this provision, along with bundling of medical reimbursements, hopefully this struggle will lessen.

This monumental legislation has renewed my faith in health care - I am so honored to be able to share in its glory as I enter the next phase of my medical career in the same year it was passed. I can already see myself telling my grandkids about it - "Back in my days when I graduated from medical school, it was the year when Obama passed health care reform, and it's the last time anyone ever heard of pre-existing conditions!"

Check out a good summary of its benefits here. To all readers who are angry/skeptical, please have compassion for your fellow men and give this legislation time to prove itself. I definitely think it's a start of many great things to come.

Stepping stone

I've lost my passion in medicine. It is match week and I cannot care less. I see people excited about residency and I do not share their sentiment.

I still love the science of medicine itself but the field as a profession holds no excitement for me, because I know practicing alone won't make a good enough dent in the life of my patients if the system as a whole does not improve, if doctors can't even agree to put their greed aside and put the interests of the patients first and foremost. One of the things I hate the most in life is a bad team, and going into medicine I know I can't control who my team members are. There are so many things wrong with medicine that I can't wait to walk away and start over - I'm distracted by the glitter of creating something that is my own and hand-picking my own team, knowing that if I fail, I will have failed with the best and it will be a great learning experience. Comparing my twitter columns, one in health care and one in social entrepreneurship, the grass is definitely greener on the other side.

It seems I have fulfilled the prediction that most medical students will have burned out by the time they graduate, but I do think I definitely crashed and burned harder than others. Deep down I hope I didn't match so that I could go into health consulting and learn something pertinent to my current passion. It doesn't look like an exciting 3 years from here, but at least I'll know how to save lives - a girl could always use that.

The vicious cycle of finding the right volunteer opportunity

I went on Idealist.org today looking for a volunteer manager. They list a total number of entries in each category as if to boast their success, but I beg to differ and argue that volume is their downfall. There are way too many listings entered without a preset, uniform standard that orients people to the similarities and differences between entries. I could not find anything and was tempted to list my request instead of doing a manual search, but found that many people have resorted to that method without success, resulting in even more entries sitting around on the server adding more work to people combing through search results.

Not sure why they do not use a Google-powered search engine, but only strings of keywords can be used - they do not accommodate syntax for advanced search (for example, cannot use " " to signify that you only want search terms in this exact format).

In the end, I came back empty-handed and frustrated. If you know a volunteer manager, please let me know.

What happened to Deep Blue?

Check out this amazing article written by Kasparov, the chess grandmaster who battled Deep Blue, the supercomputer built by IBM to play chess. Kasparov's career spanned a period when computers progressed from a weak chess player to an unbeatable one. By observing how computers quickly overpowered the best grandmasters we have to offer, Kasparov drew important insights on the human minds and artificial intelligence.

The most interesting finding made by Kasparov came from his observation at a freestyle chess tournament in 2005 where anyone could compete in teams with other human players or computers. A relatively strong human player teamed up with a weak computer quickly overwhelmed the best grandmasters or even the strongest supercomputers. The strength of human strategic planning combined with accurate calculations from a computer teammate was unmatchable.

At this point in human history, a chess grandmaster will have a tough time beating even an average chess program - humans have succeeded at building a machine to play chess. As the field of computer engineering moved on to other problems, Kasparov lingered on and noted that the chess computers we have built was nothing similar to what engineers had in mind when they decided to build machines that play chess. We wanted to build computers that play chess and think like a human - an artificial intelligence of sort. Instead, what we have now is computers that win by the sheer brute force of calculations - they assign numbers to pieces and positions, process a whole lot of numbers and possible moves, then pick the best one. They have no imagination or intuition, only processing power.

In my head I struggle between "complement" computers and artificial intelligence. Building machines that complete tasks by complementing our weakness is definitely helpful - calculators was a humble but powerful start. But do we stop there and leave imagination to humans, or do we venture further to create computers that can think for us? What are the ramifications of the world where machines can dream? If our strength is the power of imagination, what happens when we give this gift to our computer counterpart? Computers that mimic the human minds will revolutionalize our productivity, but then what is left for humans to do?

Ignored common sense

Going through medical school, I have spoken with many mid-career, rising faculty members at various institutions. I noticed that these somewhat prominent faculty physicians somehow made it without the most simple of common sense in human interaction - learn the names of the people you're talking to and listen to what they say.

It is so important that I will repeat it again - to achieve a desirable result with others, it is of utmost importance to:

1. Know their names, and

2. Listen to what they say

Sounds simple enough, but it is mind-boggling to learn that many successful people fail to do this, especially in the medical field, where everyone (patients AND providers) somehow thinks it's ok to be nasty to each other in a way that wouldn't fly outside the hospital. This is another area where other professions lead the medical field by leaps and bounds - Any good politician/leader/businessman knows the importance of these two etiquettes - it is how Joe-the-Plumber got media's attention. Most people follow these rules well when they talk to a more important person - it takes real character to follow these rules when talking to someone less important, and these faculty physicians have failed miserably in my opinion. By not learning my name and listening to what I'm saying, they come off as arrogant and uncaring, none of which makes for a good educator/physician.

Read more in "How to make friends and influence people" by Dale Carnegie, a time-tested book that creates successful leaders and businessmen over decades, but really it is something that everyone should do on a daily basis, aspiring businessman or not. Know people's names and listen to what they say - other human beings deserve this much from us.

Fun with HospitalCompare

I have mentioned HospitalCompare in many posts in the past - it is very enlightening to play with. In a prior post I claimed that elite hospitals in MA did not perform better than cheaper community hospitals in NYC despite the higher exorbitant prices charged. To substantiate that claim, we will use HospitalCompare to look at 4 hospitals:

1. Brigham and Women's Hospital

2. Massachusetts General Hospital

3. Bellevue - a community hospital in NYC attached to NYU school of medicine

4. Mount Sinai Hospital - a somewhat elite medical institution as a NYC control for Bellevue

Follow the instructions below to get outcome information for these hospitals:
1. Go to HospitalCompare

2. Click "Find and compare hospitals" button

3. Choose "Find a hospital withing a distance of a City"

4. Type "Boston" into the City box, select Massachusetts as the state, and select "In this city/zip" for distance. Click "continue" button

5. Choose "General search". Click "continue" button

6. Scroll down and choose Brigham and Massachusetts General Hospital. Click "compare" button.

7. You will have the same tables as posted in the photo above. Repeat the same process for New York, choosing Bellevue and Mount Sinai hospital for comparison.

As we scroll through the tables, we can see that Bellevue does similar if not outperforms all these elite hospitals in most measures except for pneumonia outcomes. It's stunning to see that %door-to-balloon time (D2B) at Brigham is as low as 87%, while MGH does even worse at 79%. This means that in a patient with ST-elevation myocardial ischemia (heart attacks) in which one of the most important prognostic factors is receiving cardiac catheterization within 90 minutes, only 87% of the patients get that optimal treatment at Brigham, 79% at MGH. For comparison, Mayo clinic achieves 100%, Kaiser Foundation hospitals in San Jose got 98%, in Santa Clara got 94%. Both Mayo and Kaiser have been applauded by Obama and the medical field as high-performing, cost-effective systems that do not charge nearly as much as the two elite Boston hospitals.

Overall, Brigham and MGH do not appear to be national leaders in any of these process outcomes. Maybe they are better at other things, but these outcomes are simple, objective measures that have proven to improve outcomes regardless of sickness or patient population - hospitals do not have any excuse not to excel at these outcome measures. It will be interesting to hear alternative explanations why these elite hospitals deserve the exorbitant amount of reimbursement squeezed out of the over-strained MA health system.

GoogleBuzz! Don't knock it and wait for tweaks

Buzz has good potential - integration with Google products is key. With a few tweaks it can potentially take over facebook - user profile should contain more details/personalization, the interface could be more attractive, and lack of targeted advertisement is nice. Taking over twitter is more difficult because it is a completely different platform - word limit sets it apart from facebook-like social media, making twitter more succinct and less personal, which means strangers feel comfortable tweeting to one another. However, this can be worked out easily with the option to post publicly and the option to search/follow users that are not in your Gmail contact. Overall, an interesting start!

What are we paying for?

Massachusetts Attorney General Martha Coakley recently released a report which showed that prices paid to healthcare providers in MA vary significantly based on market leverage/position - Partners Health Care (consisting of two biggest healthcare bully in the state - Brigham and Women's and Massachusetts General Hospital) being the exemplary culprit. Due to size and its brand name, Partners Health Care is a successful oligopoly that has pressured other Boston hospitals down a competitive, cost-inflating path, charging exorbitant costs and initiating medical arms race including acquisitions of surgical robots which have not been shown to be superior to human surgeons.

More importantly, Coakley's report showed what the higher price tags DID NOT correlate to. Price variations do not reflect:

(1) higher quality of care
(2) the sickness or complexity of the population being served
(3) the extent to which a provider is responsible for caring for a large portion of patients on Medicare or Medicaid
(4) whether a provider is an academic teaching or research facility
(5) differences in hospital costs of delivering similar services at similar facilities.
HealthBeat broke the report down into chewable pieces here.

In the medical field, Partners Health Care hospitals set the bar in medicine. They train the best and brightest residents and house world experts in many medical fields - their faculty members write game-changing articles and author respectable medical sources like Uptodate. In my personal experience, working in a Partners hospital resemble working in a perfect bubble - all the medical staff were top-notch, the wealth of resources made the most cutting edge tests/studies possible, almost all patients were insured, white, English-speaking middle-class who could advocate for themselves.

It's counter-intuitive to think that this perfect medical setup does not necessarily improve outcomes, but Coakley's report is not alone - try playing around with HospitalCompare and you'll find that Mass General or Brigham have worse outcomes than a cheaper institution like Bellevue, a community hospital in NYC. It is important to note that the outcomes measured are simple, objective yardsticks that should apply to all hospitals regardless of the complexity of their patient population. For example, smoking cessation counseling could and should be given to all smokers regardless of how complicated their sickness is.

Some may argue that these measures are too simple and do not reflect the ability to treat complicated cases that are often referred to brand name hospitals, like saving patients from an extremely rare malignancy. In medicine we have a saying that if you hear hoof sounds, they probably belong to horses and not zebras. Curing extremely rare malignancies is a zebra - most cases are horses of patients coming in with a heart attack, a common condition that most hospitals can treat effectively without a perfect setup, the most cutting-edge medical technology or world experts in cardiology, which is how things should be. Any average medical facility should be able to treat common conditions as well as more famous institutions, because that is what an average hospital should be able to do - treat common conditions. Not everyone can or should go to Brigham for an x-ray of a fractured wrist - we have gotten so good with this age-old technology that most hospitals can produce the same, accurate results, for much less than what is charged at brand name hospitals.

What we need to realize is this: most common causes of morbidity and mortality are, for lack of a better word, common. What we see in this healthcare system are horses, not zebras, and because they are common, we have devised cost-effective, time-tested treatments that we should use instead of shiny, experimental treatments that cost much more without proven benefit. An inflamed appendix can be as safely and effectively removed by human surgeons, much more cheaply than using a robot. This is why brand name hospitals providing the most advanced medical technology are not necessarily better for your health or your pocket.

In medicine, less is more. A good doctor should be good at keeping you out of the hospital - they should not aim to excel at providing the most invasive of treatments often advertised by marquee hospitals, but unfortunately doctors and hospitals get paid much more doing the latter. The only thing preventing this blatant conflict of interest from completely wrecking our health care system is human conscience, which is not without fallacy. A better system would reward outcomes, not volume or technology used. Until we get a new carrot on the stick, our healthcare system will continue to be overused and overpriced.

Emergency medicine - we can do better

When someone gets sick, what are their options?

They can try to make an urgent appointment that day, but how many of your doctors actually offer that? Most people will have to wait for weeks, if not months, for a regular appointment. Even if you go to a walk-in clinic, the wait will likely be hours, and you're not sure if clinics can take care of everything, so you head to the emergency room, thinking that you will get urgent care because of the word emergency in it.

And you will, after various amounts of wait time, but what do you give up in return?

To answer that question, let's see how the emergency room works.

When patients come in, they are triaged based on severity and afterwards shuffled to different parts of the ER accordingly. ER doctors then ask you just enough questions and draw just enough labs to make sure you do not have immediately life-threatening conditions. The ER does not necessarily address your chief complains or the main reason you come to the ER - it only makes sure you don't die in the immediate future. Everything else is left to be dealt with by the admitting doctors or your primary care doctors - if you have one. That means you will have to explain your medical problems at least a few times over, if not more, and the more times you tell it, the more interpretations of the story you will have, resulting in contradicting information and decreased quality of care. Moreover, that fact that there are more people involved in your care - admitting doctors, ER doctors - means that there are more hand-offs, resulting in more errors, disagreement on management, miscommunication, redundancy, waste of efforts and resources.

Why do we set ourselves up to do the same work twice? have patients repeat their stories over and over? And most importantly, why do we subject patients to risks and low quality of care?

There must be a better system, where we work together instead of separately at separate times, redoing each other's work. There must be a better triage mechanism that screens for better information that will allow doctors to collaborate as soon as patients enter the system and long after they leave the hospital. There must be a better system that allows health care personnel to get rid of their short-sightedness and view patients as a person, with identities other than medical conditions that immediately kill and worries that must be addressed other than their health. Instead of looking to finish just our responsibilities and deferring the rest to others, we should think about how to deliver complete care to patients as a group. Thinking about how to make lives easier for our colleagues will help patients and reduce work for ourselves, because we will reduce inefficiency and redundancy all around. The whole system will be more lean and happier for it.

There is no formula to a better system - we must find out through trial and error, but first we must recognize that separated we will fail. We cannot just save ourselves anymore - the world is too connected and too strained for resources for one person to make a fortune without making others poorer, and human beings by nature will not tolerate continued marginalization. It is the source of conflicts and violence in our world - war, terrorism, burglary, revolution - so let's save ourselves some agony and start giving instead of taking.

In the end, it's the individual who's not interested in fellow men who has the greatest difficulties in life and provides the greatest injury to others.

Rethinking Philanthropy

Recently I heard a 4th year medical student, a veteran of global health activities, chatting with excitement about her upcoming brief trip to the border between Thailand and Burma, in which she will develop an education program for the refugees during the 2-3 week duration of her trip.

My feeling as a Thai native was far from enthusiasm. The Northern border has become a revolving door of NGOs - the whole area has now thrived mostly on businesses catering to foreigners and sometimes I wonder if the town is inhabited by more "philanthropic tourists" than Thais and refugees. But the sheer invasion was not what irked me - it was the motives behind the influx of these philanthropic tourists.

Consider the individual level - exemplified by this medical student. Many foreigners visit without ties to NGOs in the area, hoping to do good during their time off. Most of these visits are brief - none of the visitors intend to stay permanently or even for a long period of time. They come at their convenience, not based on the timing of various needs of the refugees. They come with their preconceived ideas of what needs to be done, they come up with their own ideas of how things should be solved, and they marched into the sometimes unknowing, defenseless receptive arms of refugees, who, after their ordeal, would take any help they can get, even if that help is a bandage for the gushing cut wound that distracts away from stitches that would eventually save them from exsanguination. They somehow think that their ideas are different from others and that only they are suitable for the job - this usually results in fragmented, duplicate efforts competing for resources and creating confusion for refugees. These visitors leave, not when projects are finished or outcomes are improved, but when staying becomes inconvenienced by obligations back home. They leave and usually never turn back to look what exactly they left behind.

These issues are amplified by NGOs. Most NGOs are not so quick to enter or leave as individuals, as dinosaurs move at a slower pace than people, but the issues remain - egoism, lack of needs assessment, fragmentation/duplication, competition for resources, lack of continuity and distraction from long-term/meaningful changes, lack of accountability, and most disappointing of all, the focus on the agenda of foreigners instead of that of refugees.

We might be fooling ourselves to think that parachuting donated items or good-willed people into a needy area for a short period of time will create real change. The problem of parachuting pervades most NGO efforts, since help comes from outside and not from within. When was the last time a sanction on the Burmese government eradicated the corrupted generals? Do we expect to establish a peaceful nation by marching troops in, capturing the tyrant, then picking up our suitcases and leaving the newly-freed citizens to their own devices?

Look at China and Africa - the two are not so different. Both are plagued by human rights issues, bad health outcomes, pollution. But how come no one feels sorry for China? I don't see hoards of NGOs rushing to the aid of the Chinese people, and who do you think will emerge a victor in the next decade?

If we learned anything from our lesson in Iraq, it is that these are not our fights. The real victory springs from within the very people we are trying to help, not from us, and our only appropriate role as altruistic individuals is to empower people to fight their own battles. Empowerment is a lengthy and delicate process - one that will be damaged by parachuting, because failure and abandonment leave their marks on the faith of these fragile population.

So the next time you think about helping other countries in need, think about what you actually are doing. Think if your help is a quick fix that takes away from meaningful changes. Think if your good will might be disruptive to the real progress that needs to be made.

And most importantly, be honest and think to whom this altruistic act is really aiming for. It is not ok for you to feel better about yourselves at the expense of the disadvantaged. Remember, the road to hell is paved with good intentions.