Wednesday, September 1, 2010
Tuesday, August 24, 2010
Monday, August 9, 2010
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
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
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.
(2) Intrinsic motivation and self-determination in human behavior By Edward L. Deci, Richard M. Ryan
(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
(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
Sunday, August 8, 2010
Sunday, June 20, 2010
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.
Wednesday, May 26, 2010
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.
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.
Thursday, April 22, 2010
Saturday, March 27, 2010
Friday, March 26, 2010
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.
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.
Thursday, March 25, 2010
Monday, March 22, 2010
Tuesday, March 16, 2010
Sunday, March 7, 2010
Sunday, February 21, 2010
Thursday, February 11, 2010
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:
Follow the instructions below to get outcome information for these hospitals:
1. Go to HospitalCompare
Wednesday, February 10, 2010
Tuesday, February 9, 2010
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.
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.