Saturday, March 27, 2010

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.

Friday, March 26, 2010

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.


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

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.

Monday, March 22, 2010

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.

Tuesday, March 16, 2010

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.

Sunday, March 7, 2010

The vicious cycle of finding the right volunteer opportunity

I went on 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.