Join the discussion on how we can fix healthcare.

The answer to the title question is (B) with a little (A), but all we seem to get is (C).

A manager handles (“manages”) what is. A good manager optimizes what we have today, what we have now.

A leader moves us into the future, from what is to what will be. A semi-serious definition of a great leader is one who tells us that we are going the hell and we look forward to the trip. An effective leader has people willing and eager to follow.

A dictator also has followers, reluctant ones who follow through coercion. A dictator tells you what to think, what is correct, what to do, and what will happen to you if you do not follow. Lately on healthcare, our President has been more dictator than either manager or leader.

What is truly wrong with healthcare cannot be fixed from above. No one can dictate principles or tell us what to think, certainly not in a democracy and most particularly not to Americans.

Think back to 1993 and Hillary Clinton’s plan for healthcare. It was a ‘fix’ imposed from Washington. We did not tolerate that approach then and will not tolerate it now.

Think back further, to the founding of our nation. The Bill of Rights is the glue that has kept us together for over 230 years. Without a general consensus on principles, we could never have weathered the abolition of slavery, HUAC, or Vietnam: they would have torn us apart.

Healthcare is as contentious as slavery or freedom of speech. The fact that there is no agreement on basic principles makes it impossible to construct a system that will work.

Is health care a right? Should there be personal responsibility in health care? How should bad outcomes be handled? What role if any should the market play? Someone or something will ration healthcare: who should do it?

These are not simply interesting academic question. They govern how the system operates. The fact that there is no consensus means that the system exists without a rudder. Whoever has the loudest voice gets what he or she wants and the answers offered for this sick patient (healthcare) are political compromises rather than medical cures.

Without agreed-upon principles we have:
• A system that is both market-driven and highly regulated at the same time.
• A tort-based medical malpractice system that actually prevents learning.
• The world depends on new antibiotics, Lipitor, HIV medicines, etc. that a highly innovative U.S. drug industry creates, yet big pharma seems to be everyone’s favorite villain.
If this sounds confusing, contradictory and unstable, it is.

President Obama said in his 2010 State of the Union speech, “If there are alternative ideas out there [on healthcare], I want to hear them.”

Here is one: Start practicing good medicine on healthcare. Be a leader, and lead a national dialogue on healthcare principles.

Over time, this will create a consensus on what the system is and is not. Yes, there will initially be distrust, anger, invective, and blaming. We need to go through Kubler-Ross’ stages of death and dying because we are talking about the death of the old system. Through creative destruction, we can begin to develop a system that actually works: affordable, high quality, constantly improving, and an example for the rest of the world.

Mr. President: If you are a man of your word, you will become a great leader and help US create a workable, American healthcare system to replace the “broken” one we have now.

System MD

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The practice of medicine is plagued by TLAs and FLAs. What are they, why does it matter, and how do they kill us?

TLA = three-letter abbreviation. FLA = four-letter abbreviation.

AFI. ASD. AVC. CHD. DM. DORV. EBST. EBV. EDP. FTT. GBS. GLM. HLH. IOL. LAD. LPC. ND. NST. PNV. QNS. QRS. RAD. RDA. RPR. STD. TGA. TOF. UMRA. VSD.

I collected the abbreviations I saw in hospital charts yesterday (one day!) and listed them in italics above. Most refer to illnesses or tests in various specialties such as OB/Gyn or Pediatrics. Virtually all can refer to multiple conditions. In Cardiology, RAD refers to right axis deviation. In Orthopedics, it means radial angulation distortion and in lung medicine, RAD = reactive airways disease. When I Googled RAD, I got 61,000,000 hits!

When I see RAD on a patient’s chart, I am supposed to guess whether the patient has a heart problem, a bone disorder, or lung disease. (Do you really want your doctor guessing?!) I presume that I am supposed to infer what RAD means by the specialty of the doctor who wrote the note. But wait! I cannot read the signature and so I do not know who wrote RAD and therefore do not know what it means.

Today I received an email from the transcription service asking how I wanted to handle my APBs. I do not moonlight as a police officer. I have never put out an All Points Bulletin (ABP).

Two phone calls and two emails later I had resolved: a) that ABP referred to ambulatory blood pressure testing, and b) that I was the wrong addressee on the email (I have never ordered that test in my life.)

Doctors are ineffective communicators. They write without any thought to the possibility that the reader might not understand what they wrote, whether through TLAs or just illegible handwriting. (Every day, your pharmacist must guess at what Rx your doctor prescribed for you.)

Doctors’ and nurses’ efficiency is ineffective: it produces bad communication. Bad communication produces mistakes. In health care, mistakes cost and mistakes kill.

The solution is not to make doctors write legibly–that is impossible. The solution is not to ask doctors to give up TLAs and FLAs–they can’t and they won’t.

The solution is to create a system of communication that automatically counters these human problems. For instance, imagine a voice-activated medical note-taking system that knows who is dictating and writes “right axis deviation” when the cardiologist says RAD but “radial angular distortion” when the orthopedic surgeon dictates RAD. The system, through voice recognition, can tell who is who. This is not science fiction. It is easily implemented with present day technology. All it takes is the will to create a system whose sole function is patient protection.

TLAs can kill but we can stop them.

System MD

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The self-styled “reform” healthcare Bill is dead. Good riddance. Healthcare is saved from a fate worse than death.

Writing “healthcare is saved” in no way implies that it is fine. Au contraire, healthcare remains critically ill. Nonetheless, there are fates worse than death. For us, the healthcare ‘reform’ bill would have been one.

ObamaCare would have taken a bad situation and made it worse: expanding the bureaucracy thereby escalating costs; increasing complexity and therefore errors; raising the deficit at the worst possible time; and at the same time reducing medical services. Remember that every time the Government talks about saving money through “cutting Medicare reimbursements,” they are talking about cutting services.

Some exclaim that we must do something because things are so bad. Because things are terrible is no excuse to make things worse. ‘Anything’ is NOT necessarily better than what we have, bad as it is.

The word reform, linked in many minds with the word healthcare, does not mean “to change.” It means to change for the better. One can change things for the worse (exacerbation) and ObamaCare would have done just that. It would have been a ‘fate worse than death.’

Death would actually be good for healthcare. If it were dead, we would then be forced to replace it. Schumpeter’s creative destruction could produce a new and better system, one that we design, a system that actually works.

Most of what is written about healthcare is hyperbole, vitriol, and spin. Nonetheless, it is no exaggeration to write that the on-going crisis we call healthcare affects absolutely every single person in our country: you, me, our relatives, and neighbors or will eventually. It is not something we can personally afford to ignore.

We can wait until healthcare gradually dies of terminal (government) bloat plus provider and hospital shortages. Or, we can push it over the edge and replace it with a new, American system, one that we create and therefore we will accept.

In various social media as well as my book “Uproot Healthcare” (out next month) I have urged an extended, organized ground level national dialogue on healthcare leading to a consensus about basic principles. That is the first step in a healing process. How would you feel if your doctor began injecting you with chemotherapy without you understanding your diagnosis and without you choosing your treatment?

On a much larger scale, the reason that our country has survived and thrived is that it started with basic principles on which we all agree, such as the first Amendment. Healthcare needs a basic set of agreed-upon principles or it can never work.

People have commented that we are so polarized a nation that we can never achieve consensus on anything as contentious as our health care. My response is simple.

While we will never achieve complete unanimity, we must reach a consensus (majority agreement) on principles. Without that, healthcare cannot be cured.

“Optimism about healthcare might seem inappropriate.

It certainly may not be realistic,

but,

Optimism is absolutely necessary.”

[“Uproot Healthcare,” page 118]

System MD

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Liberal, conservative, progressive, Democrat, Republican, right, left, centrist, purist, fanatic are labels used in yesterday’s newspaper. DORV, VSD, TAPVC and PAcIVS were shorthand abbreviations used to identify patients I saw today.

Everyone uses labels, shorthands (heuristics) and abbreviations to make communication faster and therefore more efficient. More efficient maybe, but also confusing and ambiguous, and therefore less effective.

In Health Care

A hospital chart I recently read started with the following history. “A 26yo GLM P-4103 presented with fever, SOB, NPR and a h/o RAD as well as PID.” I could guess at what this means but does the patient really want me to guess? Consider just one abbreviation: RAD.

RAD in Cardiology refers to right axis deviation on an electrocardiogram. In Orthopedics, it is short for radial angular distortion. In Pulmonary Medicine, it means reactive airways disease, and in Psychiatry, it means either reactive attachment disorder or rape aggression defense. Confused? So was I while reading the patient’s chart.

In communication, using labels or abbreviations is both efficient and ineffective, meaning the desired effect–accurate transfer of information–is not achieved.

I have been attacked as being excessively liberal because I believe no one should be denied health care for lack of money. I have been attacked as being overly conservative because I believe in personal responsibility. What am I: liberal-conservative, conservative-liberal, or…something else? [My answer is that I am more than a label, and so are you.]

Many would claim that the same person cannot support BOTH health-care-for-all and personal responsibility. These are the same people who live by the “either-or” principle. They see everything as black or white. They accept the label as an adequate substitute for the person. These people cannot conceive that both better and cheaper might be possible.

In 1982, we described a way to do cardiac catheterization as an out-patient in children. This was both better medically and much cheaper. Ever heard of Lasik surgery for your eyes? Check out the prices and results in 1995 compared to 2009, when it is much better and much cheaper.

Labeling stops thinking. Once a label–a diagnosis–is applied, the provider knows what to expect, sees what he or she expects (scotoma) and worst of all, stops thinking and just reacts. Labeling closes the mind.

To practice high quality medicine requires providers to innovate. In turn, that requires an open mind and thinking outside the box. Innovation is how doctors opened blocked arteries and cured childhood leukemia. Original thinking is how they will do the same for breast cancer. Labeling stops innovation and then regulations freeze us where we are.

In Politics

On the political front, labels instantly polarize and create adversaries. Can enemies freely exchange ideas? I think not. So, as soon as we label someone or they label themselves, useful dialogue is stopped. Without meaningful exchange of knowledge and ideas, no one–repeat no one–can make a good decision.

If we want good decisions in our home or in our Congress, we need to stop accepting or even using labels. If I disagree with Nancy Pelosi (D) or John Boehner (R), it should be because I disagree with what they said or did, not because of their party label. We need to hear the messenger and judge the message without the pre-judgment created by their label.

Regretfully, most of our so-called “Representatives” in Congress follow their labels rather than their minds. Partisan decision-making is labeling made manifest into law. Unfortunately, people in Congress will do anything to support their label, even things that are clearly unethical. They rationalize that they are doing it for the greater good. We all know where “the end justifies the means” led the world

• Labeling stops effective communication.
• Good decisions require effective communication.
• Ineffective communication generates bad choices and outcomes.
• Therefore, labeling is hazardous to your health.

System MD

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In recent national discussions about healthcare, much was made about the practice of defensive medicine, especially its cost. Let’s add defensive bureaucracy to our list of grievances.

Defensive Medicine
The practice of defensive medicine occurs when a provider does things to make the record look better, specifically more defensible from lawsuits and more acceptable to regulators. Practicing defensive medicine includes three behaviors.

1) The doctor can order medically unnecessary tests that are usually harmless but sometimes can cause injury. All add unnecessary cost. 2) The doctor can avoid medical procedures that involve risk or refuse to accept high-risk patients. 3) The doctor can take the standard, accepted approach when something different would be better for the patient.

Doctors practice defensive medicine in order to avoid lawsuits or anything else that might put their privileges in jeopardy. In essence, they are simply trying to protect their jobs.

There is a paucity of solid evidence on the cost of defensive medicine. Virtually all the “data” are estimates and guesswork. One study reported that doctors admit that 18-28% of tests ordered and consultations requested are due to defensive posturing. Other studies report costs ranging from $2.4b to more than $200b (yes, that is “b” for billion) per year.

Defensive bureaucracy
Defensive bureaucracy is the same behavior by bureaucrats as described above for doctors. The bureaucrat does things that do not help or may actually harm the general public in order to protect his or her job. Example: the regulator in healthcare.

By promulgating a large number of regulations, then monitoring them and finding people out-of-compliance, the regulator provides for job security and expansion of the bureaucracy.

But wait you cry, We need regulations to protect us. Do we?! Regrettably, there is NO DATA showing that regulations protect us. Defenders of the regulatory machine have no evidence and invariably offer logic as a substitute. As science author David Webber wisely observes, “Logic is a way to err with confidence.”

Not only is there no evidence that regulations protect us, there is an equal lack of data about how much these useless-even-harmful regulations cost. Start with the easy stuff: the hassle and inefficiency.

I recently reported that for a 30-minute patient visit, I had to spend 7-9 minutes doing repetitious, redundant paperwork. I wrote my name five times, various diagnoses four times, filled out three separate forms each with a host of boxes to check. The waste of time and therefore dollars is significant. The much greater cost is in frustration. Nurses and doctors hate (I do not use that term lightly) the amount of bureaucratic nonsense and B.S. that dominates their lives, and that is driving them…away.

Regulations harm patients both directly and by opportunity cost. Regulatory compliance costs hundreds of billions of dollars each year. We–the Public–get virtually nothing for this expense, except more bureaucrats and fewer providers. The opportunity cost of useless regulations may be even higher than the dollar outlay.

The Joint Commission on Accreditation of Hospitals could be helping studies of best practices for long-term outcome as well as studies of optimal care-delivery-for-dollar-expended. They could be disseminating proven best practices, like checklists before surgery. Instead, they inspect for prohibited doorstops and surge protectors, and write out-of-compliance notices for writing µg instead of [the approved] mcg and for Cardiology keeping separate patient files. This is no exaggeration.

Incentives are just as perverse in healthcare bureaucracy as in medical practice. The system rewards the negative and then wonders why it keeps getting the negative. If we pay for sickness care, we get more sickness. If we pay regulators to find non-compliance, guess what they will find. Imagine if we paid doctors and regulators for the positive outcomes we want: good health and longevity.

Defensive bureaucracy is even more harmful to patients than defensive medicine: it costs more and produces worse consequences.

System MD

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