The art of medical literature review -- Lessons from a distant era

It just took me 20 years to write a two page paper.

The specific subject is not important to this posting (a trick to learn and recall a particular area of neuroanatomy). However, the epic adventure of producing this paper spanned a transformational period in the history of knowledge and learning. The roots of the paper were formed in the pre-Internet era; the fruit were harvested in the current environment of instant hyper-connectivity. The benefits of widespread computing and networking are obvious to all. However, reflecting on this experience it occurs to me that there were some benefits to the old ways; there are some lessons the “digital natives” can learn from the ancient “digital immigrants”.

First, the story. In 1990, I was a resident preparing a grand rounds presentation. The topic (again, not important to the story) was neuralgic amyotrophy, or Parsonage-Turner Syndrome. Preparation required an extensive review of the available medical literature. Today, this task would be performed at my desk, and the pertinent papers downloaded instantly, in less time than it took to type this posting. Here is how it worked in 1990. To some, this will seem like monks hand-copying books:

To begin, you identified key words that were used to catalog references in the Index Medicus. The Index Medicus was founded in 1879, and was in continuous print publication until 2004. Ultimately, it evolved into the National Library of Medicine (NLM) and all references may now be accessed electronically via PubMed. (for a brief history of the Index Medicus, click here)

In 1990, the Index Medicus was published as a single volume, bound annually, with monthly updates for the current year. To perform a literature review, you had to physically pull each bound copy, look up your key words, intuit from the title of the article if was pertinent to your topic and write down the reference. You then repeated that task for the previous year…and the year before…and the year before…until you were satisfied you had searched far enough back into the literature.

Next, it was time to find the actual articles. Depending on your project, you might need at least a dozen references; another project may require more than one hundred). With your references written on a legal pad, you entered the library stacks…multiple floors of bookshelves, usually dimly lit, with the unmistakable odor of old books. You had to pull each bound journal, locate the article, and scan it to see if it contained information of interest to your quest. If it passed muster, you would add it to a wheeled cart and proceed to the location of the next journal. Since the stacks were generally multiple floors, and elevator was involved. At times, the bound copy of a particularly important article was missing, or torn out of the journal by some academic miscreant. In these cases, you had to meet with the librarian to request that a copy be mailed (that is, using a stamp and a postman) from another library.




With your cart in tow, you then proceeded to the copy room to make copies of your collected articles. This sometimes involved standing in line, as others were also copying dozens of articles. Then, simple as that, your initial literature review was complete. You were finally ready to read, synthesize and write.

The entire process took at least several hours -- often days, or even weeks. The ability to search the entire medical literature, nearly instantaneously, from virtually any device, is clearly a quantum leap from the old method. It is a leap that we all now take for granted. But was there anything valuable lost in the transition?

Back to my grand rounds. As I was in the “stack wandering” phase of my project, I picked up a journal containing one of my many references. As I flipped to the appropriate page, my eye was caught by a brief paper in the same journal. It was on an entirely unrelated topic – brainstem anatomy. I read it and learned a simple anatomical trick. I started using the trick clinically, found it useful over several years, altered it a bit and started teaching it to others. Eventually, I decided to try and publish it. To this day, I have never been able to locate the article I stumbled across serendipitously. I did find others, and consolidated their concepts with my memory from the mystery paper (http://www.ncbi.nlm.nih.gov/pubmed/24713180).

So what lessons can be learned from the old ways? I think there are several:

Planning. The review process outlined above was incredibly labor intensive, and could not be easily delegated. The potential for lost time forced people to plan their literature review in advance. A primary role of a medical librarian was to assist in the development of a search which was systematic and thorough, but also time efficient.

In the current world of instantaneous searches, it is easy to use the first couple of key words that come to mind, cross reference them and generate what seems to be an adequate number of references.

Modern searchers should still invest in time to plan an important search in advance. Although time efficiency is no longer be an issue, it is still necessary to be systematic and thorough.

Quality trumps quantity. The modern search generates a tremendous volume of references. The old search methods tended to produce a more thoughtfully assembled list. The old methods felt more like being a collector of stamps or porcelain figurines – the collector, over a long period of time, searches for and acquires a particular piece that helps to augment the collection. The new methods feel more like a money whirlwind machine on a game show (Click here if you do not know what this is). The searcher grabs as many bills as possible, as quickly as possible, until time runs out.

Modern searchers could benefit from treating their efforts more like the assembly of a treasured collection.

Create quiet space. The old search process was incredibly inefficient. There was a great deal of inherent wasted time, rifling through the Index Medicus and combing through the stacks. However, it was also a very peaceful experience. The information came slowly, in bits and pieces. There was time for your mind to wander, and to ruminate on something you just read. If ideas tend to come to you in the shower, you would likely have the same experience in the stacks. Modern searchers would be well served by actively working to create quiet, reflective time, free of all distractions.

Faster is not always better.

Family Dinnertime: The Meaningless Nine and Magical Tenth

When my children were younger, my work hours were long; I would routinely get home between 8 and 9 o’clock.  In spite of the inconvenience, my wife and I committed to consistently sitting down at the table for a family dinner – no television or electronic distractions – just conversation.  I believe this was one of the best decisions we made as parents.

If you Google “the importance of family dinners”, you will produce over 2 million references from lay and scholarly sources.  Consistent family dinners have been associated with virtually every positive metric of childrearing (better grades, higher performance on standardized testing, improved self-esteem, etc.); conversely, dinners seem to be protective against almost anything parents might fear (obesity, promiscuity, drug use, etc.). 

In essence, we performed our own, nearly two decade-long nonrandomized and uncontrolled sociological experiment.  In that time, I learned one important lesson.

Cumulatively, I have experienced literally thousands of dinners with my wife and children.  I would estimate that, on average, nine dinners come and go without anything of consequence occurring.  Talk is sparse or inconsequential…nothing is really new…school was fine…

Then, suddenly and unpredictably, during the tenth dinner magic happens, and it takes a variety of forms.  Meaningful information is offered about friends.  Aspirations for the future are revealed.  Fears are acknowledged.  Arguments erupt and resolve.  A mannerism or mood is subtly different, and delicate inquiry lifts the veil of teenage obfuscation ever so slightly.  The magic is simple: real communication occurs, and it is gold.

The one important lesson I learned is that the magic cannot be scheduled.  The nine “meaningless” dinners are far from meaningless.  They are a necessary prerequisite to experience the magical tenth.  The meaningless nine establish the trust and comfort to allow communication to occur.  They build your capacity for emotional pattern recognition, so you intuitively know when something is a little off kilter.  You cannot surgically schedule the tenth, without embracing and relishing the nine.

I believe the same dynamic applies to leading people.  There are numerous gurus of leadership development.  Warren Bennis, perhaps the exemplar of all gurus, believes “ultimately, a leader’s ability to galvanize his or her co-workers resides in both understanding the co-workers’ needs and wants, along with an understanding of…their mission.” (On Becoming a Leader, click here)  What I learned from my nine dinners is the development of empathy and trust is, at least in part, a time dependent activity.  It does not happen without face time.

If a colleague or co-worker has a behavioral issue that needs to be brought to his or her attention, and you do it in the context of your one and only real conversation, it is almost impossible to convey the message effectively.  You will not have a receptive, trustful listener and you should expect a purely defensive reaction.  If you design a truly brilliant strategy in a cave, and emerge like a prophet to enlighten the masses, even flawless oratory is unlikely to galvanize a team.  If you expect to be informed about the little problems, before they blossom into crisis, it will never happen in a culture lacking trust and open communication.  You must embrace and relish the nine, to receive the gift of the tenth.

In the latest Atul Gawande New Yorker gem (click here for article), he asks why some best practices spread rapidly, and others do not.  He cites an example from pharmaceutical sales to physicians.  Apparently, the company detail (i.e. sales) people follow “the rule of seven touches”.  You must interact with a physician seven times before you develop enough trust, and enough of a relationship to influence behaviors.

Healthcare is facing a prolonged period of substantial, foundational change.  The environment is one of ever changing laws and regulations; of accelerating consolidation into larger and larger organizations; of expectations of radical transformation of a delivery system evolved over a century.   Change will come, and effective leadership will be a necessity for success.  As we drive this change, it is important to remain connected to the human part of what we do.  It is not mostly about relationships.  It is entirely about relationships.

Book Review -- Connected: The Surprising Power of Our Social Networks and How They Shape Our Lives

It is always a pleasure when our expectations are unexpectedly exceeded.  When my wife and I were married, we were late getting to the inn where we were spending our honeymoon.  As the restaurant was due to close, I called ahead to ask if they could leave us some sandwiches.  We arrived to find they kept the restaurant open, had a table waiting by the fireplace, with a live classical guitarist.  They could have served sautéed shoe leather, and it would have tasted great.

Although not quite on par with my honeymoon dinner, I had a similar experience reading Connected: The Surprising Power of Our Social Networks and How They Shape Our Lives by Christakis and Fowler (click here for link).  I expected to learn about the various forms of social media that have become such an important part of our communication landscape.  What I actually acquired was a new lens through which to view the world, and a desire to learn more about how this enhanced worldview can be used to drive positive change in communities and organizations.

I took three broad themes away from this well written and referenced work:

1. Social networks have properties, which we tend to not understand.
2. Social networks have complexity, which we tend to underestimate. 
3. Deeper understanding of social networks has the potential to enhance spread of knowledge and behaviors (good and bad).

Upon completion of the book, the authors clearly succeeded in driving home the first two themes – I have a better understanding of network properties and structure, and a greater appreciation of the variability and complexity of network structures.  However, it does not deliver quite as strongly on the third theme.  How can one use this knowledge to enhance communication and engagement of a community?  It is almost as if I had learned for the first time of the existence of DNA, had an intuitive understanding that it should be clinically important, but had no idea how to translate this knowledge into meaningful activity.

Regarding the first point – networks have properties – the authors introduce the uninitiated to an entirely new network descriptive language.  A network, that is, a collection of people plus the specific set and patterns of connections between them, must have something to spread, or a contagion.  The contagion can be an infectious disease, information, happiness, depression, obesity or wealth.  Members of a network vary in terms of their location (central versus peripheral) and connectivity (high or low transitivity).  The nature of the network impacts the pattern and efficiency of spread of the contagion.

The second point – networks have complexity – is equally well covered.  Imagine you are starting a new organization and you outline your communication plan to your board or investors.  As the leader and chief influencer, when you need to engage your organization you plan to talk to one person.  That person will be assigned to talk to one other person, who will talk to one other person, etc., etc.  This is essentially a “bucket brigade” network structure, where the bucket of water, or in this case information, is transmitted from one person to the next sequentially.  Clearly, your board is unlikely to be impressed by this plan.  Although simple, it is full of obvious weaknesses.  It is vulnerable to disruption, since if one person does not carry out his assigned task, the flow stops.  It is also likely the message will change slightly as it is carried forward, and is unlikely to survive in its intended form to the end of the chain.

This is a ridiculous example, which no one would seriously propose.  However, what we generally put in its place is a corporate organizational chart.  As chief influencer, now instead of talking to just one person, you talk to your five direct reports.  Each of them talk to their direct reports, who talk to their reports, etc., etc.  This has the advantage of increased efficiency compared to the bucket brigade, but the improvement is still marginal.  The message is still subject to at least partial transmission failure if one person in the chain fails to complete the task, and the message is still subject to change.  As nonsensical as the bucket brigade model seems, the slightly improved branching tree model is probably the most common organizational structure for businesses, hospitals and physician groups.

In fact, the real social networks, which underlie the “official” organizational chart, tend to be much more complex, and continually evolve in reaction to the environment.  There tend to be hubs of hyper-connected influencers whose behavior has a disproportionate impact on contagion flow.  Instead of laboring over the production of the perfect “org chart”, with the expectation that the ideal design will drive great communication and engagement, perhaps we should concentrate more on identifying those nodes of influence within a group and working hard to engage them.

Understanding the architecture and laws governing networks has the potential for great good.  If we can learn to understand and leverage network dynamics, perhaps weight loss, exercise, anti-smoking and anti-drug campaigns could focus on far fewer individuals with equal or greater results to broader population interventions.  Perhaps the historically slow spread of medical discovery to routine and widespread adoption into medical practice could be accelerated.   Connected is an engaging and thought provoking work, and well worth the time invested for anyone interested in more effective group dynamics in any sort of group -- doctors, nurses, students, patients, employees, etc.

Separated at Birth? Higher Education and Healthcare

A story in the Wall Street Journal last week made some concerning observations about colleges and universities in the United States. (Click here...WSJ subscription required) College tuitions continue to rise, consistently outpacing inflation. The majority of students cannot come close to paying the actual cost of a college education, particularly at private colleges. The funding gap is filled by a complex mosaic of grants, merit awards, need based financial aid and subsidized loan programs. A minority of students pays list price and helps to subsidize those who cannot pay. 

So here we have a socially critical service, access to which many would call a fundamental right. The list prices are steeply discounted for some, and costs shifted to others. In addition, the system depends on a complex stream of government subsidies that obfuscates the true cost to most consumers. If this sounds familiar, it should. This is part of the same dynamic facing the healthcare system, which caused me to wonder what other similarities are there between higher education and healthcare? Here are a few:

• National Love/Hate Relationship. We respect and admire our healthcare system. It is widely acknowledged we have the best “rescue” healthcare system in the world. That is, if you are critically ill and need a coronary artery opened quickly, or access to the latest chemotherapeutic agent for a rare cancer, you will receive treatment faster than anywhere else in the world. However, we are also uncomfortable that our national health outcomes do not justify our investment. We are unsatisfied with our average life expectancy and infant mortality rates. We have large disparities in deliver of care.   In higher education, we take pride in our institutions of higher learning as leading the world in innovation. However, at the same time we are uncomfortable that our outcomes are not what they should be – that other countries are surpassing the United States in areas critical for success in the future global economy. In particular, there is concern we are failing in the so called “STEM” disciplines – Science, Technology, Engineering and Mathematics. 

• Bubbles. The rate of healthcare inflation consistently outpaces the overall inflation rate year after year, making healthcare increasingly unaffordable. The same dynamic is true of higher education. In both cases, the consumer has been insulated from true costs of the service by fiscal intermediaries – in healthcare, free or subsidized insurance; in higher education, ready availability of subsidized loans. The separation of the service from true economic cost over decades has mitigated any power the invisible hand of the market might have had in creating a more sustainable system. In both cases, the public subsidy has grown to the point that it is probably unsustainable.

• Leadership. In healthcare, at least traditionally, physicians are culturally discouraged from assuming increased administrative responsibility. Colleagues, only half jokingly, talk about “going over to the dark side.” There is traditionally very little training in medical school or residency to prepare physicians for leadership roles in the healthcare system. Similarly, in higher education, administration is often viewed as a necessary evil. Advancement through academic leadership positions is sometimes viewed as a distraction from real academic work. Like healthcare, little is done to develop faculty to take on these roles. In both cases, the enterprises are entering a period of transformative change, with very little leadership bench strength.

• Outcomes are not entirely the system’s fault. To be sure, much of the criticism of the healthcare system is justified, and improvements are needed. However, even with “perfect” healthcare, there are other factors that almost certainly have a greater impact on the overall health of the country than the care delivery system. Environmental factors (pollution, absence of green space), genetics (some people appear genetically programmed for more severe disease) and behavioral factors (smoking, obesity, high risk behaviors) are far more critical determinants of health than access to medical care.  In higher education, although the system can clearly improve, it would be naïve to ignore other major determinants of outcome. Cultural, socioeconomic and early childhood developmental factors are clearly critical. It is no more realistic to expect the healthcare system alone to cure a long-standing diabetic, overweight, non-English speaking smoker than it is to expect a university to remediate a socially disadvantaged young adult who never learned basic principles of 8th grade math.

• “Why can’t you run this like a business?” In both healthcare and higher education, there are people in advisory and governance roles that have earned great success in a wide variety of private enterprises. There is often a feeling among these highly accomplished people that if healthcare (or higher education) just adopted sound business principles, our system would be fixed. That is true to a degree. Healthcare and higher education should be managed on a solid business foundation. However, the perverse economic dynamics of the industry, the belief that the service provided is a fundamental right and the resulting regulations to protect those rights creates dynamics you would not find in a typical business. It is unlikely a consumer would show up on a car lot, drive away in a car they cannot afford because they have real need of a car, with the promise that a third party may ultimately pay some fraction of the actual cost.

• Disruptive innovation. Both systems are facing disruptive innovators. In healthcare, Wal-Mart is progressively entering the primary care space. Radiographs can be interpreted by a radiologist on the other side of the planet at a fraction of the cost. In higher education, there has been rapid growth in for-profit colleges, with a heavy on-line emphasis. Massive Open On-line Courses (MOOCs) are attracting thousands of students to courses taught by the nation’s best instructors at little to no cost. No one can fully predict what this all will mean, but when high costs meet the public perception of poor quality or service, the disruptive niche innovators will not be far behind. 

• Shift in the international market. For the past half a century, people world-wide come to the United States for access to the most advanced care possible (and usually paid a premium for that access). They continue to come. However, the role of the global community has changed in the past few years. Many cognitively based tasks can be outsourced to countries with an educated workforce, like India. Specialty hospitals are springing up around the world, promising and delivering high quality outcomes and great customer service at a lower price. Medical schools and educational accreditors are expanding into international markets. In higher education, international students flock to universities in the United States for an exceptional educational experience. Although this continues, since the recession students have become more cost sensitive.  A small, but rapidly growing number are attending prestigious European colleges, where they can obtain an equally (at least) prestigious degree at lower cost than many public and private colleges in the US.

I am sure there are many more parallels. My sense is that both healthcare and higher education are on a trajectory headed steadily to transformational innovation. It also appears that healthcare is slightly further down that path. Hopefully, we will benefit from shared experiences.

Medical Professionalism: Jousting at Windmills, or Seeking the Holy Grail?

For physicians, this is a “good news/bad news” piece…or more accurately, “good news/word of caution.”

First the good news.

We live in an era of increased anxiety related to our health. Too many people are demanding too many services for too much money resulting in less than optimal outcomes. The good news? Even in the face of substantial challenges and uncertainty, trust of physicians (and healthcare providers in general) remains high. In fact, according to Gallop polling administered over more than three decades, the US public continues to rate the honesty and ethical standards of physicians among the highest of all professions (see chart below, and CLICK HERE FOR LINK). Although physicians rank very highly, the nursing profession deserves credit for their solid lock on first place.

Perhaps more significant than the current high trust ratings, are the trends over the past 30-40 years. During this period, almost every profession has seen an erosion of public trust. Journalists, judges, lawyers, bankers, clergy and politicians all have all experienced major reductions in public confidence. This is perhaps not surprising given the increasing speed and transparency of information flow…familiarity breeds contempt.

Healthcare providers have bucked the overall trend, and are rated as more honest and ethical than they were in the mid-1970’s. In an era of uncertainty and change, it is very good news that the public still has a high degree of confidence in the providers of care.

Now for the word of caution.

The trust place in healthcare providers is not immutable, and cannot be taken for granted. A case in point, bankers enjoyed a stable and relatively high level of trust (41% Very High or High) as recently as 2005. By 2009, this number had plummeted to 19%, following the global economic meltdown.

Jain and Cassel emphasized this point in their 2010 article in JAMA, Societal Perceptions of Physicians: Knights, Knaves and Pawns? (CLICK HERE FOR LINK). Jain and Cassel refer to a 2006 book by economist Julian Le Grand, Motivation, Agency, and Public Policy: Of Knights and Knaves, Pawns and Queens. Le Grand observed the changing public attitudes regarding civil servants in Great Britain. Immediately following World War II, civil servants were held in the highest possible regard. Schoolteachers, physicians, policemen, child welfare workers and others were heroes, part of a concerted national effort that defeated Hitler. What followed, according to Le Grand, was an era of good will and public optimism that lead to an expansion of state services… “a triumph of collectivism”.

Today, the same groups that once were celebrated are viewed as part of a faceless monolith of public services that deliver low quality services for undesirably high tax rates. Part of Le Grand’s hypothesis is that as society’s view of the motivation of a profession changes (e.g., are they Knights, Knaves or Pawns?), there is a direct impact on public policy.

Knights are driven by virtue, and are predisposed to do the right thing. Per Jain and Cassel, physician knights are stewards of the healthcare system. They can be trusted to manage resources effectively. They are life-long learners because they have an inherent love of learning. First and foremost, they are advocates of the patient. If society believes in physician knights, the public policy implication is that minimal regulation is required…knights will do the right thing to protect us…just get out of the way and let them pursue their vocation.

Knaves are driven by self-interest. Money, fame and lifestyle considerations are of primary importance, and the needs of patients are secondary. Knowledge is acquired, or research is performed, out of some expectation of personal gain. If society believes in physician knaves, then public policy must prevent malfeasance. Rules and regulations must be established to guard against greed and monitor potential conflicts of interest that may impact patient care decisions. Think of the financial regulatory environment after the US housing market collapse.

The poor physician pawns blow where the breeze takes them, helpless to act and at the mercy of the environment. They do their required continuing education because they are told to do so. If you need them to order fewer lab tests, they will comply. If next month you want them to do more lab tests, they will comply. They are reeds in the wind. From a public policy perspective, physician pawns are mindless automatons; production units with little judgment, unable to engage in autonomous decision-making. Regulation must therefore be highly prescriptive. Since physicians cannot make decisions, society must carefully create a script for them to follow.

If you accept Le Grand’s premise, then public perception drives policy and regulation. However, I think it is more of a cycle, or more accurately, a spiral. Behavior of the profession drives public perception. Public perception drives regulation. But regulation also influences behavior (which drive perception, then regulation, etc.).

Imagine two good parents have three generally well-behaved and respectful children…a teenager, child and infant. The parents have faith in their children. The children seem inclined to do the right thing. Because of the trust the parents have in the children, they are given a high degree of autonomy. They are child knights. One weekend the teenager is involved in a momentary indiscretion (you may choose your indiscretion). The transgression was not heinous, but showed poor judgment.

Perhaps the parents will continue to regard their eldest as a knight. However, if he slips towards knave status in their eyes, the parents could respond by ramping up the regulation. Curfews might be added, expectations for frequent communication heightened, friends more carefully scrutinized, social media sites monitored, etc. What influence would this heightened level of supervision, and decreased parental trust have on the teenager and middle child? It is not unreasonable to expect the children might become less transparent; they might become less communicative; they might lie about friendships and activities. In other words, the regulation designed to protect the family and children accelerates the journey to knave status. The reactive behaviors influence the parents’ opinion of the child, stimulate more rules and oversight, and drive more knave-like behavior. The cycle continues.

But what of the infant child in the family? Raised in an environment of rules, restrictions and guardrails, the child develops without the opportunity to test boundaries, make mistakes and be rewarded for making good decisions. The infant potentially grows into a child who needs regulation to survive, incapable of working through difficult problems independently. The child pawn requires more and more detailed rules, as he appears incapable of developing independent moral thought.

So by way of analogy, physicians who act like knaves will drive public perception, which in turn drives regulation, which impacts behavior and the spiral continues. One concrete example: Medicare billing guidelines are very tightly linked to documentation of the history and physical examination (because physicians are viewed as knaves by Medicare, prescriptive documentation guidelines are enforced to prevent overbilling). One of the areas of documentation is the “review of systems” (ROS). The physician asks questions about symptoms attributable to a specific organ system – cardiovascular, respiratory, gastrointestinal, genitourinary, etc. Medicare defines four levels of charges, ascending in complexity and payment. For the lowest level, no ROS is required at all. The next level up, the ROS is “problem pertinent”, and can be limited to the system directly involved with the illness under evaluation. The next highest level requires documentation the physician asked the patient about 2 to 9 systems. The highest level requires the physician ask about 10 or more organ systems. Especially in the era of electronic medical records, where much documentation is driven by checkboxes, it is not unreasonable to assume that some of the 900,000 physicians in the country will over-document their review of systems – a very small number deliberately, a much larger number innocently. Healthcare systems and practices invest in audit systems to try and catch and correct these errors in documentation. Medicare ramps up investigations to try and catch those acting badly. More regulations are spawned, and the spiral continues.

So are physicians knights, knaves or pawns? An environment that is moving towards increased guardrails and regulation runs the risk of demoralizing the knights, and creating knaves and pawns. Recognizing this risk, physicians and healthcare providers must work to interrupt the cycle by committing to fundamental principles of professionalism. Individual physicians, and the advocacy and accrediting bodies representing them, must hold sacrosanct one principle: first and always, the duty of a professional is the protection and promotion of a patient’s health. All other forms of self-interest must be unequivocally secondary. Once commitment to professionalism starts to erode, we are headed down a path where the primary protector of a patient’s well being are the rules and regulations governing the physician-patient interaction – not the physician.

Pay-For-Performance and Unintended Consequences: The International Language

Pay-For-Performance (or P4P) is an important tool in our effort to improve the quality of the nation’s health care, and control cost.  It may prove to be a critical and effective tool. However, we need to tread cautiously; P4P is no panacea.

Central to all health care reform proposals, across the political spectrum, is the observation that part of our problem is perverse economics.  The economics are warped in (at least) two ways.  First, since the post-World War II growth of employee provided insurance, and the 1965 introduction of Medicare, consumers have largely been removed from any direct financial impact of the provision of medical services.  With no consequence to consumption, demand grows without restraint.  This long-standing dynamic is starting to be reversed as employers are steadily shifting more of the financial cost of insurance to employees.

The second dynamic is equally pernicious.  In any city in the United States we have physicians who deliver excellent, evidence-based care; who are great communicators with outstanding bedside manner; who achieve outcomes beyond those of their peers.  We also have doctors in the same city (or same practice) who are insensitive, abrupt, below average clinicians with below average outcomes.   I believe, thankfully, the former category substantially outnumbers the latter.  However, here is where the economics are twisted:  the good, kind and efficient doctor will see the same sort of patient and perform the same types of procedure as the gruff doctor with poorer outcomes.  Both doctors will submit a bill for a unit of service to Medicare, Medicaid or private insurance, and both doctors are paid exactly the same thing.  A consequence of the payment system in America is the only way for a physician (or hospital) to do better financially, is to do a greater volume, pure and simple.  The sole incentive is to do more, not to do better.

Some studies show family physicians spend only 7-8 minutes with a patient in a typical visit.  It is not by their choice.  I know dozens, perhaps hundreds of family physicians.  As a group, they are wired to take time, engage in meaningful dialog, dig into complex interpersonal dynamics and try to understand how an illness impacts a patient as a human being.  This is why they chose their field.  Left to their own devices, most would happily linger with a patient for an hour or longer. 

The unfortunate economic dynamic prohibits this sort of interaction.   Family physicians are already among the poorest paid of physicians, earning less than half, or even a third of their specialist colleagues.  To pay office staff, cover overhead, keep the lights on and take home a reasonable wage, the typical doctor must see at least 30 patients a day.  I will do the math for you…over an 8-hour day, that works out to 16 minutes per patient.  Take from that time for documentation, phone calls, and sicker patients who demand more time, and you quickly get to 8 minutes per patient.

Enter P4P.  The concept is seductive in its simplicity.  Let’s stop paying doctors based on volume, and start paying them based on quality of patient outcomes and patient satisfaction.  On a purely intuitive level, this idea has almost universal appeal.  However, because something makes intuitive sense, does not necessarily mean it will work, especially when rolled out on a very large scale across a complex system.

I recently read two studies related to physician compensation as a tool to modify behavior.  Both studies had excellent and worthy goals.  Both implemented well-designed and rational compensation changes.  Otherwise, the two studies could not have been any more different, except for one other significant similarity… neither worked as expected.

The first study comes from an unexpected source:  a rural delivery system in a poor province of China.¹  The physicians in that community had two sources of income.  They billed for services in a traditional fee for service model – more volume, more income – and they were permitted to sell drugs at a substantial mark up.  The health care planners in the province were concerned that this payment mechanism was encouraging unnecessary service and over-prescription of medications.  The fix was to revise the compensation system.

The payment scheme was revised so that rural providers would now have three sources of revenue: 1) a base salary ($15/month); 2) a volume bonus ($0.06/outpatient); and 3) a quality bonus, based on defined metrics ($12.50/month).  The economic incentive to sell medications was eliminated.  Move the decimal point about three places to the right, and this payment system looks much like many US compensation models. 

Rational, thoughtful, well designed.  So what were the results?

The designers had a number of expectations. Spending would decrease on the village level.  Unnecessary care would be reduced, particularly to the young and healthy.  There would be a reduction in prescription of unnecessary drugs.  In fact, all these results were achieved, but with one significant unexpected consequence.  Sicker patients were more costly for the rural doctors to treat, and negatively impacted their quality metrics (and pay).  As a result, there was a sharp increase in the referral of the sicker patients to more expensive city clinics.  The net result after 5 years? No cost savings to the healthcare system.

From a small study in China to a massive study in the United States.²  Starting in 2005, ten physician practices were voluntarily enrolled in the Medicare Physician Group Practice Demonstration (PGPD).  These groups joined what was considered to be a precursor of Accountable Care Organizations (ACO).  Quality metrics were introduced, and cost saving monitored in the demonstration groups.  Any savings realized from more efficient, more effective care, would in part return to the physician practice.

From 2005 through 2009 there were 990,177 patients enrolled in PGPD practices.  In a quasi-experimental design, this group was compared to patients in non-PGPD practices, both during the trial, and for the four years preceding the trial.  Keep in mind, the practices that enrolled in this demonstration were best of class.  They would not have enrolled if they were not confident they had the ability to succeed. 

Like the Chinese study: good and noble goals, rational design.  The results?  Although not a total failure, the positive impact was limited to a relatively small subset of patients (see figure below, taken from the JAMA article in the footnotes).

For Medicare patients, over a five-year period, there were no statistically significant savings.  In fact, the statistical confidence interval was such it was possible the care was actually more expensive.

The group that did seem to benefit was the Medicare “dually eligible”, that is, those patients with Medicare, who were also eligible for some portion of Medicaid benefits.  This group is primarily comprised of the disabled, and the elderly poor.  The dually eligibles also tend to suffer from multiple chronic illnesses, and have a disproportionately high rate of mental health issues, so it is not necessarily surprising they benefited from the enhanced case management typically part of an ACO, “medical home” model.

Two studies, different sides of the world, different cultures, aligning incentives in a rational manner…both with disappointing results.

This is admittedly a very limited and selective review of the literature.  Although at the time health care reform was passed there was a dearth of evidence to prove P4P actually works, there has been subsequent demonstration of efficacy, at least in select populations. 

What lessons can we take away from this? I think there are three:

• Often we see the need to improve care, and the need to engage physicians and other providers in supporting change. This usually leads to a conversation around “aligned incentives”. The groupthink sometimes seems to be, “if we could design the perfect compensation system, solutions to all these problems will fall into place.” It is clear; compensation design is not a magic bullet. 

• General solutions, widely applied over a large population, are not likely to be effective for all patients. A team-based, case management intensive model may work exceptionally well for an elderly disabled patient with multiple medical conditions. It may not be the right model for a healthy young adult. 

• More important than a payment system of accountability, we need to develop a medical culture of accountability. Compensation may be a tool in shifting culture, but it is only a single tool. 

¹ Wang H, Zhang L, Yip W, Hsiao W. An experiment in payment reform for doctors in rural China reduced some unnecessary care but did not lower total costs. Health Affairs. 2011; 30(12): 2427-36.

² Colla C, Wennberg D, Meara E, et al. Spending Differences Associated With the Medicare Physician Group Practice Demonstration. JAMA. 2012; 308(10): 1015-1023.  Click for link to article