Monday, April 26, 2010

A Game the Self-Critical Can Play

It’s important to be self-critical. It’s a worry my wife has about the always-positive-reinforcement give-everyone-a-trophy modern don’t-let-anyone-feel-neglected world. How do you know if you’re any good, she says?

Well, my parents would sure go along with that. They were proud of me and the other kids, very proud. But tell us? Don’t want to do that. Might cut down on effort. So I was raised to be self-critical. Was it enough? Was it any good? Would you be able to keep it up for next time when “the others let down.” How would someone not inclined to favor you look at it? (The old Jewish problem, you have to be better to succeed.)

That’s not such a bad thing if you’re going to do something worthwhile. For instance, I haven't posted lately because as I write something, it just doesn't seem up to snuff. I hope you all appreciate that. So that's the good part. But, the bad part is that relentless self-criticism can make for depression, tension, anxiety. That’s a high price.

There are many ways to deal with this family legacy. Some are expensive. But I am here to recommend one I have come up with for your evening pleasure. Jeopardy, the old Merv Griffin stable. Jeopardy. ABC, Channel 7 at 7 PM every night. In Hawaii it’s on at 4 PM, with a rerun of an older game at 4:30. Jeopardy, not running as frequently as Law and Order, but enough for a near daily dose, if you want.

But not standard Jeopardy. Standard Jeopardy is tough. In standard Jeopardy you have to be careful. Are you sure you know the answer? How sure do you have to be to ring in? If you’re wrong, it’ll cost you with deducted cash. But you have to act fast, with instant calculations. Standard Jeopardy is nerve racking.

Instead, I play Budd-Jeopardy. Budd-Jeopardy is refreshing. Budd-Jeopardy releases you from the worry throughout the game. You don't have to wonder if your account is going up or going down. Budd-Jeopardy only goes up, never down. It’s an upper!

What is Budd-Jeopardy? It is non-critical Jeopardy. In Budd-Jeopardy, there are no deductions. You get a point only when you know the answer, and no one else on the panel on the show does. If you get it and they don’t, you get to shout, “Budd!!” Or, if your name is not Budd, you get to shout your own name, let's be clear. Maybe I should insist that it's always "Budd!" you shout, but I doubt this rule would catch on, so you can use your own name. If it is a Daily Double question, and thus only one panel member gets to guess, and you get it and he or she doesn’t, you still get a “Budd!” If you are playing with someone else in the room, and you both get it, you both get a score, and you both get to shout your names.

Budd-Jeopardy gives you only positives! For every answer you can guess the question. If you’re wrong, no problem! You can be self-critical if you want, and of course I can’t help it. I should have gotten that! I knew that! I just couldn’t pull that one out, but I did know it! The full boat of disappointments can be uttered.

But, that’s only an undercurrent. Budd-Jeopardy is an upper. You’re only adding up the pluses. In Budd-Jeopardy, par for a game is two “Budd’s!” The best I’ve ever done is about six, I think. Sometimes it’s only a one, or very occasionally zero.

Budd-Jeopardy is the opposite of golf. Why would you play a game set up for frustration?

Try Budd-Jeopardy instead! You can use your own name, but be sure to shout it in triumph. At least twice a game. It helps to throw your arms up over your head, and to look around for admiration. Or, if you’re alone – and if you do this too much you might well find yourself alone – be sure to admire yourself. You deserve it.

OK, I confessed that I have hit a little dry patch for my posting, and this might not be up to par. OK. I agree. But if I get a bunch of complaints, I'll just erase it. I can't worry about the misses; let's only count the hits. One of these days, I'll get another "Budd!" Maybe tomorrow.

Budd Shenkin

Monday, April 12, 2010

Hospitals Employ Doctors

A few articles have recently appeared in the New York Times and elsewhere, saying that newly graduating doctors are choosing to be employed by hospitals, In addition, doctors and groups in practice are choosing similarly. Locally, a large group down the Peninsula recently chose to join Palo Alto Medical Foundation (PAMF). I don't know why they did this, but at least now I can say for sure that Bayside, our group, is the largest private primary care group in the Bay Area. But I guess that's off the point. Again.

Anyway, why is this happening? People talk about the new work ethic of new grads - more leisure, more "just a job," etc. Maybe so. But, that's nothing an economic determinist would accept.

Let me be economic determinist, then. To quote "Deep Throat" in All The President's Men (the movie only - line does not appear in the book): Follow the Money.

Hospitals and large health systems command monopoly rents. They not only enrich themselves as monopolies, but by taking more of the health care dollar, they leave less for smaller, physician owned practices. The systems then use their extra money to purchase the factors of production that they have starved - the doctors.

The hospitals and systems claim, as do all expanding monopolies, that they provide higher quality (often for a hypothetical future) and better technology that only they can afford. Sometimes it may be true, unless you include as part of the quality equation personal relationships, human scale, and human trust. Patients probably prefer small offices, but the lack of a true market prevents them from voting with their feet and wallets.

But the telling point will be, who can offer the new doctors entering practice a better deal, the starved personal practices, or big, rich systems that thrive on monopoly rents? Follow the money.

Budd Shenkin

Thursday, April 1, 2010

Is Kaiser the Answer?

The question is, how is health care to be organized in the United States? One answer by the health cognoscenti has been, why not Kaiser for everyone? It is less expensive than other care, and its quality is high by all measures. So, why not Kaiser?

Since I am in the biggest Kaiser neighborhood in the country, Oakland, and since Kaiser with probably 70% or so of the private market is our biggest competitor, I’m hardly a disinterested bystander. We lose patients to Kaiser all the time, and there is not much we can do about it. They’re cheaper, and they are not out and out bad. So, grain of salt is indicated.

But, believe it or not, I have a Kaiser card myself! Why I have that card sheds light on the travails of health insurance for a business, the business in this case being Bayside Medical Group, that fine leader in primary care in the East Bay.

I have the card because we had to get Kaiser insurance for our group. We used to have a pretty good plan, although too expensive because all health insurance is too expensive. It was an exchange program run by the Pacific Business Group on Health, very much like the Health Insurance Exchange to come under Obama care. Under the exchange, we had several different levels of care, HMO’s and PPO’s, and several health insurance companies competing at each level. Most of our employees chose Kaiser, mostly because it was the least expensive alternative, and probably also because with one stop bureaucratic shopping, it is a pretty transparent system to the patient.

Anyway, it was fine, but then the system died, mostly because the health insurance companies didn’t need it and it exposed them to too much competition and squeezed them into categories of care. So it died. So we were back to choosing a plan for our group. But how to choose? We are a disparate group, from file clerks to physicians, and one plan won’t fit all. Moreover, we are a medical group, and medical groups are avoided by health insurance companies because of a perception that they are high utilizers. And, here’s the killer – the health insurance companies insist that we go all with them, or not at all with them.

Because so many of our employees were already with Kaiser, it would be very hard not to choose Kaiser. And luckily, Kaiser has a plan whereby employees can choose the classic closed panel Kaiser plan, or opt for a so-called point of service plan, which is like a PPO. It’s expensive for both premium and deductible, a rather crappy plan to be sure, but at least it’s a plan that I can use and a few of my colleagues as well. Under this plan, I get two cards – the POS card, and a regular Kaiser card. So, here I am, a prime Kaiser competitor, someone with a distaste for large institutions such as Kaiser, a pretty independent person, and I’m a card-carrying Kaiser member. Who’d a thunk it.

So there I was with a Kaiser care, so I figured, why not make a site visit? So last year I got the first annual physical of my life – I’m not a big utilizer, and I just programmed my own preventive program – at Kaiser. Then this year I returned for my second site visit, following up with the same doctor I saw last year.

What was it like? Did Kaiser appear to me to be a possible answer to the question? That is, we know that introducing a model is not easy and often impossible, so just because something works here doesn’t mean it will work there – there are all kinds of cultural questions involved. But, that’s not the question for the site visit. The question is, if it were possible to work toward something like this, would that be a good idea, in my eyes?

I have to say that the website worked well for me. I could find a doctor who was open and find out credentials, if not much more – see our website,, for what is possible with a personal touch. And I could make my appointment on line, which was great, just great.

But when I got there, it’s a visit to what socialized medicine would look like. Big institutions, big hallways, big buildings, milling crowds, big parking lots with lots of cars one after the other and you’re just another one of them, and a full dose of the hoi polloi. No matter what you had achieved in life, there you were with everyone else on an equal footing. We have to expect that Kaiser will never be the answer for everyone, just as all the socialized systems have alternatives of private care for those who can pay. Hoi polloi doesn’t work for everyone. Probably not for me. But, if I got past that and found a system and people who worked well, it could be for me. I’m opened minded enough for that, maybe.

Although maybe not. If I or a family member get something severe, I want choice. For most non-medical people they can’t use choice very well, but for me, I can use it and will – and actually did, for my hip resurfacing, for instance. But for primary care and run of the mill, I could do Kaiser, I think. Maybe. If it were good.

Overall, I did get promptness for my primary care visit. I got Oakland African-American sullenness from my first Medical Assistant – they are unionized, and no one can really fix this – but the one at my second visit was better. They take weights with clothes on, but I guess that’s just adult care. Doctor promptness was good, although the second time I went the office was almost empty of patients, so I had to wait almost 15 minutes in the exam room for my doctor. As everywhere, work expands to fill the time, and if things are slow, the staff are likely to go slower as well.

Promptness does not apply to waiting for lab tests or immunizations – I had to wait 15-30 minutes for both, and the shots are given at a separate clinic rather than at your primary care doctor’s, with another hoi polloi exposure. And waiting for labs is as slow as on the outside. Everyone there knows about it and deals with it.

The website helped right at the doctor’s office where she could make a dermatology appointment on her computer for me later the same week – great convenience. And after the visit I got emails pointing me to my lab results on the website. I could email my doc to ask for her reaction to the lab tests.

But of the vaunted Kaiser health system, that’s kind of it. It was up to me to inquire about the lab tests, she didn’t do anything about them unless I asked, even when my Vitamin D the second time was much lower than the first time, when she put me on a supplement for it. I had to remind her this year to check my level, and also the thyroid level, which she forgot she was monitoring and had supplemented. When I reminded her to order it, she even forgot she had had me on it for a year and treated it as a new prescription. She told me to come back in three months the first time but there was no prompt for me to do so – saving money, probably (I think that’s what most of Kaiser is geared toward.) Same with the yearly physical – up to me.

Kaiser is supposed to emphasize prevention. (They are prepaid, so they advertise with a slogan “Thrive!” They probably would like to add, “If you’re sick, why not enroll elsewhere?”) So, as my doctor sat on her little cart performing data entry with her Electronic Medical Record in front of her, she attempted to perform some prevention. She said, “You’re watching you weight?” I said, “Actually, I’ve gone up in my weight lately.” I think my BMI had gone up from 27 to 30 as they measure it, after my knee surgery, which knee she didn’t think to examine. So she looked at me and kind of shrugged. That was it for weight control, despite the fact that I have arthritis and am on statins and blood pressure medicine.

You would think that Kaiser would make a point of screening for depression, given that it is so widespread and treatable. But I don’t think their much into minds and feelings. I was surprised they don’t administer questionnaires. Maybe the hoi polloi won’t fill them out, but I would have. So she screened me verbally. She looked at me and said, “You’re OK, right?” I said, yeah, pretty much. Well, it was quick.

I actually can’t remember if she did a full body physical exam or not. She sure didn’t look at the sites of my operations, or ask how my hip was doing since the resurfacing operation. I do have to tell you, however, that my prostate got a good working over. Oh, yeah.

She did check this time to see if I had had my Adacel and pneumovax shots, which I guess we had skipped the first visit for some reason. The EMR at Kaiser does work well for that.

Actually, I like her. She’s a young woman from Haiti and went to a good medical school and seems nice enough. But I tend to like people. And if there were some big issues I would bring them up, I suppose. But to me, it just seems like working in these clinics is a killer. It’s institutional. What we want is really another human being taking care of us. Can I look at Marie as taking care of me? Only if she followed up the labs, asked me to come in again, gave me a roadmap of my health care, took time to ask about me and my family and my happiness or my plans to retire – I guess she did ask about that, actually. She’s a lot younger than I am and after all, I’ve only met her twice. And I’m prejudiced, hoping that Bayside can give better care than this system. But I have to say, you can put technology into the equation – and you should – but you have also got to find a way to get institutional feel out of the equation. Institutional feel kills the essence of care, and we have to be cared for. That’s what people want, to be cared for. We’re a long way away from being able to be cared for by a HAL.

I always tell our group, the key to being a successful clinician is for your patients to feel that you are competent, that you care, and that you are reliable. It’s hard to say that any of these criteria have been met by my experience at Kaiser. The quality measures cited by the cognoscenti, indicating that Kaiser’s care is of high quality? They are just markers that can be measured. Being cared for? They don’t really measure that, just as they don’t measure the competence of a clinician or a system in chasing down difficult diagnoses, following up orthopedic issues with physical therapy, and a myriad of other aspects of quality of care. Measurement of health care quality isn’t to the point where we can rely on it to indicate good care, just where it can indicate bad care.

But I also have to say, I still have the remnants of my depression-scarred father in me, and I appreciate that Kaiser cost less than other alternatives – all I had to do was pay the copay for the visit, which was reasonable, and nothing extra for the labs. I guess it’s good enough for the hoi polloi.

So, it's an interesting site visit. We can't get more out of it than that. Just one experience, just one doctor dealing with a difficult patient, another more-senior doctor. No big conclusions. It seems as though I could find another doctor if I wanted to.

But I have to say, as a system meeting the needs of a nation, leaves me unimpressed. But then, I'm a tough critic.

As for me, looks like I'll be taking care of myself for a while longer.

Budd Shenkin