Why Doctors Hate Science

[paximperium]

Doctor's Strikes are not very useful. The govt realizes that our ethics bind us to provide Emergency services even when on strike (like nurses) which renders our bargaining power almost useless. With Essential/Emergency Services provided for, the govt can wait out any group of health care providers.

TAM

Not the mention there aren't any doctor's unions in the US of any significant strength not to mention all the different specialties have completely different needs. Unionizing doctors is like herding cats

I can barely remember a doctor's strike in the US...the first one in the entire history of the US was in 1991 in NYC and I can't think of any recent ones.

 

[kellyb]

Well, there has been some interesting and useful information presented in this thread from people who have knowledge and experience in the area in question. It would be a shame to squander the opportunity.

Linda

Yes, I know you're fond of paternalistic attitudes. Patients have knowledge and experience on being on the receiving end of various incentive-induced physician behaviors.

I would think a discussion on how to set reasonable limits on the influence of third party payers on a physician's clinical judgment would be mutually beneficial, but perhaps you're right, and these things are best left to be sorted out among the third party payers who pay all of our healthcare-related bills and incomes.

We should leave the "doctor manipulating policies" discussions to the doctor manipulating experts.

You're still a poopyhead, though.

 

[paximperium]

Patients have knowledge and experience on being on the receiving end of various incentive-induced physician behaviors.

Sure. It is anecdotal but it definitely has some uses in finding the underlying problems involved...it becomes an issue when people seem to never be able to see past their anecdotes and base all their conclusions on their own personal experience.

I would think a discussion on how to set reasonable limits on the influence of third party payers on a physician's clinical judgment would be mutually beneficial, <snipped useless strawman>

So why don't you and Ivor actually do so?

We should leave the "doctor manipulating policies" discussions to the doctor manipulating experts.

That may very well be for the best. People who don't even seem to be able to get past their biases, actually listen to opposing opinion and actually have a productive discussion aren't very useful.

 

[Skeptic Ginger]

Have I told you how cute your avatar is, paxi?

 

[paximperium]

Have I told you how cute your avatar is, paxi?

Feed me.

 

[Skeptic Ginger]

Farmer Mallard, for all your Duck food requirements!

 

[kellyb]

So why don't you and Ivor actually do so?

I'm actually trying to. From my POV, I want to preserve the traditional patient/provider relationship as well as can be reasonable. I'm sort of picky about docs, but the ones who I like, I love. I trust their clinical judgment. I don't want them being manipulated by third party payers via incentives, be they positive or negative.

That may very well be for the best. People who don't even seem to be able to get past their biases, actually listen to opposing opinion and actually have a productive discussion aren't very useful.

My main dog in this race is my abhorrence with the art of coercing doctors to do what vested-interest laced guidelines demand. I think good doctors should be truly free to follow their clinical judgment. It should not cut into their paycheck if they see that a certain patient needs a treatment approach that deviates from the usual guidelines.

For me, as a patient, when looking at healthcare policy...I see a need to acknowledge that both positive and negative incentives can be used to influence physician behavior.
I have a small baby, and when I gave birth to her, my doc "let" me only do periodic (every 30 minutes or 1 hour for 15 or 30 minutes at a time) electronic monitoring, for example. He and I both knew the evidence supported this option as "as safe as" continuous monitoring. For me, the benefit of being able to wander around the room during labor was enormous. I have no idea if he would have made more money insisting that I do continuous monitoring because of CYA reasons. But I would definitely prefer that it not cost him something to have "allowed" me that option.

I think most docs are in medicine for altruistic reasons. But I think they are still human, and open bias from incentives and manipulation from their bosses like any other profession.

In the US, healthcare is really in a state of crisis. I think we have to acknowledge all the forces at play, and one of them (though far from the largest) is individual doctors' desire to stay afloat (in the case of PCPs) or make as much money as possible (on the other extreme end of specialists).

 

[kellyb]

Sure. It is anecdotal but it definitely has some uses in finding the underlying problems involved...it becomes an issue when people seem to never be able to see past their anecdotes and base all their conclusions on their own personal experience.

To get to the first point lastly...

My problems with MDs stems from various decisions coming from insurance companies, like the "6 minutes per patient" rules.
HALF of our combined income goes to medical insurance for our family. Half of our income. Absurdly hurried visits make me irritated.
But I know this is the result of a much larger problem that involves doctor reimbursement from insurance companies.

 

[BillyJoe]

My problems with MDs stems from various decisions coming from insurance companies, like the "6 minutes per patient" rules.

The "6 minutes per patient" rule?
Is ther really such a rule??
Here in Australia there certainily is not, although there are "bulk-billing" practices that rely on quick throughput to make up the difference between the private fee and the "bulk-billing" government fee, that are referred to as "6 minute medicine". There are not many though.

HALF of our combined income goes to medical insurance for our family. Half of our income.

Half you income???
Come to Australia!

 

[BillyJoe]

I want to preserve the traditional patient/provider relationship as well as can be reasonable. I'm sort of picky about docs, but the ones who I like, I love. I trust their clinical judgment.

It is often said that everyone thinks all doctors are crap...
...except their very own doc, who it just absolutely magnificent.

My main dog in this race is my abhorrence with the art of coercing doctors to do what vested-interest laced guidelines demand.

Well, the guidelines, I would hope, are evidence-based.
Are they not?

I think good doctors should be truly free to follow their clinical judgment

Good doctors follow evidence-based guidelines but use their clinical judgement as to how to apply them to the particular patient in front of them. If they deviate from the guidelines (and this is allowed by the very word "guideline"), they must have good reasons for doing so.

It should not cut into their paycheck if they see that a certain patient needs a treatment approach that deviates from the usual guidelines.

Does that really happen?

I think most docs are in medicine for altruistic reasons. But I think they are still human, and open bias from incentives and manipulation from their bosses like any other profession.

Yes, doctors are human. No one is denying that. But Ivor is making more of this than it deserves. And all the studies he quotes are open to interpretation. That study he quoted from Victoria, for example, doesn't say what he says it says. He only makes it sound that way by selective quoting.

And I would think that the entrance requirements into medical school would weed out the "unfit" and, in that sense, doctors are likely to be more caring and compassionate than the average in our society.

In the US, healthcare is really in a state of crisis.

You are not wrong. The largest per capita on health of any first world country and the least equitable.

 

[Rolfe]

I agree, and many of these things are offered, but this is often only enough to keep someone there for a year or two. As well, these incentives are not always what they seem.

For instance, you get holiday time, yes, but what if when you go to take your holidays, they cannot find a locum to replace you? If you are one of two doctors in that region, do you go on your 2 week vacation, and leave your colleague on 24/7 call for 2 weeks?

What about that financial incentive? Lots of good it will do you when you live in the middle of freaking nowhere, with nothing to spend it on.

I have lived in areas where the nearest Coffee shop was 150 miles away, the nearest Walmart the same.

Incentives help, but they are not even close to a cure all.

TAM

I know it's not as bad, but compatre this story I noticed in the paper a couple of days ago.

Just what the doctor ordered

A doctor is moving almost 600 miles to care for only 265 people in a remote Highland community after beating off applications from around the world for the part-time post.

Dr Mark Darbyshire, 34, will next month quit his job as a GP in Chepstow, South Wales, for the wilds of the Wester Ross peninsula of Applecross, which is currently finding fame in BBC TV series, Monty Hall's Great Escape.

Dr Darbyshire said he had no regrets about taking up the job after the local community drummed up interest in the vacant post by advertising it in outdoors magazines and on its own website.One of the hopeful candidates was even willing to commute between Scotland and his home in the US. [....]

When he moves to Wester Ross with his partner and two dogs, Dr Darbyshire will share the workload and £70,000 salary with the current long-serving GP Dr Janice Cargill - who provides out-of-hours cover. Until now she has been the only doctor in the area and has been on call 24 hours a day for up to six weeks at a time. [....]

Seems to have been plenty of interest in the post. Mind you, Applecross isn't 150 miles from a coffee shop, and how hard can it be, with only 265 patients on your list?

Rolfe.

 

[Dancing David]

Obviously I will want to see five or six randomised studies showing this effect before I even consider it to be plausible. After all, I'm sure employers responding to an incentive to exploit their employees is very rare.

Unlike your assertions which are not from 5-6 randomised studies.

Sorry, exploitation of salaried employees is common. In much of the US there is NO implied contract, I work in Illinois. Illinois is a 'right to work state', it means there is no implied contract, they can change the terms of your employeement at any time. And if you don't like it, there is the door.
When I worked for mental health agencies (1990-2000, 2003-2005) or for domestic violence (2000-2003) there was no compensation for over time. Period, and you were required to work it as needed. We were allowed to 'flex' meaning if your supervisor approved (and sometimes they did not) then you could take it off as straight time, but often you could not. So they increase your case load, and you no longer have anytime to do paperwork during the work day, That means an hour to an hour and a half each day, doing paper work at home. All without compensation.

So if they say, 'you have to staff the shelter' and you work another eight hour shift, that is what you do. if they say, 'that is flex' then you say 'okay', if they say 'that is not flex' then you say 'okay'.

This is also a common corporate practice, especially for salaried employees.

 

[Ivor the Engineer]

<snip>

And I would think that the entrance requirements into medical school would weed out the "unfit" and, in that sense, doctors are likely to be more caring and compassionate than the average in our society.

<snip>

What entry requirements to medical school make you believe doctors are likely to be more caring and compassionate than the average person in their society?

Given that there are far fewer places in medical schools than people applying for them, why would the resulting competition select for the more caring and compassionate people?

It seems one of the main motivations doctors get is interacting with and being thanked by the people they help.

Most professionals are helping other people, yet few need the gratification of interacting with them.

 

[fls]

Doctor's Strikes are not very useful. The govt realizes that our ethics bind us to provide Emergency services even when on strike (like nurses) which renders our bargaining power almost useless. With Essential/Emergency Services provided for, the govt can wait out any group of health care providers.

TAM

I participated in a doctor's strike when I was in Canada, and it was successful.

At the time I was at the university hospital. The physicians attending on the clinical teaching units were subject to the same fee schedule as specialists working in the community, even though the work that we did was very different in amount and kind from that of a community internist.* The bulk of the work was done by my section (General Internal Medicine), and while we wouldn't have minded more pay, our real problem was getting any other sub-specialist physicians to participate in the schedule. Because of the way that they were renumerated, it represented a huge pay cut for a sub-specialist to take on a 2-week stint on the hospital service vs. a 2-week stink on their hospital consult service. We took our complaints to the department of health - the work we were performing was far in excess of those who were paid the same amount and there were serious and unsustainable staff shortages due to inequalities in renumeration - but they wouldn't even come to the table and talk to us since, as far as they could tell, the services paid for were commensurate with what was needed. So we simply informed them that if what they were paying for was adequate, we were going to simply stop performing those services they had deemed unnecessary by virtue of making them not worthy of renumeration. This meant that we would no longer free up hospital beds by managing certain patients as outpatients (which required visits in excess of the once per week we could charge for), we no longer transferred patients from surgical wards to medical wards if their care became complicated (as renumeration was based on length on time in hospital regardless of whether the length was due to complications vs. babysitting for rehab or nursing home placement), we no longer accepted patients for admission who had already been seen by a specialist (the attending physician would not receive any renumeration for their complete history/physical/evaluation), etc.

It lasted for less than two days, I suspect mostly because of the effect on the surgical wards - it seems that people listen to surgeons, I wish I knew why. Anyway, they agreed to sit down and take another look at the fee schedule and as a result we moved to block funding rather than fee-for-service. But it's true that we were very reluctant to take that step and we really wouldn't have held out for very long.

Linda

*I used to fly in to smaller communities to provide consultation services and I was often asked to see hospital patients and ICU patients, as well. The typical hospital patient was similar to one of my more stable outpatients, and the typical ICU patient would be similar to one of my not-very-sick hospital inpatients.

 

[fls]

Yes, I know you're fond of paternalistic attitudes.

That's another good example.

I said: People with knowledge and experience have provided useful and interesting information.

You heard: People should be sub-ordinate to authority figures.

Are authority figures the only people with knowledge and experience? Does the act of carefully considering information mean you are sub-ordinate?

I would think a discussion on how to set reasonable limits on the influence of third party payers on a physician's clinical judgment would be mutually beneficial, but perhaps you're right, and these things are best left to be sorted out among the third party payers who pay all of our healthcare-related bills and incomes.

Another good example.

I said: It would be shame to squander the opportunity.

You heard: We should squander the opportunity by avoiding discussion.

I think I've figured it out, though.

We should leave the "doctor manipulating policies" discussions to the doctor manipulating experts.

Yes, it is clearly unreasonable to attempt to understand ways we can maximize outcomes and efficiency, and to make the attempt represents unwarranted manipulation of the physician-patient relationship. Instead, physicians should be free to figure out how best to line the coffers of some git they don't know at great personal and professional expense.

Linda

 

[Ivor the Engineer]

In Canada, there is no "doctor manager". There is an executive that runs a health care board. There is a hospital CEO who runs the entire hospital.

Canada, as a nation, has been battling with this for decades, and still has not come to a consensus.

TAM

That sounds like a really poor organisational structure. Why do you think it has persisted for so long?

 

[Ivor the Engineer]

That's another good example.

I said: People with knowledge and experience have provided useful and interesting information.

You heard: People should be sub-ordinate to authority figures.

Are authority figures the only people with knowledge and experience? Does the act of carefully considering information mean you are sub-ordinate?

<snip>

Perhaps I missed it, but other that anecdotes, KellyB and I are the only people to have provided any useful and interesting information.

Or do anecdotes trump data sets when the issue is close to your heart?

 

[fls]

Perhaps I missed it, but other that anecdotes, KellyB and I are the only people to have provided any useful and interesting information.

Or do anecdotes trump data sets when the issue is close to your heart?

Yes.

Linda

 

[Ivor the Engineer]

Linda said: "Yes."

Ivor heard: "**** off."

 

[fls]

Linda said: "Yes."

Ivor heard: "**** off."

I rest my case.

Linda