The Ringelmann effect, or Has family medicine lost its élan vital?
A French agricultural engineer named Maximilien Ringelmann performed a classic experiment over a century ago that you could replicate in your own backyard, playground or office.
He measured people pulling on a rope connected to a strain gauge, both as individuals and as part of a group tug-of-war. Result: People pull harder as individuals.
Ringelmann called this “social loafing.” We all remember it from group projects in school. Since as physicians we are overachievers, chances are you remember carrying the load for the deadbeats, as I do. Teachers think this is great. I think it’s nuts.
What happens to per-doctor productivity when a hospital buys a private practice and everybody goes on salary? Yep. Productivity plummets. That’s Ringelmann for you.
As the Dare to Slack poster says, “When birds fly in the right formation, they need only exert half the effort. Even in nature, teamwork results in collective laziness.”
On the other hand, teamwork is essential in the business of medicine. Without loyal, intelligent and hard-working (not to mention beautiful and handsome) colleagues, life would be a nightmare anywhere except a micropractice. So what are the laws of productive teamwork?
First, the team has to have a good Captain, and the lines of authority and responsibility must be clear. The buck has to stop somewhere; that would be the boss. Some bosses can’t make decisions, or they fear responsibility. Their teams won’t be productive.
Second, productivity must be rewarded. I’ve dealt with this at length elsewhere. In a solo practice, this happens by default. In a group, the compensation formula must be simple, fair and transparent. There is no shame in not wanting to work as hard as the next guy. The shame is in wanting to be compensated as if you were.
When I first came to Topeka in 1980, I intended to join a group practice run by a man I respected greatly. But I also wanted to start a private school for my kids. So I negotiated a half-time job. I didn’t want to be paid 75 percent of what the others made; 50 percent would have been just fine. There was nothing immoral about that. One member of the group just couldn’t believe I wasn’t going to be ripping them off, so I withdrew and went to work in the emergency room. But there’s no problem in principle for wanting an honest half-day’s pay for an honest half-day’s work.
What’s immoral is expecting the other members of a group to financially support your desire to carry on leisurely chit-chat with 15 patients per day.
The profession changes with the culture. When I was a resident, taking call every third or fourth night, old-timers thought I was a slacker. They had spent 120 hours a week in the hospital. But their mentors thought they were slackers, because they were allowed to be married. Not so very long ago, you see, only single men were admitted to medical school.
So I don’t want to play that game. You won’t find me looking down on someone because they want to enjoy spouse and family, as well as the medical profession. That’s what I wanted, and that’s what I got.
My disquiet comes from a suspicion that fledgling family physicians want their jobs microwave-ready; that maybe their mentors weren’t all that successful in private practice and found academic medicine a haven from its demands; that, perhaps, the specialty has lost the dynamism, creativity and entrepreneurial zeal it had in 1975.
Teamwork has its uses, but it is not the font of dynamism, creativity and entrepreneurial zeal. So when I hear the “leaders” of family medicine talk too much about teamwork, I want to ask: Quo vadis, Captain?
Posted at 12:01PM Jul 30, 2009 by Doug Iliff | Comments[4]
What to do with the difficult patient
These thoughts were inspired by “The Burden of Difficult Encounters in Primary Care” in the February 23rd Archives of Internal Medicine.
Since the subject surfaced in the 1990s, it has been repeatedly demonstrated that physicians of all specialties find 1 in 6 patient visits to be “difficult” (synonyms: “heartsink” and “black hole” in British literature, and “problem,” “disliked,” “frustrating,” “troublesome” or “hateful” in America).
But you know the type.
Over the years it has increasingly been recognized that this is not all the patient’s fault. The doctor plays a role, too. This article indicates that it’s a pretty big role. That’s good news, because there’s not much we can do to change anyone except ourselves.
Subspecialists have a much higher percentage of difficult encounters than general internists or family physicians. No surprise there. If you can’t handle long-term relationships, with all the attendant conflicts, choose work at the other end of a colonoscope.
The interesting thing about this survey of 423 primary care physicians is how they stratify. For instance, 41 “low difficulty” physicians were characterized by “an almost complete and unanimous indication of no perceived difficulty with patients they saw.”
On the other end, 113 “high difficulty” docs “had almost complete and unanimous indication of working with difficult patients.”
Obviously, it’s not the patients.
When I read the accompanying editorial, and before finding that 10 percent of primary care physicians experienced virtually no obnoxious patients, I was thinking, “I am either in denial or really weird.” Now I know that I have a little company.
The question is, can “we few, we happy few, we band of brothers” recruit converts from the rest of the profession?
Hints: We happy few averaged 46 years of age, while les miserables averaged 41. So hang in there another five years; there’s hope. And 50 percent of les miserables were women, compared to 27 percent in the “low difficulty” group. Somehow I don’t think a sex change operation would solve this problem.
Ethnic/racial and work status (full- or part-time) didn’t seem to make a difference. High-difficulty docs are 12 times more likely to experience burnout than low-difficulty types. No surprise there, either.
The authors duck hypotheses for the dramatic gender differences but offer two explanations for the effects of experience, one of which seems reasonable to me.
One is that older physicians have developed coping mechanisms to mitigate the difficulty. For me, one of these mechanisms is simply “tincture of time.”
I have so few perceived difficult patients in my practice that they come immediately to mind. One is a distinguished looking lady who is never, ever satisfied with the care she receives; yet she comes back for more. Recently I received the usual humane and thorough referral letter from the Mayo Clinic, which is my Golden Turf. The office staff laughed out loud as we read the author’s exquisitely phrased note, which said, between the lines, “Boy, I’m glad she’s going back to Kansas! She wore me out.”
That makes me feel better. Mayo can’t stand her, either. So we’ll just hang on and do our duty.
Another is a woman so severe-looking, with every facial line pointing toward her toes and a voice to match, that she invokes Alexander Theroux’s classic description: “Her piss would etch glass.” Since I found a huge ovarian tumor on a database physical visit she had long resisted, we have achieved rapprochement. In repayment for saving her life, she occasionally blesses us with a smile.
A smile from her is better than a slap on the back from anyone else.
Another effect of time is that the better I know a patient, the easier each encounter becomes – both professionally and personally. My world-class hypochondriac, after 20 years of relationship, now opens every encounter with, “I know you’re going to think I’m crazy, but … .” And I do, and she knows I do, and we get along just fine. She now believes my reassurances, sort of.
A second factor raised by the authors is “self-selection” on the part of patients. This doesn’t make any sense, unless they mean that disagreeable patients seek out disagreeable doctors. Here’s what does make sense: If I kindly but persistently refuse to meet the unreasonable demands of a difficult patient, either he will learn to behave or leave my practice. This is a win-win for me, and a win-lose for him. Three out of four ain’t bad.
Or it could mean this: I once gave one of my best friends the heave-ho from my practice. He was sweet as pie to me, but an absolute jerk to my staff. I don’t like “respecters of persons,” to quote St. Paul. After two warnings, he got walking papers. My staff learned that I stood behind them, even when it cost me personal pain.
My advice for all you whippersnappers is to give private practice at least a decade before throwing in the towel. But you’ve got to work at it. If you don’t, at some level, love the knuckleheads in your practice, bail early. I’d suggest anesthesia or pathology.
The authors suggest additional training in the biopsychosocial arts, or counseling, but I’m not sanguine about those. Part of it is having the right personality (maybe part of that is having the right religion), and the other part is motivation and will to fix what’s wrong in your attitude and your practice. That comes from within, not without.
Posted at 11:31AM Jul 20, 2009 by Doug Iliff | Comments[1]
Surveys and other time-wasters
In case you don’t read the papers or listen to the news, good for you! And here’s an executive summary of the last two weeks.
Health care “stakeholders” pack congressional hearing rooms; embarrassing picture taken, reminding ordinary people that no one is lobbying for them. President Obama promises a nice raise for primary care physicians, and cuts for everyone else. Procedurists scream like stuck pigs. Congressional Budget Office scores health care proposals; looks like no raises for anybody. Rep. Charlie Rangel solves scoring dilemma: tax surcharge on everyone making over $350,000. Procedurists scream like stuck pigs.
That’s the news for the last fortnight, and good luck to you if you’re counting on the politicians to save us. So, in the meantime, lets talk about something practical. Like surveys.
Surveys are big right now. If you want to be a “medical home,” you’re going to need to survey your patients. You’re going to ask them to respond (on a scale of one to five, with five being “strongly agree”) to items like “I can get an appointment with Dr. Iliff quickly,” or “Dr. Iliff spends enough time with me at our office visits.”
You know the drill. And if you’re in a big group, you’ll have to grin and bear it. Even solo physicians like myself are periodically exposed to patient surveys by insurers, although I don’t have to waste any personal time participating.
Then will come the results. You’ll find that when it comes to waiting for appointments, you rate a 4.1 against the group average of 4.3. But hey! Once you get them into the room, you’re a 4.2 against the group’s 3.9!
So what are you going to do with that information? Quicken your visits by 0.2 in hopes of shortening the wait by 0.4? And does a delta of 0.2 mean anything, anyway?
The problems associated with surveying are legion. Just ask someone doing meaningful research – that is, something other than devising the 1,232nd question to detect the closet alcoholics in your practice. If you’re relying on a survey, your research is crap. That’s why I always file them in the wastebasket.
If you’ve read this blog more than once, you sense that I’m impatient. I don’t like wasting time. If it’s not actionable intelligence, bother somebody else.
But I know I’m in the minority. If I were still in academic family medicine, it would be an infinitesimally small minority. The world is full of talkers. Cogitation and blophilating* pass for action. But they are not action. They are vapor, like carbon monoxide.
If you are a young family physician, and you like to spend time with your family while earning a good living, you’ve got to develop strategies to avoid the time wasters in your professional life. President Obama can’t do it for you. The AAFP can’t do it for you.
On rare occasions I read something heartening in my local paper. The city council voted to spend $20,000 for a study of bike trails. They were “incentivized” by the Feds, who would toss in another $80,000. That’s the way the Feds add value.
Our elderly mayor, a man of distinguished character and long experience, is fighting pneumonia. He rose from his hospital bed long enough to veto the expenditure, noting that the city planning staff is quite capable of performing that function in the normal course of their duties. In fact, the staffer who designed a wonderful plan of bike trails for our town – which is being implemented, one year at a time – is one of my patients.
The mayor knows that a whole industry has grown up to “facilitate” planning, strategizing, surveying, resolution-writing, brainstorming, consulting, goal-setting, and focus-grouping. If you don’t read Dilbert, do**: that’s where you go to get your head straight after you’ve run into one of these gurus. They want your $100 grand, in time or money.
Just say no. You must develop a bias for action, and a nose for BS. To help get you started, browse at despair.com. I put their posters on the ceiling, for patients suffering indignities in the prone position.
* neologism: "the love of being a blowhard"
** Six hours after I wrote this (no kidding) the Sunday paper arrived on my driveway. The Pointy-Haired Boss tells Dilbert to collect useless information that will be out of date before it is compiled. Dilbert: "The best way to compile inaccurate information that no one wants is to make it up." Pointy-Haired Boss (to Catbert, evil head of HR): "I hope no one ever comes here to learn our best practices."
Posted at 11:03AM Jul 17, 2009 by Doug Iliff | Comments[1]
Six myths that frame the health care debate
This week I am shamelessly plagiarizing the rant of one of my few good friends, Dave Clark, a dermatologist who was once a general internist in private practice before illness prompted a career change. It has to do with the foggy state of public thinking about medicine.
Myth 1: President Obama is trying to pull a fast one. He wants to ration care based on medical evidence.
To see how he’s getting grilled on this issue, including his awkward response to the daughter of a 105-year-old who survived a pacemaker implantation at age 100 that her doctor had advised against, see this article (I'm not a World Socialist-- it was just a good link). In fact, medical services are rationed now in any number of ways – including, but not limited to, ability to pay, insurance approval, location, transportation, attitudes of relatives and competence of medical professionals. Americans don’t get upset at rationing of BMWs or Viking ranges. Pacemakers are a horse of a different color.
Myth 2: Medical care is a private service business, like the local donut shop. Do you like cake or glazed?
In fact, the health industry is so big, and often so monolithic, that it has become more like your local utility. When it comes to utilities, Americans get pretty goosey about cutting off the juice. This issue has not been settled yet, but it doesn’t take a weathervane to know which way the wind blows. Once medical care is deemed a utility in the public consciousness, and the pipelines run short of gas, rationing is inevitable. Ask your grandparents about life during World War II, and see Myth Number One.
Myth 3: Physicians are disinterested with regard to cost-effectiveness.
In fact, every one of us makes decisions daily that remove money from the wallets of our patients and insert it into ours. A professional is an individual who works with little or no supervision, in the service of a client, with only an internalized ethical standard preventing him or her from taking advantage of an asymmetric power relationship. And the decisions of physicians – largely in those specialties where new procedures and technologies require ad hoc reimbursement determinations, or where restricted residency slots create barriers to entry and cost competition – are bankrupting the country. Often these decisions are blamed on lawyers and defensive medicine. I think greed and cowardice play a part too.
Myth 4: We’re smart enough now, or will be soon, to consistently make “best practices” decisions in our exam rooms.
In fact, we aren’t and never will be. Dave posits a good example: for that basal cell on your face, is it a curettage for $250, which leaves a white divot and a 5 percent chance of recurrence, or a Mohs for $2,500, which is invisible with a 0.1 percent chance of recurrence? Forget “number needed to treat” or “years of quality life expectancy” for choices like that. Who gets to choose? And who gets to pay?
Myth 5: Consumer empowerment, in the form of Health Savings Accounts, carrot-and-stick incentives from employers, or whatever, can save us from ourselves.
The key question is this: with or without our consent and/or cooperation? I will take it as a fact, based on being the medical director of a minor emergency clinic for 23 years, that one-fifth of the population has adequate insurance or money but still chooses to practice “breakdown maintenance” when it comes to their health. Medical home? Fuggedaboudit. What are you going to do with these knuckleheads, and the many other varieties who sabotage their bodies on a daily basis? I remember from my boyhood a Life magazine cover displaying thousands of communist Chinese doing mandatory morning exercises in Tiananmen Square. That would be my personal solution, but somehow I think I’d get lynched before it was implemented.
Myth 6: We’re in a war between Republicans and Democrats, capitalists and socialists, and to the winner belongs the future of health care.
This is a logical fallacy (“false dilemma”) which omits consideration of other reasonable alternatives. Republicans and Democrats are Tweedle-dum and Tweedle-dee. In fact, Americans of all political and philosophical persuasions are increasingly locked into a mindset of radical individualism, of personal rights without commensurate community responsibilities. This is the back story of this debate, and politicians may not be up for the challenge.
Optimism has worked pretty well for me over 60 years, although I’ve been mugged by reality and have scars to prove it. I agree that all of these are more-or-less myths. But I won’t be sucked into a reductio ad absurdum: Taken uncritically, the sum of these myths is that the cost of health care is inevitably going to bankrupt America, and there’s not a doggone thing we can do about it.
I’m not smart enough, wise enough, or clairvoyant enough to predict the final solution. But one way or another, the polis will accept some limitations on their desire for unlimited benefits, some responsibility for their own actions, and some requirement for wiser shopping and sharper questions – all in some way compatible with the unique character of Americans.
One way or another, primary care is going to be in the middle of that solution. I’ll probably be in a rocking chair by the time we figure it out. In the meantime, there is no excuse for family physicians not to be doing well (or at least better) by doing good.
Posted at 11:50AM Jul 09, 2009 by Doug Iliff | Comments[5]
Dittoheads of the world, unite!
I know I’m running out of things to say about practice management when I read a series of great articles in great publications – and all I can add is “ditto.” I never wanted to be a dittohead, and I don’t listen to Rush Limbaugh. But there are only so many valid points to make, and unless I want to make them again with different examples, or move on to some other subject, I’m reaching the end of my tether.
Dr. Mark Sklar, an endocrinologist and assistant professor of medicine at the hospitals of Georgetown and George Washington University, popped a good opinion piece in the June 23rd Wall Street Journal. Although he is a specialist and I am a generalist, the fact that we have both experienced academic bureaucracies and opted for private practice makes us blood brothers. Like this:
"Contrary to what you may have heard, my experience is that smaller practices provide better patient care than larger practices. There are no economies of scale in medicine. If you hire more physicians, you need to hire more support staff to deal with the increased work demands. Larger practices with less support per physician often end up providing worse service. They also require office managers, and sometimes even managers of managers, all of which just bloat costs."
Like I said before, doctors are really piece workers. There are no efficiencies in numbers. Have I mentioned that I don’t have an office manager, so I don’t have to pay my share of a $50,000 salary? That goes to my kids’ college fund. True, I have to make small day-to-day decisions between patients. Also true, I don’t have to meet with the office manager to go over those decisions, and check on the implementation later. I wouldn’t remember anyway. Short attention spans have their advantage, in the right setting.
"I worked in a university multispecialty practice for seven years before establishing my own private practice. At the university practice, I found that patients' requests often went unfulfilled. Phone messages didn't get to me, and charts and laboratory tests were routinely lost. In my own practice, my fingers are continuously on the pulse of my staff and patients. Because I can overhear how staff interact with patients, I can intervene rapidly if patients are not getting good service. We routinely have patients transferring to us from larger multispecialty practices where they often wait for hours to be seen, aren't called with their test results, and their phone calls are ignored."
My town is crawling with good doctors, including primary care – we had a family practice residency here for a long time, and lots of them stayed put. Every time I call my primary hospital, I listen to an advertisement for my competitors while I’m on hold; I read their full page ads in the paper; they dominate the evening news and the Yellow Pages. How is a solo FP supposed to compete? Like Dr. Sklar says. Our patients are treated like royalty. I was recently invited to join a large “concierge” organization, but there was a major problem: How was I going to offer VIP patients better service than they’re getting now for nothing?
"Electronic medical records have been praised as a way to save money and avoid duplication of tests. It's true that electronic medical records will save some money, but not as much as you probably are counting on. In my practice, if a patient tells us he had a test performed, we call the physician or medical facility to retrieve the results…. When I refer a patient, I fax or mail over pertinent notes, lab work and radiology results so that the specialist knows the patient's problem and doesn't need to perform additional unnecessary tests. The specialists that I refer to either call me or write comprehensive consultation letters so that I am aware of their treatment plan and can coordinate future care with them."
When I read articles lauding EMRs, I feel like I’m in a parallel universe. You need an EMR to avoid duplication of tests and services? Like Dr. Sklar says, that’s what a fax machine is for. An EMR will save paper? Every time I get a “Practice Partner” five-minute office visit from one consultant, it occupies four pages of trees. An emergency room visit runs to eight single-spaced pages. It’s damn difficult to find the important stuff in all that computer-generated, ass-covering verbiage. If everyone shared a common platform, that would be one matter. But the government refused to mandate that a decade ago, and I’m paying for the results. Some day the Betamax/VHS, Blu-Ray/DVD, 8-track/cassette issue will be settled, and that’s the day I’ll shop for an EMR.
Don’t try telling that to the Patient-Centered Medical Home folks, though.
Posted at 12:22PM Jul 02, 2009 by Doug Iliff | Comments[4]
