|THIS WEEK AT GIST—ON THE ROAD
What we learned this week from our work in the real world.
The power of saying “I’m sorry”
The past few months have been rough for my extended family, with three separate admissions to the hospital. In two of these episodes, while the care received was not ideal, we did get to observe best-practice risk management in action. My uncle, healthy and in his early 60s, had an elective total knee replacement at a high-volume, hospital-based program. He attended “joint boot camp” to learn about the procedure and recovery, and was discharged less than a day after what seemed like a routine procedure. A few days later I received a text message with pictures of his leg from a concerned relative. You didn’t need a medical degree to see that something was incredibly wrong. He went to the ED, and was admitted for four days of IV antibiotics to treat a bad case of postoperative cellulitis.
Post-op infections can happen despite best efforts, but in this case there were other issues at play. My uncle had called the surgeon, concerned about his leg, and reported that the doctor was abrasive and told him everything had been covered at discharge, suggesting that his lack of activity could be causing the problem. Even more concerning, the hospital sent him home with the wrong medications, mixing up his discharge prescriptions with another patient’s. Rightfully, he and his family were angry. After he was feeling better, I encouraged them to write a letter to the health system’s CEO detailing their experience—CEOs read patient letters and they make an impact. Their response: “Maybe, but it’s ok now. And the surgeon said he was sorry the next time we saw him.”
Just last week, my 96-year-old grandmother was admitted to a community hospital for her second heart failure exacerbation in three months. She became confused, and despite having a sitter she fell when getting out of bed, and broke her shoulder. This injury could lead to significant lifestyle and financial consequences for my family. If she can’t manage her personal care, “Granny” may have to leave her assisted-living apartment and move in with family, or into a nursing home. I was upset, but my mother, her primary caregiver, noted how quickly the hospital team responded—and how many people kept apologizing. “They’re doing their best,” she said.
As a physician, I know both situations were not healthcare’s “best”. But they illustrate how well the cornerstone of risk management works: angry patients who experience real lapses in care are often satisfied by being told “We’re sorry, and will work to ensure it doesn’t happen again.” We get asked regularly by doctors about the impact of “defensive medicine” on healthcare costs. My family’s recent experiences illustrate that the best defense against malpractice claims is not ordering marginal tests to cover all possibilities, but taking a few extra minutes to develop a relationship with a patient. And should something unexpected happen, being quick to acknowledge it and say, “I’m sorry”.
Questioning the value of physician employment
This week was a busy one for me. I spent time with a range of different groups, including the board meeting of a West Coast independent practice association (IPA), a market-wide physician retreat hosted by a large, for-profit health system, and the executive team meeting of a management services organization (MSO) that enables physician practices to implement population health management strategies. Common across all three organizations was a shared point of view about how the healthcare delivery system ought to be structured, centered around maintaining the independence of physician practices. Although each of the markets I visited was in a different place in terms of provider consolidation, transition to risk, and adoption of care management models, the perspective of the majority of physicians I met with was that the downsides of employed practice, whether becoming part of health systems, health plans, or even the new breed of private equity-backed aggregators, outweigh the benefits. The physicians I spoke with largely agreed that the loss of decision-making authority, the risk of a “civil service” mentality, and the bureaucratic burden of entering employed practice were enough to keep them striving for ways to remain independent, despite rising practice costs and an increasingly difficult market environment. Surprisingly, this was true even among the younger, millennial doctors I talked to, despite the conventional wisdom that what newer doctors really want is a job, not an entrepreneurial challenge.
Of course, there was some selection bias at work here: you’d expect the groups I was with to take a dim view of physician employment. But what I heard was consistent with the gestalt I’ve started to sense more broadly. Anecdotally, it seems to me there’s a growing backlash against the employment trend of the past few years, particularly among primary care doctors. I’m picking up on increasing skepticism among doctors that employment can provide the answer to some of their more pressing concerns—practice sustainability, succession planning, investment in new staff and technology. While some practices have benefited from being part of a larger system, the frustration of being a “cog in the wheel”, and just another “mouth to feed” for health system medical groups is palpable. At the same time, I’m hearing growing interest in alternative paths to maintaining independence: shifting to a concierge model, building a direct primary care practice, or looking to new “enablers” (like the MSO I was with this week) to provide infrastructure that allows doctors to preserve independent practice. Meanwhile, I’ve begun to hear health system execs complain that employing doctors hasn’t yielded the benefits they’d hoped for, given how expensive it can be. It’ll be worth watching whether these early rumblings portend a broader shift in the market over the next couple of years.