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Monday, September 15, 2014

IT frustration and criticism are by no means unique to healthcare

Read an awesome book last week:

I've been reading a lot of books and other stuff online lately, anything pertaining to "education," "training," and "learning," e.g., see my Sept. 2nd post.

Excerpt from Getting Schooled:
At some point before the first passing bell I will need to turn on my laptop and log onto PowerSchool in order to take attendance as quickly as possible. The process is always slower than I hope. My habit in past years was to take a few minutes at the start of each period to set a positive tone, tell a joke, praise a student’s achievements in another school activity, recount a current event, or read a passage I’d come across that seemed worth reading aloud, all the while taking attendance out of the corner of my eye and noting it in my grade book. The present system is more jealous of my attention. Often my first words to the class are related to the minutiae of the record keeping. We are expected, for example, to record missing homework, so that teachers in subsequent study halls can follow up and see that it gets done. To start a class by asking for a show of hands from those who haven’t done their homework (something I’ve always preferred to do confidentially and at least a few minutes into the period by walking discreetly among the students) is hardly the best way to set a positive tone. If I hit the wrong key, I need to cancel out my notations and do all of them again. If a tardy student walks into the room a minute after I’ve hit “submit,” then I need to call up the screen and do the entire roster over. As noted by the outside consultants who manage the system, it “currently lacks the capability” of maintaining a daily record of absences beyond “total to date”— a must for any teacher who hopes to keep track of when a student was and wasn’t in class and therefore was or wasn’t responsible for a missing assignment or on hand for an essential presentation of material. This means I must take attendance twice, once on the computer and once in a notebook I consult whenever I wish to know for sure what a student may have missed on a given day. The bottom line here— and I use the phrase with an eye to the mind-set that promotes these “systems”— is that I am increasingly devoting more time to the generation and recording of data and less time to the educational substance of what the data is supposed to measure. Think of it as a man who develops ever more elaborate schemes for counting his money, even as he forfeits more and more of his time for earning the money he counts.
Keizer, Garret (2014-08-05). Getting Schooled: The Reeducation of an American Teacher (pp. 51-52). Henry Holt and Co.. Kindle Edition.

My notes home become a moot point after a while because my Friday afternoons— chosen for my latest stays because of the hour and a half it takes my wife to get home from her Friday job at Dartmouth— are soon taken up with other tasks, many of them occasioned by the modern school’s almost insatiable thirst for “data” and the timely (i.e., as close to instantaneous as possible) recording of the same. In addition to grades and homework assignments, we are required to do a “productivity rubric,” which must be tallied for each student for each marking period and for the “progress report” periods in between; in other words, eight times a year. The productivity rubric is a feature of the PowerSchool grading system that allows teachers to assign numbers of 1 to 4, with 4 being the highest, to criteria presumably not subsumed by academic grades, such as “initiative,” “cooperation,” “attendance,” “behavior,” and “responsibility.” A faculty committee has designed a two-page spreadsheet that defines the meaning for each criterion of “productivity”— what distinguishes a 3 for behavior from a 2, for instance— and also attempts to reduce the vexing overlap between categories like “initiative” and “responsibility.” It goes without saying that the guide creates as many questions as it answers. What score should I give to a student who is missing far too many days of school but who does a better job of meeting her deadlines than a number of students with close to perfect attendance? Do I give her a number that amounts to a wink at truancy or a number that turns a blind eye to the efforts of a kid who’s anything but a deadbeat? What conclusions will she, or her parents, draw from the word unsatisfactory or the word acceptable? I can only give a number that designates a word; I cannot put the word into a sentence.

Though I approach the process with as much care and diligence as I can, vowing to myself that I will never allow skepticism to be a cover for shoddiness, I resent the chore deeply. I see it as part and parcel of the way in which “the school of the twenty-first century” is continually trying to mask the ambiguities of evaluating student performance by a pretense of rigorous objectivity. In English classes, for example, we avoid assigning an “arbitrary” grade for a piece of writing by constructing a “scoring rubric” of roughly ten criteria and assigning ten no less arbitrary scores to each, adding them up to achieve a grand total of subjectivity that is undoubtedly as solid as a Freddie Mac mortgage or a Miss America scoring card.

Even more I resent the way in which our jobs are increasingly dictated by the tools we employ. Form doesn’t follow function; form dictates function. I don’t want to sound dogmatic or, worse, ungrateful. Without a doubt, the PowerSchool program, once mastered, offers a more efficient way of recording grades than I’ve ever encountered. Every time you add a grade to the roster, the student’s average for the marking period is automatically computed and displayed. The end-of-marking-period all-nighter with a roped-in spouse doing backup duty on a calculator has mercifully gone the way of the mimeograph blues. But digital technology abhors a vacuum even more than nature does; it insists on reinvesting whatever time it saves, and it insists on doing so according to its own agenda. The purchaser’s need to justify the cost of the technology also plays a part. If a school system invests money in a sophisticated computer program that includes a feature for calculating the daily growth rate of a user’s moustache, then don’t we owe it to the taxpayers to see that every man, woman, and child capable of growing a moustache begins doing so at once?

The first time I try to do my productivity rubric it takes me several hours. I have roughly eighty students and five criteria, which means four hundred separate considerations and data entries. Times eight, that comes to thirty-two hundred by the close of the year; I try not to think too much about that. There are few people still left at school on a Friday afternoon, but I have received a good tutorial in advance. I should note that I never find myself floundering with a computer task because someone has handed it off with an attitude of sink or swim. But somewhere in the inner sanctums of the school’s IT system, or in the empyrean of cloud computing, or perhaps in the domain of PowerSchool itself, there resides a spore of latent indignation. Suddenly my screen is taken over by red headlines accusing me of things I’m not sure I even understand. The launching of a North Korean nuclear warhead could hardly produce a more alarmist screen. I’m unable to give a precise account of the wording because my screen goes black before I can read it a second time. Fearing that one inadvertent keystroke may have caused a digital meltdown, I run for the English teacher in the room next door, who is also working late, and ask for her help. She is a compassionate, careful woman who teaches both Advanced Placement and remedial-level English with the gentle hand that each requires, and I can tell that my stress is causing stress for her. I can also tell that she is doing her best to avoid any insinuation of stupidity on my part when she asks, “As you were going along, did you happen to hit save?”

Not once. I feared that saving before I could double-check my entries would lock in mistakes that I might not be able to change, a foolish notion perhaps, though not inconsistent with what I’ve seen so far of the system’s potential for capricious finality. As for the Armageddon screen display, it strikes my colleague as nothing more than what these machines will sometimes do. Every so often a gargantuan gorilla will seize a woman in his paw and climb to the top of the Empire State Building— just the nature of the beast, I guess, no different from the way that an exhausted human being overcome by a sense of futility will sometimes break down and sob. I will do that only once in the entire school year, and I keep myself under control until my colleague leaves the room. Anyone who stops in thereafter might wonder which member of my family has died. But there are no casualties to speak of beyond the loss of an hour or two with my wife and the jettisoning of a few quaint intentions. I entered the scores first in my paper grade book, so it seems I’ve “saved” them after all. I’ll find some other use for the fancy note cards.
[ibid, pp. 87-89]
Health IT grousing certainly has its counterparts in other domains. Easy to forget that.

This (below) is also worth noting. In the wake of his being out sick for an extended period of serious illness (PNU), Garret is given a teacher's aide to help him work his way back up to speed:
It’s remarkable how much smoother things go with a competent assistant. Some teachers have the benefit of an aide, though strictly speaking the aide is often not the teacher’s but a particular kid’s. Which is to say that the need for an aide is usually predicated on a handicapping condition in a student, not by the limits of what one human being with two hands and two feet can accomplish in a room full of twenty to thirty kids. It might surprise you, though it shouldn’t, that teachers are among the few professionals with no assistants. Think of a doctor without a nurse or a receptionist, a lawyer without a law clerk, a chef without a prep cook, even a clergyperson without an acolyte or deacon. Plumbers and electricians routinely have helpers. Rock musicians have guitar techs. Golfers have caddies. So much for the important professions. A teacher in charge of the educational development of fifty to a hundred diverse and needy human beings is routinely on his or her own. [ibid, pp. 226-227]
I could not recommend this book more highly. I posted more excerpts on one of my other blogs.

So, I seem to have sort of a study group core connect-the-dots "seminar curriculum" accruing:

By no means exhaustive. But, IMHO, useful for probing and synergizing the salient elements of effective education for a "Just Culture/Talking Stick" healthcare workforce.

I've not given any prior play to Daniel Pink's book "Drive," so I will cite from the Recap Summary:
Drive: The Recap 
This book has covered a lot of ground— and you might not be able to instantly recall everything in it. So here you’ll find three different summaries of Drive. Think of it as your talking points, refresher course, or memory jogger. 

Carrots & sticks are so last century. Drive says for 21st century work, we need to upgrade to autonomy, mastery & purpose. 

When it comes to motivation, there’s a gap between what science knows and what business does. Our current business operating system— which is built around external, carrot-and-stick motivators— doesn’t work and often does harm. We need an upgrade. And the science shows the way. This new approach has three essential elements: (1) Autonomy— the desire to direct our own lives; (2) Mastery— the urge to make progress and get better at something that matters; and (3) Purpose— the yearning to do what we do in the service of something larger than ourselves...
Chapter 4. Autonomy
Our “default setting” is to be autonomous and self-directed. Unfortunately, circumstances— including outdated notions of “management”— often conspire to change that default setting and turn us from Type I to Type X. To encourage Type I behavior, and the high performance it enables, the first requirement is autonomy. People need autonomy over task (what they do), time (when they do it), team (who they do it with), and technique (how they do it). Organizations that have found inventive, sometimes radical, ways to boost autonomy are outperforming their competitors.

Chapter 5. Mastery
While Motivation 2.0 required compliance, Motivation 3.0 demands engagement. Only engagement can produce mastery— becoming better at something that matters. And the pursuit of mastery, an important but often dormant part of our third drive, has become essential to making one’s way in the economy. Indeed, making progress in one’s work turns out to be the single most motivating aspect of many jobs. Mastery begins with “flow”— optimal experiences when the challenges we face are exquisitely matched to our abilities. Smart workplaces therefore supplement day-to-day activities with “Goldilocks tasks”— not too hard and not too easy. But mastery also abides by three peculiar rules. Mastery is a mindset: It requires the capacity to see your abilities not as finite, but as infinitely improvable. Mastery is a pain: It demands effort, grit, and deliberate practice. And mastery is an asymptote: It’s impossible to fully realize, which makes it simultaneously frustrating and alluring.
Chapter 6. Purpose
Humans, by their nature, seek purpose— to make a contribution and to be part of a cause greater and more enduring than themselves. But traditional businesses have long considered purpose ornamental— a perfectly nice accessory, so long as it didn’t get in the way of the important things. But that’s changing— thanks in part to the rising tide of aging baby boomers reckoning with their own mortality. In Motivation 3.0, purpose maximization is taking its place alongside profit maximization as an aspiration and a guiding principle. Within organizations, this new “purpose motive” is expressing itself in three ways: in goals that use profit to reach purpose; in words that emphasize more than self-interest; and in policies that allow people to pursue purpose on their own terms. This move to accompany profit maximization with purpose maximization has the potential to rejuvenate our businesses and remake our world.

Pink, Daniel H. (2011-04-05). Drive: The Surprising Truth About What Motivates Us (Kindle Locations 2737-2798). Penguin Group US. Kindle Edition.

Much of alternative medicine originated with a “lone genius” who had an epiphany, thought he had discovered something no one had ever noticed before, extrapolated from a single observation to construct an elaborate theory that promised to explain all or most human ills, and began treating patients without any attempt to test his hypotheses using the scientific method. Some of them were uneducated laymen, others were scientifically trained medical doctors who should have known better.
From my requisite daily priority blog surfing stops. Good stuff also here at one of my other destinations, The Neurologica Blog:
INTEROPERABILITY SHOULD HAVE COME FIRST: A leading health policy voice in Congress said this Monday that the nation may have put the cart before the horse when it comes to the exchange of electronic health information. Rep. Mike Burgess, a physician, noted that federal health laws and regulations placed an emphasis on providers adopting EHRs, while putting off until later the EHR systems’ exchange of patient information. “I don’t know if the focus being on meaningful use originally, maybe that focus should have been on interoperability, and the meaningful use stuff come later,” Burgess said at ONC’s Consumer Health IT Summit. He reiterated calls for wiser use of meaningful use dollars — almost $25 billion have been spent to date. Burgess said after his 10-minute talk that the House Energy and Commerce Committee, on which he is vice chair of the health subcommittee, is looking at changes to the meaningful use program as part of its 21st Century Cures work. “What that would look like is still under discussion,” he said.
From Healthcare Dive:
Part of what sucks the value out of EMRs is the reality that providers can't share data with one another. Free, compatible data flow from doctors to hospitals to other health facilities is still at a primitive stage. That's the case despite demands from policymakers that EMRs become "interoperable," a nice way of asking that vendors drop the walls forcing providers to use their product and their product only.
Yeah, but it continues to be the prevailing business case that "Opacity (+barriers to entry) = Margin." Efficient Markets Hypothesis 101.

More to come...

Friday, September 12, 2014

"The Fallacy of Value-Based Health Care" - Margalit Gur-Arie

Margalit Gur-Arie writes the ever-astute ON HEALTH CARE TECHNOLOGY blog. You would do well to bookmark it. Cross-posted with permission.

Value-based health care is antithetic to patient-centered care. Value-based health care is also diametrically opposed to excellence, transparency and competitive markets. And value-based health care is a shrewdly selected and disingenuously applied misnomer. Value-based pricing is not a health-care innovation. Value-based pricing is why a plastic cup filled with tepid beer costs $8 at the ballpark, why a pack of gum costs $2.50 at the airport and why an Under Armour pair of socks costs $15. Value-based pricing is based on manipulating customer perceptions and emotions, lack of sophistication, imposed shortages and limitations. Finally, value-based prices are always higher than the alternative cost-based prices, and profitability can be improved in spite of lower sales volumes.

Health care pricing is currently a smoldering mixture of ill-conceived cost-based pricing with twisted value-based pricing components. For simplicity purposes, let’s examine the pricing of physician services. As for all health care, the pricing of physician services is driven by Medicare. The methodology is neither cost-based nor value-based and simultaneously it is both. How so? Medicare fees are based on relative value units, which are basically coefficients for calculating the cost of providing various services in various practices, of various types and specialties. The price, which is also the cost since it includes physician take home compensation, is calculated by plugging in a dollar value, called conversion factor. The conversion factor, which is supposed to represent costs, is not in any way related to actual production costs, but instead it is calculated so the total cost of physician services will not exceed the Medicare budget for these services. Buried in this complex pricing exercise is a value-based component. A committee of physicians gets to decide the requisite amount of physician effort, skills and education, for each service. Whereas in other markets the value decision hinges on buyer perceptions, in health care it is masquerading as cost.

The commercial insurance market adds a more familiar layer of complexity to the already convoluted Medicare fee schedule baseline. Unlike Medicare fees, which are nonnegotiable, private payers will engage in value-based negotiations with larger physician groups and health systems that employ them. Monopolistic health systems in a given geographical area can pretty much charge whatever the market can bear, just like the beer vendor at your favorite ballpark does, and brand name institutions get to flex their medical market muscles no differently than Under Armour does for socks. This is value-based pricing at its best. Small practices have of course no negotiation power in the insurer market, but as shortages of physician time and availability begin to emerge, a direct to consumer concierge market is being created, providing a new venue for independent physicians, primary care in particular, to move to a more profitable value-based pricing model.

Unsurprisingly this entire scheme is not working very well for any of the parties involved, except private insurers who thrive on complexity and the associated waste of resources. Upon what must have been a very careful examination of the payment system, Medicare concluded that it does not wish to pay physicians for services that fail to lower Medicare expenditures, and Medicare named this new payment strategy value-based health care, not because it has anything in common with value-based pricing, but because it sounds good. Another frequently used term in health care is value-based purchasing, which is attempting to inject the notion of quality as the limiting factor for cost containment. However, since Medicare is de facto setting the prices for its purchases, there is really no material difference between these two terms.

We need to be very clear here that value-based health care is not the same as quality-based health care. The latter means that physicians provide the best care they know how for their patients, while the former means that physicians provide good health care for the buck. To illustrate this innovative way of thinking, let’s look at the newest carrots and sticks initiative, scheduled to take effect for very large medical groups (over 100 physicians) in 2015. Below is a table that summarizes the incentives and penalties that will be applied through the new Medicare Value-based Payment Modifier (pdf).

There are several things to note here. First, if your patients receive excellent care and have excellent outcomes, you will receive no perks if that excellence involves expensive specialty and inpatient services, whether those are the accepted standard of care or not. You would actually be better off financially if you took it down a notch and provided mediocre care on the cheap. The second thing to notice is that you will not get penalized for providing horrendously subpar care, if you do that without wasting Medicare’s money.

Another intriguing aspect of this new program is that you have no idea how big the incentives, if any, are going to be. The upside numbers in the table are not percentages. They are multipliers for the x factor. The x factor is calculated by first figuring out the total amount of penalties, and that amount is then divided among those who are due incentives. If there are few penalties, there will be meager incentives. Lastly, those asterisks next to the upside numbers, indicate that additional incentives (one more x factor) are available to those who care for Medicare patients with a risk score in the top 25 percent of all risk scores.

As with everything Medicare does, this too is a zero sum game. For there to be winners, there must be losers. One is compelled to wonder how pitting physician groups against one another advances collaboration, dissemination of best practices, or sharing of information, and how it benefits patients. Leaving philosophical questions aside, the optimal strategy for obtaining incentives seems to be transition to a Medicare Advantage type of thinking: get and keep the healthiest possible patients, and make sure you regularly code every remotely plausible disease in their chart. Stay away from those dually eligible for Medicare and Medicaid, the very frail, the lonely, the infirm, or the very old, and don’t be tempted to see a random person who is in a pinch, because there is always the chance that he or she will be attributed to your panel following some hospitalization or other misfortune.

The Value-based Payment Modifier is for beginners. It is just the training wheels for the full-fledged risk assumption that Medicare is seeking from physicians and health care delivery systems in general. The grand idea is not much different than providing an aggregated and risk adjusted defined contribution for a group of assigned members, and having the health care delivery system absorb budget overruns, or keep the change if they come in under budget. There is great value in such a system for Medicare and commercial payers certain to follow in its footsteps, and perhaps this is why they decided to call it value-based. Ironically, the equally savvy health care systems are fighting back precisely by building the capacity to create a true value-based pricing model for their services through consolidation, monopolies, corralled customers, artificial shortages, confusing marketing, and diminished physicians.

It is difficult to lay blame at the feet of health systems for these seemingly predatory practices, because transition to a perpetual volume-reducing health care system is by definition unsustainable. The infrastructure and resources needed to satisfy all the strategizing, optimizing, counting and measuring activities required for value-based health care, whether the modest payment modifier or the grown up accountable care organization (ACO), are fixed costs added to health system expenses year after year. However, the incentives or shared-savings are temporary at best, because at some point volumes cannot be reduced further without actually killing people. Either way, in the near future, and for already frugal systems, in the present, all incentives will dry up leaving only massive outlays for avoiding penalties coupled with increased risk for malpractice suits.

And as these titans are clashing high above our little heads, two outcomes are certain: individual physicians will be paid less and individual patients will be paying more for fewer services. This is how we move from volume to value. Less volume for us, more value for them.

Below, apropos?

BREAKING: Merger creates largest nonprofit system in Illinois
By Katie Bo Williams | September 12, 2014

...This merger is a big deal, according to Jordan Shields, vice president at Juniper Advisory, which provides hospital M&A services. The deal "is going to shake people," Shields said. "What this does is change the gravity in the metropolitan area."

Still, despite the scale of the merger, the combined system will still control only 25% of the local market, which the Chicago Tribune calls "fragmented" compared to other metropolitan areas. Perhaps its biggest influence on the Illinois healthcare market will be a fresh spate of mergers in the area. Michael Sachs, chairman Skokie-based healthcare consulting firm Sg2, expects a rise in M&A activity following the deal:

"This will probably trigger another set of consolidations; it's bound to occur," said Sachs.

The big win for Advocate here—beyond the normal benefits of merging, like reducing costs through coordinated care and boosting buying power with suppliers—is the incorporation of NorthShore's patient base into its business model. The North Shore suburbs are a wealthy area and as such, have a lot of patients with commercial insurance, as opposed to less-lucrative Medicare or Medicaid coverage. Moreover, the four-hospital system has a reputation as an efficiently-run operation with a strong balance sheet.

There will likely be layoffs as the system reduces redundancies.
"Nonprofit." Right.

Thursday, September 11, 2014

Sad anniversary

Thirteen years later, the barbarity continues unabated around the planet. We are one crazed species, too "clever" by half for our own sustained survival.

Tuesday, September 9, 2014

The late Joan Rivers, and some troubling health care system questions

Joan Rivers died while I was back in NJ attending my high school 50th reunion. Very sad. From THCB:
What Killed Joan Rivers? Piecing Together a Medical Mystery

There are minor operations and procedures, but there are no minor anesthetics.  This could turn out to be the one lesson learned from the ongoing investigation into the death of comedian Joan Rivers....
There is no way to know, without further information, whether the root cause was trouble with her heart, her breathing, a sudden stroke, or another type of catastrophic event. There is no way to know if problems were due to sedative drugs she might have received.
There is no way to know, without further information, if the extra equipment and personnel available in a full-service hospital as opposed to an outpatient clinic would have made any difference in Ms. Rivers’ resuscitation and outcome.

But this much is clear:  there is pressure today from the government and insurers for physicians to perform complex procedures even on high-risk patients in free-standing ambulatory centers. Why? To save money. The extra equipment and staff in full-service hospitals are expensive...
Read the entire post. How many non-celebrity octagenarians routinely expire in the wake of surgical anesthesia? Will the rate worsen as we push more patients to ASCs?

Hospital business model threatened, but retail outlook bright
High deductible insurance plans are causing some headaches for healthcare providers — keeping utilization depressed

The currents of health reform and consumerization are getting more treacherous for incumbent hospital businesses, according to a new report by Standard and Poor’s Rating Services.

With an influx of newly-insured populations and the growth of Medicare’s baby boomers, American healthcare continues to be a massive market for goods and services. The landscape, however, is shifting for better and worse, depending on the market segment.

The new norm of high deductible plans is “causing some headaches for healthcare providers — keeping utilization depressed,” write S&P analyst Mariola Borysiak and colleagues. Retail companies, meanwhile, “are realizing quickly that this consumerization trend is an opportunity, even beyond their existing pharmacy businesses.”

Traversing this new landscape with a dependence on traditional fee-for-service business models, hospitals largely face a negative credit outlook in S&P’s view: “top line revenue constraints,” “soft demand, in part because of high deductible plans,” and the transition to value-based payments from fee-for-service...

THCB has a bunch of great posts today. to wit:
Is Healthcare a Business?
Edmund Billings, MD

In the United States, the question has been asked time and again but never satisfactorily answered. By virtue of publically financed healthcare systems, the rest of the developed world has decided, to a greater or lesser extent, that medicine and healthcare are not pure businesses—that citizens have a right to care, even when they can’t pay all associated costs.

It’s starting to look like Americans won’t be able to duck the question for much longer.

In the last year, the profitability of U.S. hospitals eroded for the first time since the Great Recession, pushing some closer to and others over the solvency precipice. Revenues are down and costs are up.  And these issues appear systemic and entrenched, giving rise to a series of important and relevant questions: How can hospitals adapt?  If they do, will they still survive? And, do we as a nation think it’s important to make hospitals accessible, even if they lose money?...
Yeah. From an email correspondence I had a while back with my friend Joe Flower:
Another question not asked enough: How much should it rightfully cost to have that trauma-equipped hospital with its ER down the street (or the fire department station, etc)? We all talk about “staying out of the ER and the hospital,” but when YOU really need it, you want it to be there. Having that kind of standing capacity, effectively equipped and staffed, is gonna COST, period... 
Gladwell makes note of the distinction between “actuarial” and “social” insurance. We don’t see enough emphasis in public discussion. Moreover, an irony I always talk about is that health “insurance” on the actuarial/risk indemnity side is a ~60 year proposition (speaking just of adults here), yet we continue to sell it in one-year chunks, wasting a lot of resources in the process. PPACA does nothing to abate that...
See my May 2009 post "The U.S. health care policy morass" from back when I first started writing about these issues.


The scary Apple Watch future
You think your smartphone is a privacy-destroying tracking device? You ain't seen nothing yet

Andrew Leonard,

Watching the livestream of Apple’s iPhone and Apple Watch event Tuesday morning was an intriguing exercise in cognitive dissonance. On the one hand, the fanboy adulation that swamped Cupertino seems almost unseemly in its jubilation. When CEO Tim Cook uttered the legendary “One More Thing” mantra for the first time since the death of Steve Jobs, a good third of the assembled audience appeared ready for instant Rapturing. Yet at the same time, on Twitter, an endless parade of snark and carping threatened to overwhelm any attempt at actual analysis.

And that was too bad, because the company’s rhetoric about its new products exposed a fascinating contradiction at the heart of Apple’s evolution. Apple simultaneously made an explicit commitment to keep our personal information private, while at the same time demo-ing a device designed to capture an unprecedented degree of our most personal, intimate details...

But wait, not five minutes after stressing the importance of keeping information private, Apple introduced the Apple Watch, a device that connects directly to your skin and comes with multiple sensors that will be able to monitor a wide range of biometric data. During the Apple Watch rollout, I lost count of the number of times I saw critics complain that “millennials don’t wear watches” or “I don’t need a $349 device to tell me what time it is” or “why do I want to duplicate all the functionality of my phone on a smaller device while still having to carry my phone with me?” All these observations are true enough (though I’ll bet that somewhere down the line, the Apple Watch will be able to stand alone without an iPhone). But they miss completely the positive case for why people might seek out such a device. The fact that the Apple Watch tells the time is the least interesting thing about it. If you’re the kind of person who likes to keep track of your exercise metrics, the Apple Watch is an instantly seductive fitness tracker. As a cyclist with a bike computer that’s beginning to show its age, I can easily see replacing it with an Apple Watch. I know scores of people who track their steps every day with pedometers, who might enjoy a device that can also give them turn-by-turn directions while they walk. And I know diabetics who are desperate for simple user-friendly devices that can be used to track their blood glucose levels.

We’ll find out sometime in 2015 if the use-cases for the Apple Watch are compelling enough to make the product a success. But for now, the intriguing point is that the Apple Watch is well positioned to act as a device that continually monitors our physical and biological state — and it just doesn’t get any more personal than that.

So yeah, here’s hoping that Apple means it when it boasts about not being in the business of collecting our information.
Particularly if you're a celebrity taking nude "selfie" photos, 'eh? Dunno. I wear a Fitbit now. Pretty crude device, actually. I'd like to be able to continuously monitor more parameters.

Below, more from THCB.
Should Wearables Data Live In Your Electronic Medical Record?

The great promise of wearables for medicine includes the opportunity for health measurement to participate more naturally in the flow of our lives, and provide a richer and more nuanced assessment of phenotype than that offered by the traditional labs and blood pressure assessments now found in our medical record.  Health, as we appreciate, exists outside the four walls of a clinical or hospital, and wearables (as now championed by Apple, Google, and others) would seem to offer an obvious vehicle to mediate our increasingly expansive perspective.

The big data vision here, of course, would be to develop an integrated database that includes genomic data, traditional EMR/clinical data, and wearable data, with the idea that these should provide the basis for more precise understanding of patients and disease, and provide more granular insight into effective interventions.  This has been one of the ambitions of the MIT/MGH CATCH program, among others (disclosure: I’m a co-founder).

One of the challenges, however, is trying to understand the quality and value of the wearable data now captured...
Good post. And a great following comment:
Does wearable data belong in an EHR? Yes, eventually. Medicine is undergoing a major shift because of information technology. And by information technology, I am not referring to just EHR systems, but everything that enables the collection, searching, and analysis of data. Clinical care has always been an information intensive field, but for most of its modern history paper and brains have been the only to information management tools available.
Fast processors, sophisticated databases, high-capacity storage, and fast networks are relatively recent occurrences in the history of health care. We are still ironing out information and data exchange standards. Information technology has advanced faster than our ability to incorporate its capabilities into routine care. 

Dumping data from wearable devices onto already stressed providers is a bad idea because current EHR systems are not ready to manage what they would receive. Clinical decision support is still primitive. Data analytics is more often said than done.

Fortunately, there is a general acceptance that information technology is a part of clinical practice. With this acceptance, we can now turn our attention to making software that better supports clinical care. And by better I do not mean adding a few new features to systems designed to be patient data repositories (EHR systems) and declaring them to be the solution, but rather designing systems from the ground-up to intimately support clinical work (clinical care systems).
And, an equally fine, cautionary response:
William Hersh, MD says:
The answer to this question depends in part on, Whose EHR? Although there probably should be, there is not yet a single EHR for each person. When there is, we could possibly discuss where personal information like this might reside, how it might be summarized for quick overview viewing by clinicians, and so forth.

But in our current state of numerous EHRs, belonging to each and every clinician, hospital, etc., this question is too vague. Should personal fitness data go into the primary care EHR? Since that may be a physician with limited resources, should we expect his or her system to be able to accommodate such data? In our still predominantly sickness-based health care system, how much time and effort should we expect that physician to devote to it?

This is a complex question whose answer depends on the underlying context.
Transform: Health and technology need to bridge economic gaps
September 9, 2014 12:49 pm by Dan Verel

The intersections of health, culture, socioeconomic status and emerging technologies must be weaved together more seamlessly in order for the healthcare delivery system to truly improve health outcomes for those most in need. Meanwhile, consumer-focused care and the application of new data and analytics by payers and providers will only accelerate in the coming years.

With respect to so-called big data, even the most advanced provider organizations are struggling to cope with an onslaught of new information, and it can be overwhelming.

“We’re in the middle of an exponential data explosion like we’ve never seen before, and it’s getting faster and faster,” said Mike Rhodin, senior vice president of IBM Watson. “All of that information is starting to swell up.” Information is being culled from already-published data in medical journals and from drug clinical trials, to name just a few sources. On top of that, new information from EHRs and claims data is being added to the mix.

“All that information is creating an environment where we need new tools that can work with us, not in place of us,” Rhodin said, adding that it won’t slow down anytime soon.

“Information and IT is going to start being as important to medicine as the discovering of drugs to diseases and surgical practices,” he said.

But while technology and health IT will play a key role, significant barriers to health persist, including economic conditions that often portend poor health outcomes in both urban and rural environments.

“Economic parity would go a long way in overcoming health outcome gaps..."
"Upstream factors?" Recall also from my August 13th post?

Larry Keeley, of Doblin Innovation Consultants, said innovation has to take into account both technology and public health, and that disruption should be focused on social issues, not simply one industry or one company.

“What if community health is more about economic health and status and only a little about medicine?” he posited...
It is, in fact.


Just kidding, of course. The above is from Science Based Medicine's post "Autism Prevalence Unchanged in 20 Years."

Tuesday, September 2, 2014

The healthcare workforce today. Where do we stand, and what should we do to expand and improve it?

Well, I'd planned to write about this topic yesterday, apropos of Labor Day. But, I got asked to read and review a new book on Amazon. So I did. See The Rise and Fall of Homo Economicus: The Myth of the Rational Human and the Chaotic Reality, my review.

Good book. Worth your time. He's right.
The rise of poverty and the great widening of inequalities observed in many economically advanced countries generate risks and may possibly lead to political outcomes that will not be to anyone’s benefit. In other words, we could have a regression to extremes through the ascendancy of populism, nationalism, xenophobia, and protectionism. This must not happen. We cannot avoid mistakes, but we can avoid repeating the same mistakes. Or, even better, as a famous psychologist said, to replace our mistakes with other, smaller ones.
Another one (below), central to the theme of this post.

I reviewed it as well. Excerpt:
I liked this book from the start. Initially I thought "looks like four stars for sure." I just finished it. A definite 5 Stars. Smartly written, solidly argued, drawing from a substantive breadth of credible citation sources, many of whom I was aware of, some delightfully new to me. What is particularly refreshing is the author's smooth connecting of the myriad dots. His firm grasp of a cogent argument becomes more and more obvious with each passing page.

Had I Bill Gates' money, I'd buy a copy for every teacher in the U.S. and require that each read it -- and be tested on it as a component of certification. The topic is extremely important. We risk permitting a vast expansion of a chronic (and increasingly restive) "cognitive underclass" who will be unable to compete and contribute to modern society...

...[O]ne needs to genuinely CARE about helping people learn effectively (the principal thesis in this book) -- both children and adult learners. Ian Leslie points out just how important (and how difficult) that is. Distance "Learning," MOOCs, and University of Google are not going to be our salvation. They are good ancillary tools for the "Cognitive Haves," but they will also tend to widen the educational divide, which in turn cannot but exacerbate the socioeconomic divide.

I'd implore everyone to buy it, study it closely, and pay it forward to any teachers you know. (BTW, add to the contextual reading list Schein's "Humble Inquiry."

Sorry. Couldn't resist.

OK, recall from my last post?

Where will we find sufficiently educated, trained, experienced, and competent healthcare staff, from physicians on "down"? What will it cost, and, more importantly, what about the "pedagogy"? e.g., From my Atlantic subcription.

The paradox of undergraduate education in the United States is that it is the envy of the world, but also tremendously beleaguered. In that way it resembles the U.S. health-care sector. Both carry price tags that shock the conscience of citizens of other developed countries. They’re both tied up inextricably with government, through student loans and federal research funding or through Medicare. But if you can afford the Mayo Clinic, the United States is the best place in the world to get sick. And if you get a scholarship to Stanford, you should take it, and turn down offers from even the best universities in Europe, Australia, or Japan. (Most likely, though, you won’t get that scholarship. The average U.S. college graduate in 2014 carried $33,000 of debt.)

Financial dysfunction is only the most obvious way in which higher education is troubled. In the past half millennium, the technology of learning has hardly budged. The easiest way to picture what a university looked like 500 years ago is to go to any large university today, walk into a lecture hall, and imagine the professor speaking Latin and wearing a monk’s cowl. The most common class format is still a professor standing in front of a group of students and talking. And even though we’ve subjected students to lectures for hundreds of years, we have no evidence that they are a good way to teach...
Interesting model, the Minerva thing. Methodologically very similar to my own grad school experience (with way better technology). My UNLV "Ethics and Policy Studies" Master's curriculum:
1. Argument Analysis: Reasoning and Judgment
2. History of Ethics
3. History and Theories of Jurisprudence
4. Seminar in U.S. Constitutional Law
5. Advanced Statistics for the Health Sciences
6. Aristotle's Nicomachean Ethics
7. Seminar in Corporate and Public Morality
8. Seminar in Policy Analysis
9. Environmental Policy and Scientific Objectivity
10. Integrating Reason, Ethics, and Policy
11. Thesis
36 semester hours (6 hours of Thesis). All except #5 taught in conference room small group seminar format, led/facilitated by PhD faculty. "History of Ethics" (#2), for example, had 11 required texts spanning the ancient Greeks through modern day moral philosophers. Each of us had to lead analytical discussion of a chapter or so of each book every week. Similar parsing attended each of the other courses. It was a deep, probing, bracing experience. To the extent that the Minerva pedagogy mirrors this approach, it should be a fine, effective experience for their students. This is truly "education" ("e-ducere" -- drawing out from within the student), rather than mere "instruction" -- the didactic "pouring in" of factual "structure," or its more rote and regimented cousin, "training."

We shall see.

With respect to healthcare, I have concerns about the proliferation of this kind of stuff (below).

My email inbox overflows with these kinds of pricey pitches every day. Beyond the commercial diploma mills like University of Phoenix and all manner of strip mall "colleges," a lot of mainstream universities and colleges seem to see these as profit centers. Exorbitant "Executive MBA" programs catering principally to the well-heeled have long been around, and we're increasingly seeing the concept bleed over into other domains such as healthcare. "School of Professional Studies" is always a yellow flag for me.

Worth it?

Tangentially, also in that issue of The Atlantic, see
The Law-School Scam
For-profit law schools are a capitalist dream of privatized profits and socialized losses. But for their debt-saddled, no-job-prospect graduates, they can be a nightmare.
So, cost (and brazen fraud) aside, what of "pedagogy"? From another of my recent reads:

I had spent several months at Columbia during my final year of fellowship, so I remembered well the mess of traffic and food carts that we encountered in front of the Milstein Pavilion that winter morning. Inside the marble lobby, we were met by Santo Russo, a young Italian cardiologist I had worked with. Santo was a handsome, wiry man who, despite his ill-fitting clothes and unfashionable ties, still managed to maintain a dashing air. Though he had completed his fellowship only a few years earlier, his gentle manner and good European common sense— he was pragmatic, direct, rational— made him someone I looked up to and aspired to emulate. He always had a lot to say about the hospital and American medical education. “Medical school teaches people the bad lesson that in order to succeed, you have to memorize,” he’d once told me. “People go through four years of medical school, three years of residency, three years of subspecialty fellowship, and they are never taught to think. Then all of a sudden at the end of fellowship, they are told to start doing basic or clinical research. ‘What do you mean, you don’t know the relevant research question? We don’t care that for nine years you were taught not to ask questions, to accept the prevailing wisdom. We don’t care about that. We want you to start doing research!’ A better way”— he’d gone on facetiously—“ would be to teach medical students for six days of the week and on the seventh day make them forget everything they’ve learned because it will soon be outdated anyway.”

Jauhar, Sandeep (2014-08-19). Doctored: The Disillusionment of an American Physician (pp. 79-80). Farrar, Straus and Giroux. Kindle Edition. 
"Memorization," "rote learning" is a bad idea in a world of Google instant lookup gratification? I recall one day in our HealthInsight conference room, during one of our routine HIE staff meetings. A question arose. Laptop keyboards quickly clicked all around the table. An answer was rapidly obtained and proffered. One of my colleagues, Kym Roundtree, joked "Remember back when we actually had to know stuff?"

So, well, uh, I Googled some stuff in search of an Einstein quote. Ran across this.
Educators need to be ready to foster creativity in children’s education
Many experts and futurists believe that our schools in particular need to place greater emphasis on right-brain functions such as big-picture thinking and the ability to conceptualize.
Yeah. Agree. To a point. But I couldn't suppress the immediate thought of the curmudgeonly Thomas Szasz.

A bit of Piaget, anyone? Sensorimotor stage, preoperational stage, concrete operational stage, formal operational stage...

From Curious:
The proposition that “knowing is obsolete” sounds excitingly futuristic, but its roots extend back centuries. The idea of what is sometimes called a curiosity-driven education— an education largely free of the necessity to memorize academic knowledge imparted by adults— is so attractive that we reinvent it every generation...

The trouble with adults, according to Rousseau, is that they are too eager to force their unnatural and arbitrary “knowledge” into young minds. “What is the use of inscribing on their brains a list of symbols which mean nothing to them?” he asked. Students might be able to repeat lists of facts, but they won’t understand them; the facts sit in their memories, inert and useless, destroying their ability to think for themselves.

In the late nineteenth and twentieth centuries, a series of thinkers and educators founded “progressive” schools, the core principle of which was that teachers must not get in the way of the child’s innate love of discovery. Traditional academic subjects such as history or languages or arithmetic were relegated in importance; after all, few children seem naturally interested in them. The emphasis was put on “learning by doing”— hands-on experience, rather than verbal exchange. Instructional teaching was banned or limited, exercises in play and self-expression encouraged.

Maria Montessori’s schools form the most celebrated example of the progressive philosophy in action; Larry Page and Sergey Brin both attended Montessori schools and credit the Montessori ethos as a contributor to their success. In the 1970s, Paulo Freire, an influential Brazilian education scholar, criticized teachers who “filled” students with facts alien to their “existential experience.” Rather than treating pupils like bank accounts in which we deposit information, he said, the job of education is to help children take responsibility for themselves.

The contemporary version of this progressive philosophy is associated with the phrase “learning skills” (sometimes called higherorder skills, thinking skills, or, more recently, twenty-first-century skills). Montessori and her contemporaries believed passionately in education for its own sake. The proponents of learning skills are more concerned with how schools prepare students for the world of work. They share the progressive belief that schools should spend less time on teaching specific knowledge of specific subjects. Instead, they argue, schools should focus on abstract skills such as creativity, problem solving, critical thought, and curiosity. Such skills, it is said, will equip children for whatever the future throws at them.

It’s a philosophy that has made its way deep into the educational mainstream. It can be found wherever you see an approving reference to students “taking control of their own learning” or a teacher criticized for spending too much time on instruction instead of allowing children to express themselves...
What’s less understandable is that their ideas have been proven false, repeatedly—repeatedly— shown to contradict everything modern science tells us about learning— yet are still discussed as if new, shiny, and bursting with possibility. We now know that Rousseau was wrong. The curiosity of children does not work in anything like the way he believed or his contemporary adherents propose. His ideas are seductive, but the reason they have to be constantly reinvented is that they do not work.

Leslie, Ian (2014-08-26). Curious: The Desire to Know and Why Your Future Depends On It (pp. 108-112). Basic Books. Kindle Edition.
Consider chess mastery and memorization.
On the face of it, chess is a game of pure reasoning. But the core of chess ability is knowledge; chess masters have more positions stored in their memories and are thus able to instantly recognize more positions as they come up, which frees their conscious minds to focus on evaluating the next move (or the next several moves). William Chase and Herbert Simon replicated de Groot’s experiment, adding a crucial twist. The players were shown not only real chess positions but random arrangements of pieces that would be impossible in an actual game of chess. The experts performed just as well as they had in de Groot’s experiment with the real positions, but when it came to the scrambled positions, they performed no better than the amateurs.

Chess, rather than being about an abstract thinking skill, is highly knowledge bound. Top players have tens of thousands of chess positions stored in their memories. Similar experiments have been repeated with experts from physics, algebra, and medicine, always with the same results. When the task is changed to one that lies outside the experts’ domain, they fail to transfer their skills to the new problem, because their skills are bound up with knowledge of that specific field.

Another way of putting this is that a mental skill is not the same as an algorithm— a process that can be applied to any problem, regardless of subject. Learning skills grow organically out of specific knowledge of specific domains— that is to say, facts (and I’m including here cultural knowledge, of the plot of Hamlet, for example). The wider your knowledge, the more widely your intelligence can range and the more purchase it gets on new information. This is why the argument that schools ought to prioritize learning skills over knowledge makes no sense; the very foundation for such skills is memorized knowledge.* The more we know, the better we are at thinking. (ibid, pp. 117-118).
Yeah. You gotta have a multiplicity in the pedagogy. Yes, we have to inculcate curiosity and "creativity." Yes, we have to stress "critical thinking" (my particular area of instruction some years back). Yes, we have to have a mutually respectful "Talking Stick" "Just Culture" via which to nurture and improve communication in the trenches. And, yes, we will still have to "know stuff" -- without having to resort to University of Google to bail us out all the time.

apropos, from former Kaiser Permanente CEO George Halvorson's keynote slide deck at NYeC 2013 last year, as he concluded by addressing "disparities."


This is gonna be a long post. Just getting started, there's so much to consider. Stay with me. Need.More.Coffee. I made two typos in my post title (now fixed).

Google Glass startup lands $8M
Wearable Intelligence aims to broaden its healthcare marketshare
SAN FRANCISCO | September 2, 2014

A startup that plans to take Google Glass to healthcare and other markets has landed $8.4 million in venture capital.

San Francisco-based Wearable Intelligence describes itself as a technology company dedicated to building enterprise solutions using wearable computing hardware -- such as Google Glass.

It already has a partnership with Beth Israel Deaconess Medical Center in Boston, which is using Google Glass in the ER to give them medical information hands free. With Google Glass, clinicians can call up patient information on its tiny screen.

"The deep technology knowledge and professional expertise of the folks at Wearable Intelligence, which I've personally experienced, will help us all accelerate the adoption of Google Glass in healthcare," Beth Israel Deaconess Medical Center CIO John Halamka writes in as testimonial on the Wearable Intelligence website...
Hope they'll be at Health 2.0 in Santa Clara later this month. Would love to interview them.



And back Down in The Weeds'
VIII. Medical Education and Credentialing as Barriers to Progress

A. Extending the health care reform agenda to medical education and credentialing

1. A century of stagnation
Productive use of advanced medical knowledge requires an integrated system of care with a rational division of labor in which all participants see clearly how their roles contribute to solving medical problems. All participants should be able to avail themselves of knowledge that individually they do not possess, practitioners should not be permitted to perform at a level beyond their demonstrated competence, and no group of practitioners should be able to pursue its own interests to the detriment of the larger system of care.

Progress towards a rational division of labor within an external network of knowledge tools is largely absent. Isolated advances are not evolving and coalescing into an integrated system of care. We all are trapped in a non-system, where an elite class of practitioners is permitted to rely on limited personal knowledge and intellect. Graduate medical education and credentialing protect this physician elite from competition that could otherwise reshape medical practice. The health care system has thus been remarkably slow to adapt to the new environment created by modern information technologies. And that environment is still developing. Our culture is still working out the right division of labor between human cognition and external information tools. The subculture of education, however, lags far behind the domains of science and commerce in that development...

Were Flexner to return today, he would find that current knowledge has the power to confer vastly greater advantage than it did a century ago. But he would not find that society reaps a greater fraction of that advantage. “Between the health care that we have and the care we could have lies not just a gap but a chasm,” the Institute of Medicine has found. Failings in medical education and credentialing are a central reason the chasm exists...
2. The medical school experience
According to the Institute of Medicine, “many believe that, in general, the current curriculum is overcrowded and relies too much on memorizing facts” and that “the fundamental approach to clinical education has not changed since 1910.”...
Teaching skills and behaviors is not emphasized in medical education. Rather, its “traditional emphasis is on teaching a core of knowledge, much of it focused on the basic mechanisms of disease and pathophysiological principles. But no definable core of knowledge is actually transmitted to or used by practitioners in patient care with any kind of uniformity. Whatever core of knowledge medical schools attempt to teach varies from one institution to another, students do not learn all they are taught, they retain only part of what they do learn, that residue varies with each individual, and some of that residu quickly becomes obsolete. Continuing education courses merely continue this futility. It should thus come as no surprise that continuing education has been found ineffective... [pp. 191 - 200]
"Relies too much on memorizing facts"? Well, maybe "too much," but Ian Leslie's book gives one pause here. Perhaps the issue is one of balance. "Facts" that are firmly fixed in the relevant sciences are one thing. Those that are transient are another. But, how can we know ahead of time?

Moreover, how certain can we be that salient, hard-won, critical recalled "facts" are uniformly recalled accurately at dx or px time?

Cognitive science is not reassuring in this regard.

Back down in the Weeds'. It gets worse:
In assuming that students must be indoctrinated with received knowledge as preparation for real patient care, medical schools trap student minds in what Tolstoy called “the snare of preparation.” Like a drug, such education has toxicity as well as benefit. One of its toxic effects is to reinforce a basic human need to deny uncertainty. Dr. Jay Katz has described “how readily any awareness of uncertainty succumbs to venerable authority and orthodoxy. These powerful defenses against awareness of uncertainty continue to rule professional practices.” Sociologist Robert Weaver has further described findings in the literature on this phenomenon:
A major task undertaken during medical training is learning to manage the uncertainty associated with medicine and medical education. For instance, medical students learn the disadvantages of “doubting too much” and displaying these doubts to peers, superiors, and patients. Instead, they often develop a misleading sense of certitude or come to don a “cloak of competence” to help them manage the impressions of others and, ultimately, the image they have of themselves. Confidence and belief in what one is doing is a central component of the “clinical mentality” as Friedson describes it. Doubts about the ambiguities of “unusual” cases, even when acknowledged by the practitioner, are often “silenced” or otherwise not shared with the patient.
Medical students emerge from this process with insufficient sensitivity to patient
uniqueness and the fallibility of medical knowledge.
[pg 202]
Ouch. I have seen this sort of thing in another domain in which I worked for a number ofd years -- financial risk modeling. From my 2008 post 'Tranche Warfare" --
Consider this lament by best-selling author Geneen Roth, in her recent article "I was fleeced by Madoff":

"I often asked Richard, the head of our feeder fund, how Madoff made such consistently good returns. Although Richard tried to explain it to me, it was clear he didn't know, either, because I'd leave our meetings still unable to explain to anyone else how it worked..."
Well, consider this little excerpt of recent MEGO financial jargon pertaining to the post-crash doings of the now-infamously bailed out AIG:

Pursuant to Section 13 or 15(d) of the Securities Exchange Act of 1934
Date of report (Date of earliest event reported): November 25, 2008
...Well, I'm a reasonably intelligent person with a Master's degree and more than 20 years' experience spanning a variety of business domains (including credit risk modeling), but this kind stuff leaves me bamboozled.

That's what they 'bank' on. We among The Great Unwashed (including, um, the regulators) can never hope to fathom such financial "sophistication," better to simply leave these things to the "experts."

Part of a short email note I sent to Ms. Roth in the wake of reading her lament:

You oughta read some Taleb, the "Fooled by Randomness" guy. Part of the problem I see (in agreement with Taleb) is that nobody really understood much of any of this, but once you get to a certain level of "expertise" in the financial world, you simply cannot admit to being clueless. So, it becomes a mileau of ongoing mutual bullshit...
When financiers blow smoke, people go broke. When clinicians do so, people die.

A CSC paper (pdf):

What is the Caregiver Shortage?
Evidence of a growing caregiver shortage in the United States emerged in the early 2000s when the Association of American Medical Colleges (AAMC), the American Hospital Association (AHA) and other industry groups began investigating the potential impacts of demographic changes such as baby boomer aging, population growth and chronic disease growth. Although projections vary slightly, one agreement among initial and subsequent studies has been that there will be a shortage and it will become substantial. Most studies before passage of the Affordable Care Act projected shortages of at least 124,000 physicians and 500,000 nurses by 2025 (see Table 1); and there is general agreement that the additional 32 million covered lives resulting from the Affordable Care Act requires inflating those projections — by 31,000 physicians, for example, according to the AAMC.
Physician dissatisfaction:
Physician job dissatisfaction is a growing problem. In addition to filtering back to students who are on the fence about medical school, it is impacting and threatening to impact the current physician population in other ways. One example is physicians approaching retirement age, many of whom are threatening early rather than late retirement to avoid demands such as increasing paperwork and the push for electronic health record (EHR) adoption...

Nurse dissatisfaction:

Perhaps even more disconcerting is nurse dissatisfaction. Unlike the physician shortage, which is resulting from supply not keeping up with demand, the U.S. population of nurses is projected to shrink — by 50,000 between now and 2015, and 130,000 by 2020.49 A big reason is dissatisfaction — almost one-half of nurses responding to a February 2010 survey said they plan to make career path changes within the next 1 to 3 years. A frequently-cited reason was concern for their own health.

Nurse practitioner and other mid-level provider challenges: 
Increasing roles for mid-level providers (nurse practitioners, physician assistants and nurse-midwives) is a big part of just about every caregiver shortage strategy documented during the past 10 years. The industry needs them to share some of the care load traditionally limited to physicians, and in the process free physicians to take on new roles, such as patient-centered medical home managers...
Comments on reimbursement reform and other caregiver shortage implications for health care delivery organizations are a reminder that reducing caregiver shortages and their impacts on care delivery are an integral part of health reform. That is, successful solutions to shortage challenges require not only specific efforts to address problems and implement solutions the industry has identified, but also are very much dependent upon (as well as a part of) the overall success of industry reforms. As the AAMC noted in its November 2008 Physician Supply and Demand Report, “… simply educating and training more physicians will not be enough to address these shortages. Complex changes such as improving efficiency, reconfiguring the way some services are delivered, and making better use of our physicians will also be needed.”
Interesting. "And the Health IT/Informatics/Analytics workforce shortage is not even mentioned in the paper.  So, yeah, a boxcar load of moving parts to consider, beyond just pedagogy issues.


"Remember back when we actually had to know stuff?"

OK, I got the learning solution right here.

Just joking, but, who knows? A whole new meaning to "your head is in the Cloud." What will it mean to be human, "after the (putative) Singularity"? Central to the "content acquisition / rote learning" pedagogy model is a "No Pain, No Gain" proposition, wherein synaptic connections that neurally bind increasing long-term memory knowledge require sustained and often difficult cognitive effort. Again, this is a core observation and concern in Ian Leslie's book. Significant evidence indicates that, in particular, there can be no "transfer of training effect" where there is no factual content knowledge base. Experts in field X are typically just laypeople in fields Y and Z, and their specific domain expertise is in large measure a function the knowledge bases inside their skulls, not their adroit abstract "critical thinking skills."


I cited this book some time back (April 29, 2012 post).

Approximately 15 percent of all healthcare workers and 25 percent of all physicians in the United States were born and educated elsewhere.1 This means that 1.5 million healthcare jobs are “insourced,” occupied by foreign-born, foreign-trained workers brought into the United States on special visas earmarked for healthcare jobs. This number is 50 percent greater than the total number of jobs in the US auto-manufacturing industry...

[E]ach year, we bring thousands of nurses from China to work in even better-paying jobs, rather than train young people in this country to become nurses...

On the surface, insourcing may appear to be a harmless or even win-win solution to the country’s healthcare-worker shortage. The hospital receives a much-needed worker, and the worker escapes life in a struggling country for a better life here. But we should be training more people in this country to work in those professions, especially people from rural poor and minority communities. Rather than investing in our own people and communities, however, we have decided to take the best and brightest workers from struggling countries...

Our unofficial policy of relying on the world’s poorest countries to pay for the training of workers whom we then entice and bring to this country is devastating healthcare systems around the world. The loss to a developing country when a single physician, representing what may be a significant portion of their total number of physicians, emigrates is far greater than our gain. Our failure to provide education for our own citizens and to better plan for healthcare staffing and distribution does not justify hiring nurses and physicians from the countries that can least afford to lose them.

Garrett, Laurie; Tulenko, Dr. Kate (2012-04-24). Insourced (Kindle Locations 286-398). University Press of New England. Kindle Edition.

Yes, Doctors Are Sick of Their Profession. And You’re Making Things Worse!

Dr. Sandeep Jauhar, a cardiologist, believes with good reason that many physicians have become “like everybody else: insecure, discontented and anxious about the future.” In a recent, widely-circulated column in the Wall Street Journal, “Why Doctors Are Sick of Their Profession,” he explains how medicine has become simply a job, not a calling, for many physicians; how their pay has declined, how the majority now say they wouldn’t advise their children to enter the medical profession, and how this malaise can’t be good for patients...

The truth behind “quality” metrics
There is no question that some physicians are inherently more talented, more dedicated, and more skilled than others. In every hospital, if you speak to staff members privately, they’ll tell you which surgeon to see for a slipped disk, a kidney transplant, or breast cancer. They’ll tell you which of the anesthesiologists they trust most, and which cardiologist they would recommend to someone with chest pain. But none of these recommendations are based on simplistic metrics like readmission rates or even mortality rates. They are based on observations over time of the physicians’ ability, integrity, and conscientiousness–all of which are tough to quantify.
The comments are interesting as well.

More to come...