One of the things I've enjoyed about Family Medicine is that it's really the one area of medicine - aside from perhaps Pediatrics - that can get patients to start living healthy lifestyles before they develop disease. It's not a common occurrence - I've really only had a few patients come in where they were truly in a pre-disease state and could have their risk profiles change with lifestyle modifications - but in a medical system that is still primarily reactive, it's a valued opportunity.
For all our medical advances, nothing beats a healthy lifestyle to ensuring continued well-being. A balanced diet, sufficient exercise, adequate sleep, stress control, elimination of smoking, and moderation of drinking. For most patients, these six habits will do more to provide a long, happy life than anything any physician can provide.
These interactions have also been a great reminder to put the emphasis on my own health. Over the past two years, my health habits have fallen to pieces. I went from getting regular high-intensity exercise to getting virtually none. My diet went from reasonable-to-good to consisting of a lot of sugar-heavy foods. I started getting less and less sleep, of poorer and poorer quality (call and 5:30 am shifts didn't help much with this). Stress was naturally through the roof during clerkship. On the plus side, I fortunately didn't start smoking and my drinking stayed fairly moderate, so we'll count those as wins.
As I move out of the craziness of clerkship and onto the regular craziness of what will hopefully be the rest of my life, I'm trying to get some of those healthy habits back. I got a FitBit recently as a present and it's proved to be pretty good motivation (even though research shows it might be detrimental, at least to weight loss). I'm trying to push my daily steps a bit higher and I've started running again. On the sleep front, I'm now more aware of what helps me sleep soundly and what doesn't, thanks for FitBit's helpful - albeit somewhat unreliable - sleep tracker. It's also making me chart what I eat, which if nothing else is making me a bit more mindful of what goes in my stomach. It's led to some specific changes - since I was a kid, I'd have a glass of juice in the morning with breakfast. Every morning. While it gets presented as a healthy serving of fruit, juice is pretty much pure sugar with very little nutrition. I'm drinking tea now instead - never was a coffee drinker - and appreciating the change. Cutting it out eliminates a fair number of empty calories and tons of sugar from my diet.
I never want to be that hypocritical doctor lecturing my patients about good health when I'm not willing to make those changes myself. If only to understand the difficulty that can go along with making these positive lifestyle changes, I'm finding these new efforts worthwhile - and hopefully my own health improves as a result!
Thursday 29 September 2016
Monday 26 September 2016
Communication Skills
When it comes to being a clerk, I consider myself pretty average. I keep up with my readings, know my patients pretty well, and generally put in a good effort into my clinical duties. However, I'm far from exceptional in any of these domains. Where I do consider myself a bit stronger is when it comes to communicating with patients and their families. I have plenty to learn and perfect on that front, but I'll put myself a bit ahead of the pack on that front.
A major component of this is learning how to say "no" without it seeming like an exercise in power. The phrase I hear some doctors rely on which irks me so much because of the problems it causes patients (and other providers) is "I won't". A patient makes a request and the physician says "I won't do that". There is typically a good reason for the refusal and the physician either can't or shouldn't fulfill the request in the first place. Even with an explanation of the refusal, "I won't" sticks in patients minds, because they see the physician as being capable of helping, but actively choosing not to. It hurts a lot of patient-physician relationships. I like using "I can't" as much as possible, provided it's appropriate. Fortunately, most "I won't"s can be framed as "I can't"s. Patients are still disappointed by refusals presented this way, but I find they're less disappointed in me as a care provider, and that helps to maintain the therapeutic relationship a bit better. Physicians and patients have a natural imbalance, which patients certainly feel. By emphasizing your own lack of ability to change things with phrases like "I can't", it can help to lessen the feeling of that imbalance, and to make it clear that even if you aren't able to solve all their problems, you're still trying to do what you can.
4) Ensure you're on the same page
Even when a physician is an amazing communicator, patients don't always understand the full plan. Medicine is vast and confusing, even to the initiated. Human memory is flawed in healthy people and gets worse when we're sick or stressed. Letting patients know what's coming is only effective if they absorb what was said and remember it.
Some easy strategies can help retention. I frequently try to repeat whatever plan we agree on in a concise way at the end of an interview. I then provide an opportunity for questions, in case there are any points of confusion.
Even that leaves plenty of room for things to slip through the cracks. Two approaches I'd like to use more often - but have difficulty implementing as a learner - is having patients repeat back the plan and/or writing down the plan. At this stage, all my plans are tentative, subject to approval by my supervisors and, in many cases, subject to change without my knowledge. I can't pin down anything I say at the risk of having the patient remember my suggestions ahead of the attending physician's actual recommendations. I've already had at least one instance where this has caused trouble. So, for now, I've held off these strategies, but would like to implement them once I gain some more ability and independence.
None of the above elements are overly difficult to implement and with practice become second nature. However, they are not always intuitive, rarely taught, and virtually never reinforced in medical training. We could be doing a lot better to develop a culture of effective physician-patient communication.
I though I'd take a post to go through some of the basics of my approach to patient communication, as it's not something I feel is well taught or reinforced in medical education. I often see clerks, residents and staff committing some very basic errors when speaking with patients.
1) Establish rapport first, don't forget to maintain it
That having a good rapport with patients is critical to achieving optimal care with patients is no surprise to most medical students. It's an art - no two people will have the same method for achieving a good rapport yet drastically different approaches can be equally effective depending on the circumstance and the physician's personality. However, there are some basics to establishing and maintaining rapport which I've seen get forgotten, neglected, or perhaps never learned.
To start, taking 10-15 seconds at the beginning of an interaction for some simple pleasantries can go a long way. It's fine to get down to business quickly, but don't forget that your trust hasn't been earned just because you're a physician, and that first minute or two can make a world of difference. I try to work in a quick joke within that time if an appropriate opportunity arises - I find it puts people at ease far more easily than anything else. Most physicians understand this critical introductory period and do make an effort to come across as an actual human being for the first few minutes, though some are more effective than others, some use blatantly scripted approaches, and some forgo this entirely.
Where I see more stumbles is that once that initial phase passes, the physician's attempt to connect with patients disappears entirely. Once those pleasantries are completed, it's on to business, no time for things like emotions or empathy! This kills a lot of physician-patient relationships. Trust not only has to be earned, it has to be maintained. A few empathetic statements, jokes, or check-backs with the patient to establish understanding throughout the interaction are practically essential. They show that the patient is heard and that their presence is appreciated rather than simply tolerated.
To start, taking 10-15 seconds at the beginning of an interaction for some simple pleasantries can go a long way. It's fine to get down to business quickly, but don't forget that your trust hasn't been earned just because you're a physician, and that first minute or two can make a world of difference. I try to work in a quick joke within that time if an appropriate opportunity arises - I find it puts people at ease far more easily than anything else. Most physicians understand this critical introductory period and do make an effort to come across as an actual human being for the first few minutes, though some are more effective than others, some use blatantly scripted approaches, and some forgo this entirely.
Where I see more stumbles is that once that initial phase passes, the physician's attempt to connect with patients disappears entirely. Once those pleasantries are completed, it's on to business, no time for things like emotions or empathy! This kills a lot of physician-patient relationships. Trust not only has to be earned, it has to be maintained. A few empathetic statements, jokes, or check-backs with the patient to establish understanding throughout the interaction are practically essential. They show that the patient is heard and that their presence is appreciated rather than simply tolerated.
2) Manage expectations
People will accept almost anything if they can prepare themselves for it. I've seen patients take news of a death sentence in stride because they knew it was coming before any words were spoken. The opposite is also true. People react very badly to surprises, even rather benign ones. Sick patients and their families, who may be emotionally and physically exhausted, are that much more prone to dealing with the unexpected poorly.
Medicine is inherently unpredictable. Doctors make educated guesses and can be pretty good at it, but very little is known with certainty. Good communication requires imparting some of that uncertainty to patients and their families. It's also vital to communicate exactly where that uncertainty lies. Are you uncertain because you don't know, or because you can't know? If you don't know, is it because you need input from a colleague, results from a test, or simply the time to let things play out?
Ultimately, the goal is to have their expectations be your expectations. You want your patients to hope for the best but plan for the worst, just as you will in your practice.
Being proactive is the key. Physicians frequently assume their patients are on the same page as them without confirming that this is the case. Taking 30 seconds to explain the plan, with considerations for how the plan might change and why, is an extremely important yet often neglected point of any patient interaction.
3) You're not all-powerful - don't pretend to be
Similar to the previous, be very clear about what is in your power and what isn't. Patients think doctors have a lot more authority and ability than we actually do. Physicians, sadly, tend to play into this myth. Fortunately, it's an easy trap to avoid.
Being clear about your role from the beginning is important, particularly for trainees. Never assume a patient knows what you can and can't do.
A major component of this is learning how to say "no" without it seeming like an exercise in power. The phrase I hear some doctors rely on which irks me so much because of the problems it causes patients (and other providers) is "I won't". A patient makes a request and the physician says "I won't do that". There is typically a good reason for the refusal and the physician either can't or shouldn't fulfill the request in the first place. Even with an explanation of the refusal, "I won't" sticks in patients minds, because they see the physician as being capable of helping, but actively choosing not to. It hurts a lot of patient-physician relationships. I like using "I can't" as much as possible, provided it's appropriate. Fortunately, most "I won't"s can be framed as "I can't"s. Patients are still disappointed by refusals presented this way, but I find they're less disappointed in me as a care provider, and that helps to maintain the therapeutic relationship a bit better. Physicians and patients have a natural imbalance, which patients certainly feel. By emphasizing your own lack of ability to change things with phrases like "I can't", it can help to lessen the feeling of that imbalance, and to make it clear that even if you aren't able to solve all their problems, you're still trying to do what you can.
4) Ensure you're on the same page
Even when a physician is an amazing communicator, patients don't always understand the full plan. Medicine is vast and confusing, even to the initiated. Human memory is flawed in healthy people and gets worse when we're sick or stressed. Letting patients know what's coming is only effective if they absorb what was said and remember it.
Some easy strategies can help retention. I frequently try to repeat whatever plan we agree on in a concise way at the end of an interview. I then provide an opportunity for questions, in case there are any points of confusion.
Even that leaves plenty of room for things to slip through the cracks. Two approaches I'd like to use more often - but have difficulty implementing as a learner - is having patients repeat back the plan and/or writing down the plan. At this stage, all my plans are tentative, subject to approval by my supervisors and, in many cases, subject to change without my knowledge. I can't pin down anything I say at the risk of having the patient remember my suggestions ahead of the attending physician's actual recommendations. I've already had at least one instance where this has caused trouble. So, for now, I've held off these strategies, but would like to implement them once I gain some more ability and independence.
None of the above elements are overly difficult to implement and with practice become second nature. However, they are not always intuitive, rarely taught, and virtually never reinforced in medical training. We could be doing a lot better to develop a culture of effective physician-patient communication.
Wednesday 21 September 2016
Overconfidence
So, I got cocky. Had a run of incredibly good days on elective. I was nailing my evaluations, getting good diagnoses, and even developing reasonably complete plans for my patients. A few days felt like I could actually run the show in the near future. I still had plenty to learn, but I was spending more of my time refining my approach and decision-making than starting from the basics. I was even trying to work on speed in my assessments.
Well, that came crashing to a halt this past week. I had two days where it seemed like I couldn't get anything right. My evaluations were incomplete, my diagnoses were flawed and my plans were lacking. I was horribly slow, even for my stage of training. I wasn't close to being independent - heck, I was barely adequate for a 4th year medical student.
It's been a big wake-up call. On reflection, I stopped doing the things that got me to this point successfully. I wasn't keep up with my readings. I wasn't thinking through my approach when I stepped in the room, acting more on instinct than deliberately considering the possibilities. I rushed through my presentations, leading to slower reviews with my supervisors and costing more time overall.
So, I'm trying to do more regular reading, every night if I can, on 1-2 topics. I attempted to be more deliberative in my assessments and more organized in my presentations. Most importantly, I've tried not to be so hard on myself. I won't get every evaluation perfect at this stage, not even close. I needed to recognize that while I have made large strides in my abilities, I'm still in the learning phase of my training. I'm going to get things wrong, miss things I should pick up on, and that's ok for now.
Good reminder that it's alright to have a bad day or two - as long as you learn from them.
Well, that came crashing to a halt this past week. I had two days where it seemed like I couldn't get anything right. My evaluations were incomplete, my diagnoses were flawed and my plans were lacking. I was horribly slow, even for my stage of training. I wasn't close to being independent - heck, I was barely adequate for a 4th year medical student.
It's been a big wake-up call. On reflection, I stopped doing the things that got me to this point successfully. I wasn't keep up with my readings. I wasn't thinking through my approach when I stepped in the room, acting more on instinct than deliberately considering the possibilities. I rushed through my presentations, leading to slower reviews with my supervisors and costing more time overall.
So, I'm trying to do more regular reading, every night if I can, on 1-2 topics. I attempted to be more deliberative in my assessments and more organized in my presentations. Most importantly, I've tried not to be so hard on myself. I won't get every evaluation perfect at this stage, not even close. I needed to recognize that while I have made large strides in my abilities, I'm still in the learning phase of my training. I'm going to get things wrong, miss things I should pick up on, and that's ok for now.
Good reminder that it's alright to have a bad day or two - as long as you learn from them.
Saturday 17 September 2016
Electives - Initial Thoughts
Got to start my electives over the past few weeks. They say the 4th year of medicine is the best year, and based on my experiences so far, it's hard to disagree. I don't have to worry about evaluations, I'm getting sleep and a bit of actual exercise, and I'm learning a ton. Getting to choose my rotations, or at least have significant input on them, is a major bonus. Learning comes so much easier when you want to learn and are motivated to do so.
It is a bit disorienting though. Perhaps not quite as much as clerkship, because I at least know the medicine well enough. Yet, being in a different environment every 2 weeks, particularly when that often involves being in a different city, it does take a fair bit of mental energy just to keep up.
There's a trade-off between variety and consistency when it comes to absorbing new information. Too much variety and there's so much rattling around in your brain that little if anything sticks. Too much consistency and you only pick up what's right in front of you, missing experiences you may have to encounter on your own later down the line. Right now I'm on the "variety" side of things and I am definitely missing my time where I could count on doing roughly the same thing for weeks on end - I'm getting a lot of experience I otherwise wouldn't, but less is sticking than I'd like.
The other wrinkle here is that this is my main chance to explore different settings for residency considerations. As someone leaning heavily into FM, the main question I'm wrestling with right now is how rural do I want to go? I knew I didn't want to do the extremes on either end - I don't want to be in the GTA, nor do I want to do overly remote medicine. However, that still leaves open anything from mid-sized cities to small towns with only a few thousand inhabitants. I don't have any major preferences when it comes to living in these locations, so it's coming down to practice types. In larger centres, FM is much more restricted to clinic work, home visits, and nursing home care, possibly with some OB thrown in. Smaller centres, you could be running clinic, covering the ER, taking care of inpatients, then doing trips to people's houses or to nursing homes, potentially all in the same day.
I'll have more to say on that soon - right now, I'm trying to keep an open mind to fully explore each of these settings and which ones might be a better fit for my residency, and my eventual practice.
It is a bit disorienting though. Perhaps not quite as much as clerkship, because I at least know the medicine well enough. Yet, being in a different environment every 2 weeks, particularly when that often involves being in a different city, it does take a fair bit of mental energy just to keep up.
There's a trade-off between variety and consistency when it comes to absorbing new information. Too much variety and there's so much rattling around in your brain that little if anything sticks. Too much consistency and you only pick up what's right in front of you, missing experiences you may have to encounter on your own later down the line. Right now I'm on the "variety" side of things and I am definitely missing my time where I could count on doing roughly the same thing for weeks on end - I'm getting a lot of experience I otherwise wouldn't, but less is sticking than I'd like.
The other wrinkle here is that this is my main chance to explore different settings for residency considerations. As someone leaning heavily into FM, the main question I'm wrestling with right now is how rural do I want to go? I knew I didn't want to do the extremes on either end - I don't want to be in the GTA, nor do I want to do overly remote medicine. However, that still leaves open anything from mid-sized cities to small towns with only a few thousand inhabitants. I don't have any major preferences when it comes to living in these locations, so it's coming down to practice types. In larger centres, FM is much more restricted to clinic work, home visits, and nursing home care, possibly with some OB thrown in. Smaller centres, you could be running clinic, covering the ER, taking care of inpatients, then doing trips to people's houses or to nursing homes, potentially all in the same day.
I'll have more to say on that soon - right now, I'm trying to keep an open mind to fully explore each of these settings and which ones might be a better fit for my residency, and my eventual practice.
Friday 9 September 2016
How Could We Reform Physician Compensation?
With the rejection of the tPSA by OMA members, we're back to square one in the negotiation with the Ontario government regarding physician compensation. It will likely be a long, ugly battle, just as it was before the tPSA came to light. Still, it's a good opportunity to delve into the discussion about what a reasonable adjustment to physician compensation could look like. After all, while I was strongly opposed to the tPSA, I'm not at all opposed to sensible efforts to save money on physician compensation, and I believe there are ways to do it which are in the best interests of patients and taxpayers which wouldn't unduly burden physicians themselves.
1) Implement Relativity
This came up frequently in the "Yes" side of the tPSA arguments and, despite being a "No" voter, I support this approach. Relativity in the context of physician payment negotiations in Ontario essentially means that physicians should be paid comparable amounts for the work that they do. More specifically, the argument is that if cuts are to occur, they should fall on those who are paid more than their counterparts with similar training and working conditions.
There are some specialties where physicians clearly earn more than is justified, in relative terms at least. I could name several specialties or subspecialties here, but I'll single out Ophthalmology, as it's one of the more commonly cited examples. Ophthalmologists have extremely high gross billings on average. Their high overhead reduces this number considerably, but their take-home income is still quite high. Their patients are generally low acuity with threats to morbidity rather than mortality, and their working hours are on the lower end, particularly for a surgical specialty. Importantly, there is no shortage of individuals wanting to work in Ophthalmology in Ontario - both job openings and residency positions are extremely competitive - so we could cut Ophthalmology compensation without significantly affecting our ability to fill available positions. Ophthalmology does involve complex, technical work with an important impact on quality of life for their patients and their pay should reflect that expertise. However, with outsized incomes, the overall Ophthalmology compensation could be cut without significant ill-effects on patient care, as could the income for a number of other specialties or subspecialties.
One point to mention here - in no way would I argue for equal pay for all practitioners, or even equal hourly pay. I'm going into Family Medicine (if I have any say) and expect to earn on the lower end of things for a physician. That's fair to me - I'm actively choosing to avoid long training times and long work hours with high acuity patients (outside of some ER shifts potentially). Some inequality in pay is justified.
2) Eliminate Cash Cows
Overpay between specialties is worth addressing, but so is overpay within specialties. Each specialty tends to have its own cash cows, procedures or practice arrangements that overpay relative to other activities. These cash cows skew practice patterns. The economics of healthcare do not work the same way they do for other products, but many of the same principles apply. In this case, if you pay doctors more for doing something, they'll do that something more often, even if that something isn't the best use of time or resources. It also produces some inequality within specialties, as practitioners who establish themselves with a certain high-pay procedure, or control the infrastructure necessary to perform it, end up with higher incomes than those without the privilege. Eliminating cash cows by pricing high-pay activities more modestly could provide some savings with a neutral or possibly even beneficial effect on patient health.
There are a few caveats here, however. In some cases, cash cows are actually a case of good incentives. Some activities are inherently undesirable for practitioners, yet necessary for patients. High compensation in these situations may be required to provide patient access. Another consideration is that cash cows can compensate for low-paying or even net negative activities. Our billing system is bad enough that some activities actually cost practitioners money, or pay so little that they aren't economically feasible on their own. Physicians often still provide these procedures or services because they're valuable for their patients, while making up for the lost time and money through higher-yield services. Taking away those overpaid activities means fewer practitioners can realistically afford to provide underpaid activities.
Bottom line is that adjustments to billing codes have a significant potential to save money on healthcare costs, but require careful consideration. There are a lot of secondary effects to changing billing codes that aren't immediately apparent to an outsider.
3) Strengthen Primary Care
Reducing physician costs in the provincial budget really can only be done one of two ways - reduce the cost per service provided by physicians, or reduce the number of services provided. The first two items discussed deal with the former. The rest of this piece will focus on the latter.
Primary care is the gateway to healthcare services, whether through Family Physicians or through Emergency Rooms. We rely on these practitioners to restrict access to specialists only to those who truly need them. The more that primary care providers can manage without calling on specialists, the less specialty services will be used. By strengthening the capabilities of Family Physicians, we might be able to save money on more expensive specialists, reducing how often patients require their care.
This is obviously easier said than done and in many cases, not a good idea. Primary care physicians don't see some conditions often enough to develop sufficient expertise and they shouldn't hesitate to get experts involved in these situations. Likewise, other expensive elements to healthcare, such as some diagnostics or interventions, are restricted to specialists to release, limiting their use and arguably saving the overall system a fair bit of money. Opening these resources up to Family Physicians would not be beneficial to patients or taxpayers.
Nevertheless, with reasonably wide variation in referral practices between Family Physicians, especially between locations, we do have room to cut back on referrals without sacrificing quality of care or adding costs to other parts of medicine. Emphasizing (and ideally compensating) continuing medical education, while strengthening the training for primary care providers (particularly in medical school!) would be my favoured initial methods. Incentive schemes to keep referrals to a minimum may be worth considering, if they can be carefully constructed not to punish necessary referrals.
4) Train Fewer Doctors
Ok, this is a can of worms, but let's open it just a little bit. Canada tried this approach and it largely didn't work. Back in the 90's, Canada's medical schools didn't keep up with population growth and in some cases, medical school enrollment was actively curtailed. Of course, physician services were still necessary, and ultimately, healthcare costs continued to rise unimpeded. Physicians, now scarce, saw their salaries rise, while non-physician providers like Nurse Practitioners and Physician Assistants slowly grew in number. Eventually, the deficit in physicians was too high and Canada reversed course, massively expanding medical school enrollment while opening up new residency opportunities for foreign-trained physicians. The idea that restricting physician numbers could save money was fairly clearly wrong.
Well, sort of. The problem in the 90's was that Canada restricted physician numbers so much that baseline demand for services couldn't be met. That led to compensatory spending to make up that deficit. Now, however, physician numbers are much closer to the OCED average and still on the rise. We're starting to see some first signs of physician oversupply, with unemployment and underemployment on the rise, but this has been largely concentrated in resource intensive, hospital-based specialties where jobs can be restricted by constraining the availability of those supporting resources. This speaks to an inherent problem in funding physicians to meet patient demand - demand for healthcare services often expand with supply and physicians can create their own demand. Specialties that can finance their own infrastructure tend to have great job markets regardless of the local supply of physicians.
The example I always mention is Psychiatrists in Toronto. They are in far greater supply there than in smaller cities and rural areas, yet do not seem to have trouble getting work and make salaries comparable with national averages. They just take care of far fewer patients than their counterparts elsewhere, seeing them more often or for longer. This isn't necessarily a bad thing, but it clearly a more expensive arrangement for the province. This is hardly a unique situation. Most specialties, including Family Practitioners, could easily double (or more) the number of people in their clinics or procedure rooms if they had the time and resources to do so. As we start to see the number of physicians rise, and especially as we see more students going into fields like Family Medicine, Psychiatry, and Geriatrics, we could see physician billings substantially increase, as these new practitioners will not be nearly as constrained by public resources, and can cause - rather than simply respond to - increasing demand for healthcare. I do think we need to shift more physicians towards these specialties, which are likely still undersupplied relative to other specialties, but we are likely overshooting on overall physician supply. Cutting back on this oversupply would likely help the bottom line in the long run.
1) Implement Relativity
This came up frequently in the "Yes" side of the tPSA arguments and, despite being a "No" voter, I support this approach. Relativity in the context of physician payment negotiations in Ontario essentially means that physicians should be paid comparable amounts for the work that they do. More specifically, the argument is that if cuts are to occur, they should fall on those who are paid more than their counterparts with similar training and working conditions.
There are some specialties where physicians clearly earn more than is justified, in relative terms at least. I could name several specialties or subspecialties here, but I'll single out Ophthalmology, as it's one of the more commonly cited examples. Ophthalmologists have extremely high gross billings on average. Their high overhead reduces this number considerably, but their take-home income is still quite high. Their patients are generally low acuity with threats to morbidity rather than mortality, and their working hours are on the lower end, particularly for a surgical specialty. Importantly, there is no shortage of individuals wanting to work in Ophthalmology in Ontario - both job openings and residency positions are extremely competitive - so we could cut Ophthalmology compensation without significantly affecting our ability to fill available positions. Ophthalmology does involve complex, technical work with an important impact on quality of life for their patients and their pay should reflect that expertise. However, with outsized incomes, the overall Ophthalmology compensation could be cut without significant ill-effects on patient care, as could the income for a number of other specialties or subspecialties.
One point to mention here - in no way would I argue for equal pay for all practitioners, or even equal hourly pay. I'm going into Family Medicine (if I have any say) and expect to earn on the lower end of things for a physician. That's fair to me - I'm actively choosing to avoid long training times and long work hours with high acuity patients (outside of some ER shifts potentially). Some inequality in pay is justified.
2) Eliminate Cash Cows
Overpay between specialties is worth addressing, but so is overpay within specialties. Each specialty tends to have its own cash cows, procedures or practice arrangements that overpay relative to other activities. These cash cows skew practice patterns. The economics of healthcare do not work the same way they do for other products, but many of the same principles apply. In this case, if you pay doctors more for doing something, they'll do that something more often, even if that something isn't the best use of time or resources. It also produces some inequality within specialties, as practitioners who establish themselves with a certain high-pay procedure, or control the infrastructure necessary to perform it, end up with higher incomes than those without the privilege. Eliminating cash cows by pricing high-pay activities more modestly could provide some savings with a neutral or possibly even beneficial effect on patient health.
There are a few caveats here, however. In some cases, cash cows are actually a case of good incentives. Some activities are inherently undesirable for practitioners, yet necessary for patients. High compensation in these situations may be required to provide patient access. Another consideration is that cash cows can compensate for low-paying or even net negative activities. Our billing system is bad enough that some activities actually cost practitioners money, or pay so little that they aren't economically feasible on their own. Physicians often still provide these procedures or services because they're valuable for their patients, while making up for the lost time and money through higher-yield services. Taking away those overpaid activities means fewer practitioners can realistically afford to provide underpaid activities.
Bottom line is that adjustments to billing codes have a significant potential to save money on healthcare costs, but require careful consideration. There are a lot of secondary effects to changing billing codes that aren't immediately apparent to an outsider.
3) Strengthen Primary Care
Reducing physician costs in the provincial budget really can only be done one of two ways - reduce the cost per service provided by physicians, or reduce the number of services provided. The first two items discussed deal with the former. The rest of this piece will focus on the latter.
Primary care is the gateway to healthcare services, whether through Family Physicians or through Emergency Rooms. We rely on these practitioners to restrict access to specialists only to those who truly need them. The more that primary care providers can manage without calling on specialists, the less specialty services will be used. By strengthening the capabilities of Family Physicians, we might be able to save money on more expensive specialists, reducing how often patients require their care.
This is obviously easier said than done and in many cases, not a good idea. Primary care physicians don't see some conditions often enough to develop sufficient expertise and they shouldn't hesitate to get experts involved in these situations. Likewise, other expensive elements to healthcare, such as some diagnostics or interventions, are restricted to specialists to release, limiting their use and arguably saving the overall system a fair bit of money. Opening these resources up to Family Physicians would not be beneficial to patients or taxpayers.
Nevertheless, with reasonably wide variation in referral practices between Family Physicians, especially between locations, we do have room to cut back on referrals without sacrificing quality of care or adding costs to other parts of medicine. Emphasizing (and ideally compensating) continuing medical education, while strengthening the training for primary care providers (particularly in medical school!) would be my favoured initial methods. Incentive schemes to keep referrals to a minimum may be worth considering, if they can be carefully constructed not to punish necessary referrals.
4) Train Fewer Doctors
Ok, this is a can of worms, but let's open it just a little bit. Canada tried this approach and it largely didn't work. Back in the 90's, Canada's medical schools didn't keep up with population growth and in some cases, medical school enrollment was actively curtailed. Of course, physician services were still necessary, and ultimately, healthcare costs continued to rise unimpeded. Physicians, now scarce, saw their salaries rise, while non-physician providers like Nurse Practitioners and Physician Assistants slowly grew in number. Eventually, the deficit in physicians was too high and Canada reversed course, massively expanding medical school enrollment while opening up new residency opportunities for foreign-trained physicians. The idea that restricting physician numbers could save money was fairly clearly wrong.
Well, sort of. The problem in the 90's was that Canada restricted physician numbers so much that baseline demand for services couldn't be met. That led to compensatory spending to make up that deficit. Now, however, physician numbers are much closer to the OCED average and still on the rise. We're starting to see some first signs of physician oversupply, with unemployment and underemployment on the rise, but this has been largely concentrated in resource intensive, hospital-based specialties where jobs can be restricted by constraining the availability of those supporting resources. This speaks to an inherent problem in funding physicians to meet patient demand - demand for healthcare services often expand with supply and physicians can create their own demand. Specialties that can finance their own infrastructure tend to have great job markets regardless of the local supply of physicians.
The example I always mention is Psychiatrists in Toronto. They are in far greater supply there than in smaller cities and rural areas, yet do not seem to have trouble getting work and make salaries comparable with national averages. They just take care of far fewer patients than their counterparts elsewhere, seeing them more often or for longer. This isn't necessarily a bad thing, but it clearly a more expensive arrangement for the province. This is hardly a unique situation. Most specialties, including Family Practitioners, could easily double (or more) the number of people in their clinics or procedure rooms if they had the time and resources to do so. As we start to see the number of physicians rise, and especially as we see more students going into fields like Family Medicine, Psychiatry, and Geriatrics, we could see physician billings substantially increase, as these new practitioners will not be nearly as constrained by public resources, and can cause - rather than simply respond to - increasing demand for healthcare. I do think we need to shift more physicians towards these specialties, which are likely still undersupplied relative to other specialties, but we are likely overshooting on overall physician supply. Cutting back on this oversupply would likely help the bottom line in the long run.
Sunday 4 September 2016
CaRMS Cycle - Go Time
So, the new CaRMS cycle started this week. My CaRMS cycle.
It's a very weird feeling, having residency start to become a reality rather than an abstract concept in the future. Before this week, anything I did - aside from passing all my courses and rotations - only had a tangential effect on my residency chances. Now it's all quite direct, and that is... well, a little stress-inducing.
Don't get me wrong, I've got months to get things ready and have put myself in a reasonable situation. Most of my documents are already prepared. I've only got a few personal letters and letters of reference to arrange, but not too much else beyond that. Still, I've had months disappear on me in the blink of an eye, so I don't want to get complacent.
On the positive side, it feels like I'm coming to the end. I'm done my pre-clerkship courses, the ones I merely tried to get through while doing as much as I could outside the standard curriculum. I'm finished clerkship, where I largely enjoyed the work, but detested the working conditions and treatment of patients for many rotations. Someone reminded me that, because I'm going into Family Medicine, the required part of my training to become a fully qualified, independent physician is now over half complete.
I can't wait to start working. I know I have a lot to learn before I'm able to do that, but I'm so excited to get to that point, to be finally done with my formal education and onto learning for life instead.
So, as stressful as this is, starting my CaRMS application is a great step to be allowed to take. It signifies that it's time for the next stage of my training. I'm quite thankful for that opportunity.
It's a very weird feeling, having residency start to become a reality rather than an abstract concept in the future. Before this week, anything I did - aside from passing all my courses and rotations - only had a tangential effect on my residency chances. Now it's all quite direct, and that is... well, a little stress-inducing.
Don't get me wrong, I've got months to get things ready and have put myself in a reasonable situation. Most of my documents are already prepared. I've only got a few personal letters and letters of reference to arrange, but not too much else beyond that. Still, I've had months disappear on me in the blink of an eye, so I don't want to get complacent.
On the positive side, it feels like I'm coming to the end. I'm done my pre-clerkship courses, the ones I merely tried to get through while doing as much as I could outside the standard curriculum. I'm finished clerkship, where I largely enjoyed the work, but detested the working conditions and treatment of patients for many rotations. Someone reminded me that, because I'm going into Family Medicine, the required part of my training to become a fully qualified, independent physician is now over half complete.
I can't wait to start working. I know I have a lot to learn before I'm able to do that, but I'm so excited to get to that point, to be finally done with my formal education and onto learning for life instead.
So, as stressful as this is, starting my CaRMS application is a great step to be allowed to take. It signifies that it's time for the next stage of my training. I'm quite thankful for that opportunity.
Friday 2 September 2016
Likes and Dislikes in Anesthesiology
For a number of reasons, I didn't get much time on my Anesthesiology rotation. That's a shame, because it was quite enjoyable! Here are my Likes and Dislikes.
1) Anesthesiology is not boring
The stereotype of the anesthesiologist slumbering behind the curtain is still alive and well, but I found myself to be quite busy when on the service. The actual act of putting someone under general anesthetic, sedation, or otherwise providing pain relief is not a simple process. There is a lot of preparation and planning that goes into it. Deciding what supports are needed, from the type of respiratory support, to the number of IVs, to the presence of an arterial line takes some quick decision-making. Securing all these supports, especially in the fast-paced setting of an OR, is not an easy task. Intubating is hard, and I failed at it, a lot!
2) Ok, sometimes Anesthesiology is boring
In ORs with regular turnover between cases and reasonably complex anesthetic requirements, there is plenty of action. In ORs where neither of these is the case... well, it can get pretty dry. Cases that last for half the day mean hours of sitting doing not a whole lot for Anesthesiologists. If the patient becomes unstable or threatens to, then things can get interesting, but that happens relatively infrequently, a testament to the efficacy of what Anesthesiologists do. On the other side, cases which only require mild or moderate sedation do not involve much preparation, and so tend to proceed like clockwork. I still found these cases interesting for a few weeks, but I doubt I'd be able to sustain interest for years or even months.
3) Teaching, teaching, teaching
Anesthesiologists, at least the ones I worked with, were really great about teaching. I got to go over a wide variety of topics not just once but multiple times. Aspects of medicine I hadn't touched on previously were like second-nature after finished the rotation. Even with limited time on the rotation, I felt like I got a lot of key points of my education covered thoroughly, simply due to dedicated teaching time and repetition of important elements. I really wish more of medicine had the degree of emphasis on teaching and focus in topics as Anesthesiology seemed to.
4) Happiness Test
Anesthesiologists seem pretty happy. Sometimes a little bored, no doubt. Saw more than one playing Candy Crush during an OR. I think the downtime helps though. Medicine is such a whirlwind, it's easy to get caught up in it. Anesthesiology comes with built-in breaks, slowing things down even if just by a small amount. A little bit of boring can be enormously beneficial.
1) Anesthesiology is not boring
The stereotype of the anesthesiologist slumbering behind the curtain is still alive and well, but I found myself to be quite busy when on the service. The actual act of putting someone under general anesthetic, sedation, or otherwise providing pain relief is not a simple process. There is a lot of preparation and planning that goes into it. Deciding what supports are needed, from the type of respiratory support, to the number of IVs, to the presence of an arterial line takes some quick decision-making. Securing all these supports, especially in the fast-paced setting of an OR, is not an easy task. Intubating is hard, and I failed at it, a lot!
2) Ok, sometimes Anesthesiology is boring
In ORs with regular turnover between cases and reasonably complex anesthetic requirements, there is plenty of action. In ORs where neither of these is the case... well, it can get pretty dry. Cases that last for half the day mean hours of sitting doing not a whole lot for Anesthesiologists. If the patient becomes unstable or threatens to, then things can get interesting, but that happens relatively infrequently, a testament to the efficacy of what Anesthesiologists do. On the other side, cases which only require mild or moderate sedation do not involve much preparation, and so tend to proceed like clockwork. I still found these cases interesting for a few weeks, but I doubt I'd be able to sustain interest for years or even months.
3) Teaching, teaching, teaching
Anesthesiologists, at least the ones I worked with, were really great about teaching. I got to go over a wide variety of topics not just once but multiple times. Aspects of medicine I hadn't touched on previously were like second-nature after finished the rotation. Even with limited time on the rotation, I felt like I got a lot of key points of my education covered thoroughly, simply due to dedicated teaching time and repetition of important elements. I really wish more of medicine had the degree of emphasis on teaching and focus in topics as Anesthesiology seemed to.
4) Happiness Test
Anesthesiologists seem pretty happy. Sometimes a little bored, no doubt. Saw more than one playing Candy Crush during an OR. I think the downtime helps though. Medicine is such a whirlwind, it's easy to get caught up in it. Anesthesiology comes with built-in breaks, slowing things down even if just by a small amount. A little bit of boring can be enormously beneficial.
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