New rules for paying MDs proposed by hospital system in NY

New York City’s Health and Hospitals Corporation (HHC), which runs 11 hospitals in four of the five boroughs of New York, is negotiating a new deal with the union representing some 3,300 salaried physicians. The corporation wants to base MD pay raises on 13 quality indicators.

The New York Times article that broke the story does not list all of the indicators but mentioned the following: how well patients say their doctors communicated with them, rates of readmission within 30 days after discharge for heart failure and pneumonia, how quickly emergency department patients go from triage to beds, whether doctors get to the operating room on time and how quickly patients are discharged.

The union has countered with suggestions that more indicators be used such as “going to community meetings, giving lectures, getting training during work hours, screening patients for obesity, and counseling them to stop smoking.” And they may ask that more doctors and support staff be hired.

As is typical of the doctors' union, they had problems with the plan. They already get paid for giving lectures and training during work hours. Aren't screening patients for obesity and counseling them to stop smoking considered part of a physician's normal work? I do agree that doctors should receive combat or hardship pay for attending community meetings.

Another feature of the plan, which was glossed over in most secondary reports, is that the bonuses “would be given to physicians as a group at each hospital, rather than as individuals, so that even the worst doctor would benefit.” (More on this below)

The Times piece quotes officials from both sides and outside experts who offered opinions ranging from it’s a wonderful new world order to it will never work.

I tried to obtain a list of all 13 performance indicators, but it is nowhere to be found. However, looking at the ones in the Times article may be enough.

Patient assessments of how well their doctors communicated with them is going to be confounded by the fact that there are no private patients and few one-to-one doctor-patient relationships in the HHC system. Add in layers of medical students, physician assistants, residents and fellows combined with a patient population that, in many cases, suffers from a language barrier and may not even know who their doctors are, and it will be difficult to tell just who is a poor communicator.

I have discussed rates of readmission within 30 days after discharge for heart failure and pneumonia in a previous blog. This is a very poor indicator of quality and depends greatly on patient compliance with medications and instructions such as diet and activity.

How quickly emergency department (ED) patients go from triage to beds is a function of the census in the ED. This depends on many variables the MDs can’t control, such as availability of inpatient floor and ICU beds, nurse staffing, promptness in room cleaning, and many other factors.

Whether doctors get to the operating room on time is an interesting issue. As a former chairman of surgery, I have tackled this one in three different hospitals without success. First of all, what does this have to do with quality? Secondly, I truly believe that it will never be solved.

How quickly patients are discharged: Does this mean the time from admission to discharge, or is it the time from when the decision to discharge a patient is made until he actually leaves? If it’s the latter, again there are many forces at work. Does the patient want to go home? Can he get a ride? Is the bed ready at the nursing home or rehab center? If he’s being transferred by ambulette, will it arrive promptly? Is the nurse too busy to do the paperwork? Is the doctor, who may be a resident, too busy to do the paperwork?

The fact that bonuses will be tied to group, not individual, performance dooms the plan to failure. It reminds me of high school when someone threw a spitball and the teacher made everyone stay after school.

What do you think?

Instrument toss: I claim the Guinness record for distance

A recent exchange on Twitter reminded me of an incident that occurred when I was a resident.

There are many stories about surgeons throwing instruments. I was never a habitual instrument thrower but I had my moments.

I was doing a cutdown (a minor surgical procedure to gain intravenous access) on a newborn in the neonatal ICU. This was in the early 1970s, and the section of the hospital that contained the unit was not air-conditioned.

It was the middle of August. I was having some trouble finding a suitable vein. The instruments on the cutdown tray were all discards from the operating room. They were stiff and didn't work well.

At a critical point in the process, I put a clamp on a tie around a flimsy vein. Because the jaws of the instrument were not aligned, it slipped and the tie was lost.

My patience, still to this day not one of my strong points, was also lost.

I threw the clamp toward the open door of the unit. It skidded along the floor out the door across the hall and through the open doors of an elevator. The doors closed and the clamp was never seen again.

I somehow managed to finish the procedure.

Other than occasionally into a garbage can, I haven't thrown an instrument since.

Non-US citizen at a Caribbean med school wonders what his chances are for getting a surgical residency

On "Ask Skeptical Scalpel," a non-US citizen at an offshore medical school asks what I think his chances of obtaining a residency position in general surgery are.

Here's a link to that post.

Law school applications are way down; could it happen to med schools?

The number of people applying to law schools is in steep decline. So says a recent post on a website called “The National Jurist.”

The post cited some remarkable statistics from the American Bar Association. In 2012, law school applicant numbers were down 14% from 2011 and 23% from 2010.

For the fall of 2012, there were 44,481 first-year law students enrolled, a drop of about 4,000 from 2010.

Many schools have decreased enrollments with more than 90 cutting class sizes by more than 10%.

On January 2, 2013, the Wall Street Journal said, “The Bureau of Labor Statistics estimates that the economy will provide 21,880 new jobs for lawyers annually between 2010 and 2020; law schools since 2010, however, have produced more than 44,000 graduates each year.”

For the non-math majors, that’s a ratio of more than two graduates for every job.

There are way too many lawyers around anyway.

Could something like this happen in medicine? It might not be exactly the same, but an interesting dilemma is looming. A 2011 paper in the New England Journal of Medicine expressed concern that in a couple of years, the number of US medical school graduates will exceed the number of first-year residency training positions available.

In response to projected physician shortages, many medical schools have expanded their class sizes, and several new medical schools have opened or are soon to open.

But the problem is that many years ago, the federal government established a cap on the number of residency training positions in this country. And there are persistent rumors that spending on graduate medical education (GME) will be among the many future budget cuts. It is also not a “given” that existing residency programs could be expanded or more programs could be established even if funding became available.

Here is what Dr. Thomas Nasca, CEO of the Accreditation Council for Graduate Medical Education, had to say in that NEJM article. “We estimate that … domestic production of medical school graduates [will] functionally surpass our current total number of GME postgraduate year-one pipeline positions (posts that lead to initial specialty certification) by 2015 or sooner.” This excludes 10,000 non–US citizen international medical graduates (IMGs) and 3700 US citizen IMGs who seek GME posts in U.S. teaching hospitals.

In other words, not only will there not be enough residency training positions for graduates of US medical schools, there will be no positions at all for IMGs and US graduates of offshore schools.

Then there’s this. The other day, I heard an advertisement on the radio extolling the virtues of one of the new US medical schools and soliciting applicants for its “charter class of 2013.”

I have been a doctor for over 40 years. I’ve never heard of a US medical school advertising for applicants.

The rumor is that the school that is advertising may not be happy with many of its applicants so far.

Could this be a harbinger of things to come? What do you think?

OR staff hair and patient infections

A reader asks Skeptical Scalpel about covering OR staff chest & arm hair to prevent patient infections. To view this post click here.

Breaking news! Operations take longer when residents are involved

Yes, you heard it here first. A new study shows that for six common laparoscopic procedures, resident participation resulted in the surgery lasting from 20% to 47% longer.

The six laparoscopic operations were appendectomy, cholecystectomy, gastric bypass, fundoplication, colectomy, and inguinal hernia.

The paper, published in the Journal of the American College of Surgeons, culled the frequently mined NSQIP database for information on 89,720 operations. The database receives input from a large number of US hospitals, both teaching and non-teaching.

The key results were as follows:

All of the time differences are statistically and clinically significant.

Hospital length of stays for all groups did not show important differences. Cases involving residents were associated with significantly more morbidity for all procedures except inguinal herniorrhaphy and fundoplication. The authors feel that the increased morbidity seen was not clinically significant. It isn’t clear upon what they based that feeling. There was no difference in mortality rates for the two groups for any operation.

In no less than four places in the text, the statements similar to the following were made. “The presence of a resident during a surgical procedure is a surrogate marker for a learning environment in which there are likely to be other health care learners at each of the stations in the operating room.” The other health care learners might be anesthesia residents, medical students, nursing students or others.

This is a completely unfounded assumption. For example, in three hospitals I worked in over the years, we had a surgical residency training program with no anesthesia residents and no student nurses. Conversely, it is certainly possible to have no residents but have training programs for student nurses or scrub techs.

The authors rightly point out that the increased operative duration associated with resident training translates into some inefficiencies. A single operating room might not be able to process as many cases as it could when cases are done by attending surgeons. Also, longer cases might cost someone (third-party payer? patient?) more money since OR costs are tallied by the minute.

The paper concludes, “Additional work must be undertaken to identify strategies to optimize operating room efficiency and to develop alternate strategies to prepare participants for the performance of the procedure.”

And what would those “alternate strategies” be? You can pick up beads on a simulator all you want, but it’s not the same as doing an operation. And assuming open surgery is still being done somewhere, there is no simulator for open surgery.

A patient wants to know when to speak up

A reader asked if I could discuss how to question a doctor without being a nuisance.

Read the question and answer on "Ask Skeptical Scalpel."