In a column last week about chief medical officers I mentioned physicians who were interested in a change of careers by trading their "white coats" for business suits. That got me thinking, what is it with those coats anyway?
In the land of Wimbledon, where tennis players must wear white at the All-England Tennis and Croquet Club's famous tournament, government agencies have instituted guidelines banning physicians from wearing traditional white coats and any long-sleeved garments in order to decrease the possible transmission of bacteria within hospitals. Essentially, the Brits determined that cuffs of long-sleeved shirts are bacteria carriers and should be excluded from hospitals.
The British ban on white coats and the wearing of long sleeves may have seemed a little silly to some on this side of the pond. I mean, the red coats seemed pretty silly, too, and wearing that garb didn't turn out to well for the British. Yeah, that's another story, and coat color isn't the issue.
But a group of physicians and researchers at University of Colorado Health Sciences Center in Aurora, CO, didn't take lightly the British physician coat and long-sleeve ban, and went looking for the proof in the puddin'.
Indeed, numerous studies have demonstrated that white coats and uniforms worn by healthcare providers are frequently contaminated with bacteria, including both methicillin-sensitive and resistant Staphylococcus aureaus and other pathogens. The contamination could come from a variety of environmental sources, from patients, or even the doctors themselves, sneezing, for instance.
Marisha Burden, MD, interim chief of hospital medicine at the University of Colorado Health Sciences Center, and her colleagues began a study last year evaluating the British rule by testing infrequently washed white coats and freshly laundered scrubs of 100 physicians. Burden says the researchers expected the white coats to be loaded with lots more bacteria.
"We compared the physician white coat to the physician standard scrub, short-sleeved and with a pocket," she said. What they found surprised her. "When we compared them, there was no significant difference in the contamination," Burden explained.
In a study published last month in the Journal of Hospital Medicine, Burden and her colleagues noted that not only did they find no real difference between newly laundered uniforms or infrequently washed white coats, they found little difference in the contamination of long and short-sleeved shirts or on the skin at the wearer's wrists following an eight-hour work day.
"Our data do not support discarding long-sleeved white coats for short-sleeved uniforms that are changed on a daily basis," their study states, adding, "no association was apparent between the extent of bacterial or methicillin-resistant Staphylococcus aureus (MRSA) contamination and the frequency with which white coats were washed or changed."
"Bottom line: there was no statistical difference after an eight-hour workday in total bacterial colony count or MRSA," Burden tells me. "It doesn't support the UK guidelines."
According to the Colorado report, 16% of cultures from physicians wearing white coats, and 20% of those wearing short-sleeved uniforms were positive for MRSA. Colony counts were greater in cultures obtained from the sleeve cuffs of the white coats compared with the pockets.
Interestingly, most of the contamination of the newly laundered uniforms occurred within hours of physicians putting them on, Burden says. While the newly laundered uniforms were pristine before use, within three hours of wear, about 50% of bacteria counted at eight hours were already there. So, the bacteria jump on garments fairly quickly, she says. "When they came out of the laundry, they had zero bacteria," Burden said.
Studies are time-consuming and money-consuming. So are the repercussions of decisions by regulators, whether in the U.S. or in Britain.
In September 2007, when the British Department of Health developed guidelines for healthcare workers regarding uniforms in Britain, evidence was lacking, it appears. "There was no conclusive evidence indicating that work clothes posed a risk of spreading infection to patients," Burden's report states.
Burden doesn't think she's causing a stir, per se, just pointing out that Britain's physician clothing policy is misdirected. She says she knows of no such policy making the rounds in the U.S. Colleagues in Britain have told her about disciplinary action if they don't follow the policies.
And even though those white coats seem to hold up pretty well, bacterially speaking, against scrubs or uniforms, "we are not advocating for physicians not to wash their white coats," Burden says with a laugh.
"You have to consider patient preferences," Burden says. "They don't want their physicians to have a dirty white coat. (Patients) want physicians to look professional." She wears a white coat, "I'm a younger physician and it helps distinguish me," she says.
As for those bacteria clinging to the clothing pretty quickly in the study, MRSA in particular is "pretty scary", Burden said. "I thought a significant portion of the uniforms or white coats had it."
Whether having long sleeves or white coats, "I guess promoting hand washing is what you can do to prevent the spread of the bacteria" in healthcare," she added.
For physicians who trade their white coats for business suits by taking chief medical officer positions, there's still the pull of clinical work: that white coat.
In some ways, physicians, ever competitive and super-achievers, want it both ways as CMOs. And that may not be a bad thing for healthcare, but for the physicians, that may mean more work, and for a few, simply not liking the job.
A recent survey of chief medical officers at health systems and hospitals reveals hints of what I'm talking about. The Physician Executive Leadership Center's annual compensation survey for 2009-2010 showed that more physician executives are adding clinical duties to their plates, and going through formal management training and education.
Reflective of physicians' competitive natures, perhaps, a significant percentage of CMOs currently in a senior position, with an average age of 55, have or are pursing a management degree. And the numbers are increasing: from 60% in 2001 to more than 80% in 2009, the survey shows. The degrees sought are MBA or other specialized graduate degrees.
"For most physicians, they are wanting a bigger impact than they have as an individual physician," says David Kirschman, executive vice president PELC, which specializes in physician executive search. PELC has conducted the survey of chief medical officers in hospitals and integrated systems since the early 1980s.
The survey also indicated that the percentage of fulltime CMOs in hospitals and health systems who have clinical duties was up to 15% -- up from 12% the previous year. "More physicians doing clinical work this year – that was a surprise," Kirschman says. "Every chief medical officer in a hospital works a lot of hours and [has] many things to do. When do they have time for clinical work? My guess would be they don't have much time for it."
A note in the survey report suggests that the findings seem "counter-intuitive given the increased administrative and leadership responsibilities of the chief medical officer positions."
Eventually, something will have to give, the report suggests. Eventually the number of CMOs who have clinical responsibilities "will remain low or perhaps fall even further" as the complexity of the CMO position increases. "We believe that those who do report continued clinical and academic duties are in reality minimally involved in those activities on a day to day basis," the report states.
Still, physicians who are continuing to work as CMOs as well as clinicians, whether at urgent care centers or even volunteering at clinics, "see it as a challenge," Kirschman says, "keeping a hand in something they were trained in for so many years." He notes that physician executives sometimes face criticism for "not being physicians anymore: suits." By involvement in clinical activities, "they are keeping their hands in it; and it helps credibility," Kirschman says.
Generally, service line leaders such as CMOs do not have much independence in decision-making, according to the HealthLeaders Media Survey 2011. About 70% of respondents say they have moderate decision making authority, with some independence but major decisions must incorporate other hospital initiatives and priorities. About 6% say their decision-making is largely independent.
Keeping a hand in clinical activities doesn't always mean more money. Interestingly, the PELC survey shows, those with clinical responsibilities earn about 10% less in compensation than those who don't. There's no clear explanation for this, says Aamir Rehman, MD, senior vice president of Navvis & Co., the parent corporation of PELC. "We intend to follow up on this data point in next year's survey."
Contrary to years past, hospitals and health systems are working with physicians on a formal basis in quality and informatics issues on a fulltime basis, he says.
And in that process, the evolving physician and hospital relationship is only gaining importance with integrated systems. Those relationships are still being ironed out. I asked J.R. Thomas, president and CEO of MedSynergies of Irving, TX, a provider of hospital-physician alignment strategies, about this issue. The leadership and experience of a physician in clinical matters appears to help the physician and hospital relationship, Thomas says, citing "doctors who are clinically involved and respected by staff" in healthcare facilities.
With an added responsibility for quality and operations, CMOs are finding their duties have much more "intensity" than in other years, according to the PELC survey. "We project continued emphasis on these duties in incoming years," the survey and attached report states.
Generally, CMOs having more clinical duties also have had more years of clinical practice before entering management, and were happy they made the career turn in that direction. "Virtually all participants feel that their move into management was an excellent decision and they are mostly satisfied with their career and current situations," the PELC survey states.
According to the survey compensation increased 2.5% in 2009 for physician executives serving in a full time chief medical officer position, with the average total annual compensation at $323,967, including base compensation and bonus or incentives. Hospital CMOs reported that they expected their 2010 salary to also increase 2.5 % over 2009, a "gain we expect we will expect to see in the next survey results," the survey shows.
However, the survey notes that 15% indicated "dissatisfaction with their current position, citing significant changes in their duties from previous years resulting in more responsibilities, suggesting that they like being a physician executive but not necessarily in their present situation."
"Their jobs are changing, their responsibilities are increasing and there is probably more work for them to do," says Rehman. "For physicians, more work is not often seen as a disadvantage, but rather a sign of their value to their organizations." In addition, they "assigned work volume" may be too much as part of an expanded job. There may be also instances in which management skills may be required that "they feel they may not have," Rehman says.
And some executives may feel some added stress, he says, because of the physician executive work. "Most physician executives seem to be working as hard if not harder than when they were not in the exec role," he says.
You don't need to be a neurologist to figure out the intricacies of developing the best patient care for a hospital. Well, maybe it helps.
Roger J. Packer, MD, head of the division of child neurology at Children's National Medical Center in Washington, DC, was thinking about multidisciplinary approaches long before they became the focus of many hospital strategies.
The neurosciences team at Children's National Medical Center is one of the largest in the country, having more than 85 pediatric specialists, and dozens of programs focusing on patient care from epilepsy to general neurology. For years, the service line was disorganized. "There was a void until we hit the right structure," Packer, senior vice president of the Center for Neuroscience and Behavioral Medicine at the Children's National Medical Center, tells me.
A decade ago, Packer and his team began a reorganization process that "fostered development of numerous multidisciplinary programs and is fiscally sustainable," Packer and his colleagues write in the recent issue of Pediatric Neurology in a piece entitled, "Center for Neuroscience and Behavioral Medicine: An Innovative Administrative Structure and Possible Paradigm for the Future." That process of change and reorganization, when necessary, continues today, he says.
When the Children's National Medical Center opened in 1970, it soon faced challenges involving its economic stability. At that time, the structure included a department of neurology, with some specialties reporting to it within separate divisions. Other aspects of care that now would be blended within the neurology function reported to a department of pediatrics.
"With a silo mentality, there were individual divisions, and (people) not communicating or being responsible for one another," Packer recalls. That structure, it was decided, "wasn't going to take us where we wanted to be," he adds. "We didn't have the depth of resources to allow people not to communicate or not work toward the common goal."
Among the organizational changes was creation of a Center for Neuroscience and Behavioral Medicine under one roof, in essence, to coordinate aspects of care, Packer says, referring to his neuroscience specialty. In the process, various executive duties were changed and clinical programs underwent reorganization. Meanwhile, the number of board-certified or eligible child neurologists for the program tripled to more than 30 over a decade.
"A stated premise of this new administrative structure involved breaking down artificial divisional barriers to allow the development of multidisciplinary, patient-centered programs, so as to overcome 'turf' issues and [a] 'silo mentality," Packer and his colleagues wrote. "For the Neuroscience and Behavioral Medicine Center, all programs that dealt primarily with conditions of the central and peripheral nervous system would operate under the purview of the center, without constraints of determining if these were 'owned" by neurology, neurosurgery, psychiatry, psychology, genetics, child development or physical therapy."
Within the divisions under the center "we made it clear to the division chiefs at least 50% of the goals had to be common goals, they have had to be shared goals," he tells me. "We use the multiple goals of the division chiefs to make sure we are working together. We don't let turf stand in the way." In that way, "multidisciplinary programs" were carried out, Packer says.
As programs grew, "turf issues were minimized by promoting the approach that all disorders primarily centered on nervous system function were the primary responsibility of the center and not of individual subspecialties or divisions, and the center would set priorities and determine the optimal program structure," according to Packer's report.
Besides issues involving care, "a unique component of the center's structure" involves its administrative and financial responsibility. Since 2001, the center has met its financial targets, and patient revenues for the center have increased from $50 million to more than $77 million anticipated in 2010, according to Packer.
The center's work does not remain static and is continually refined. With the growth of neurogenetic programs, for instance, a division of genetics was transferred to the center.
"In terms of patient care, this is value added," he says, referring to the work of the center and the constant review of its multidisciplinary work. And there's a lesson for others who seek to revamp their structures: "without commitment," he says, "it can unravel quickly."
The priorities and concerns of 1,500 of your colleagues in healthcare leadership are revealed in this comprehensive multi-part survey: HealthLeaders Media Survey 2011.
Although physicians are no fans of healthcare reform and worry about financial outlooks, they are enthusiastic about quality improvement initiatives for patient care being launched within their healthcare systems, according to the HealthLeaders Media 2011 Annual Survey.
The framework for this kind of improvement is being built by many healthcare systems, done best through teambuilding and a multidisciplinary approach for improved patient care.
That certainly was evident at a HealthLeaders Media Rounds panel discussion this week, focusing on cardiac care leadership for improved alignment and outcomes, and held at the Baylor Health Systems in Dallas, TX. Three top officials of Baylor discussed the shared vision for physicians and administration as partners, and the vital need for transparency and data collection as the process evolved.
Specifically, their talkfocused on the Baylor Heart and Vascular Hospital (BHVH), which is part of the Baylor Health Care System. The BHVH opened in 2002 as the first joint venture hospital within Baylor Health Care System with, its officials say, the purpose of aligning physicians and hospital administration for heart and vascular patients. The hospital is 49 % owned by physician partnership and 51% by Baylor University Medical Center.
While it’s important to “facilitate the economic model,” says Kevin Wheelan, MD, chief of staff at BHVH and co-medical director of cardiology, a desire of physicians and administration is to “solve a common goal of providing excellent patient care.”
“It’s about achieving excellence in providing a commitment to the community and environment where we can practice the art of medicine,” he added. “Baylor has been a physician friendly institution, but the dynamics of that relationship has changed dramatically” following the creation of the BHVH, with the “medical staff and working at an equal partnership.”
As Wheelan and other top Baylor officials, Nancy Vish, RN, FACHE, president of BHVH, and Paul Convery, MD, MMM, chief medical officer for the Baylor Health Care System, see it, improving coordination between physicians and administration is a constantly evolving process. Variables within the system run through it, such as medical leadership meetings; the hospital system’s physician leadership councils – responsible for medical staff governance and alignment roles – and other work products, such as a special focus committees, where physicians and administrative staff focus on common goals. In addition, hospital leadership established a physician leadership development program, which includes training for physician “champions” –physicians who are considered high-level doctors in quality and safety specialty core areas.
Indeed, the HealthLeaders Media industry survey shows that physicians nationwide are heralding quality improvement initiatives, with 76% saying they believe such programs will have a positive or strongly positive impact on their organizations. The survey shows that quality and patient safety experience, and developing an accountable care organization are among the top priorities they see over the next year, according to the survey data.
Physicians consider the impact of patient experience and patient-centered care as extremely positive. The survey shows that 60% and 20% respectively, believe such initiatives will have a positive or strongly positive impact on their organizations.
When the Baylor Heart and Vascular Hospital began, physician and administrative team started with common goals and a similar vision for improved patient care, but Vish acknowledged there were challenges “getting the entire team on board.”
But that has changed. The hospital’s twice-monthly medical leadership meeting involving physician and administration leadership is a key element toward “problem solving, goal creating and strategizing,” says Wheelan. The meetings “get longer with the complexities of certain issues and the government always continues to throw us curve balls of new processes and paperwork to deal with,” he says.
“The meeting is the environment in which we do a lot of problem solving. It’s a very open environment to address issues of quality, service, finance,” Wheelan says. “Data is a very critical element to our process and we believe the data needs to be transparent. Without metrics, comparisons and benchmarks, it is very difficult to achieve a higher level of excellence.”
“A lot of physicians will bring ideas problems from a clinical perspective and then hand off to an administrative team,” says Convery. While there have been tendencies to “compartmentalize,” meetings between administration and physicians on a “regularly structured basis helps keep all of that moving.”
The Accelerating Best Care at Baylor is an innovative educational program that focuses on healthcare quality and improvement, teaches healthcare leaders theory and techniques of rapid cycle quality improvement, outcomes management and staff. It facilitates the enhancement of skills by physicians, nurses, administration and others to lead quality improvement efforts.
Referring to physician and hospital alignment in co-management plans, panelist Tim Attebery, CEO of Wellmont Cardiology Services in Kingsport, TN, expressed some caution for those embarking on the process. He says many physicians are taking the wrong, initial steps. “A of cardiology groups are in discussion with hospitals about an integration arrangement and they have not put together a service line management arrangement,” he says. For physicians to be “truly at the table to be accountable for the overall performance of the enterprise, they have to have management responsibility and those responsibilities need to have quality metrics, cost metrics, patient satisfaction metrics and growth metrics. The physicians need to maintain a level of intensity and engagement.”
Suzette Jaskie, MBA, executive director of Frederik Meijer Heart & Vascular Institute for Spectrum Health in Grand Rapids, MI, says physicians are weighing autonomy or working within a system after determining “their ability to impact the system of care.” They may find that “autonomy is a small price to pay for impact,” she says.
The fallout is just beginning in Maryland over the state’s highest court’s decision last month that upheld a state law prohibiting physicians from referring patients for MRI, CT and radiation therapy services to providers in their own group practice.
Radiologists, who applauded the court’s decision, and orthopedists, who were on the losing end of the court’s determination, each say their arguments were made on behalf of patients. But the court battle also was about doctor vs. doctor, over money, with the backdrop of healthcare reform in the debate.
The radiologists say the case was one of selfish self-referral, pure and simple. “Studies have shown that there is very little, if any patient benefit to self-referral of advanced imaging and radiation therapy,” says John A. Patti, MD, chair of the American College of Radiology board of chancellors, quoted by John Commins in HealthLeaders Media. “Instead the practice often results in significant unnecessary utilization of imaging, unwarranted radiation exposure, lower quality of care and increased cost that is ultimately passed on to patients.”
Siding with the radiologists, Baltimore Sun columnist Jay Hancock also wrote recently that having the door open for such self-referrals is, “what’s choking American healthcare.” He added, “The system is becoming unaffordable because of many unneeded heart stents, lab tests, surgeries and MRI scans.”
Lost in all this, says the American Academy of Orthopaedic Surgeons, is that having the in-office referrals makes healthcare easier for patients. “Significant technological advances have been made in our field so that patients can receive timely and available screenings from the comfort of their doctor’s office,” says John J. Callaghan, MD, president of the academy.
“This ruling could have a dramatic effect on the treatment and quality of the care of Maryland patients,” Callaghan says. “In the interests of our patients, the academy will maintain our commitment to this issue.”
Self-referral has been a stormy issue nationally for years. In its recent decision, Maryland’s highest court affirmed a 2007 decision by a lower court prohibiting the self-referral of patients. The Maryland State Board of Physicians had not taken a position on the issue regarding MRI machines and other equipment until 2006.
The American Association of Orthopaedic Surgeons has been following the case closely as it unfolded over three years ago. In 2007, the American Association of Orthopaedic Surgeons filed an amicus brief in the case, along with the American Association of Neurological Surgeons, the Society of Cardiovascular Computed Tomography, the American Urological Association and the American College of Surgeons.
“There is a very significant health care policy discussion to happen here, …it’s wrong,” says attorney Howard Rubin, who represented a dozen practioners, emergency medicine doctors, and urologists involved in the case, says of the Maryland high court’s decision. “It shuts down ability of a patient where to get their scans.”
“The heart of our healthcare policy is moving toward integrated systems,” he adds, “as opposed to fragmented, created silos. It’s a question of trust.” But there are doctors who don’t trust the motives of other doctors. Laura I. Thevenot, CEO of the American Society for Radiation Oncology says that the ruling preserved strong patient protection against abusive physician self-referrals.
“Today’s ruling represents a victory for patients in Maryland,” she says. “We hope this decision will jump start congressional action to ensure that all Americans can make independent treatment decisions based on quality care, not perverse financial incentives.”
The federal Accountable Care Act requires self-referring physicians to disclose their financial interest to patients and tell them about other facilities near them. Last year, the American College of Radiology says it unsuccessfully led an effort to put language in the federal ACA that would eliminate the in-office ancillary services, exception for advanced imaging and radiation therapy.
An article in the January issue of HealthLeaders Media, explains that Medicare payments for non-invasive diagnostic imaging (NDI), including MRI and computed tomography (CT ) scans are now higher to non-radiologists than to radiologists, citing an article in the Journal of the American College of Radiology.
Self-referral among non-radiologist physicians is behind the change, says David Levin, MD, of the department of radiology at Thomas Jefferson University Hospital in Philadelphia. Non-radiologists have become increasingly aggressive in their performance and interpretation of imaging, according to Levin. If policymakers, healthcare executives and other leaders want to control the costs of imaging, they need to either bar self-referrals or significantly restrict them, he said. “This is what is driving up costs.”
Levin acknowledges the issue of self-referrals is “a political hot potato.”
No kidding. In Maryland, the issue won’t stop with the state medical board, or the high court. There is now legislation being considered in Maryland’s General Assembly, where lawmakers will debate whether to implement the self-referral exemptions that the orthopedists want. And there will be more debate, too, doctor vs. doctor.
A study finds a "significant gender gap" in starting salaries, by gender, of physicians leaving residency programs in New York State between 1999-2008. But researchers writing in Health Affairs say this is an unexplained trend that seems to be growing over time, and needs to be further studied.
Within a decade, male physicians leaving residency programs were consistently and increasingly paid more than women, 17% more in 2008, reflecting significant gender pay gaps, according to a Health Affairs study released Thursday.
On the face of it, just looking at the numbers, it seems, either blatantly sexist or the result of gender discrimination. Not so fast, say the authors. There may have been other reasons intrinsically involved, such as women who wanted special working arrangements, or had different lifestyle goals, such as related to child rearing. Or, they may have had different negotiation styles or agreements that set the stage for the salary levels.
Or it may be the result of all of the above, because, as far as authors of the study are concerned, their findings are simply inexplicable, or in their words, "unexplained."
In examining starting salaries by gender of physicians leaving residency programs in New York state during 1999-2008, the researchers found a "significant gender gap" that they say cannot specifically be explained by specialty choice, practice setting, work hours or other characteristics. That flies in the face, generally, of previous research that shows gender differences can specifically be accounted for by a tendency of women to go into primary care, take time off for children, or cut back hours, they say.
The gap, they say, existed throughout the ten-year survey period. According to their figures, in 2008, male physicians newly trained in New York made on an average $16,819 more than newly trained female physicians, compared to the $3,600 in 1999.
"The power of physicians' observable characteristics – such as gender and specialty choices – to explain the differences in salaries diminished over time, which has created a widening unexplained starting salary gap between male and female physicians in recent years," authors wrote in the study.
"I was surprised by our findings, in particular by the widening, rather than shrinking gap in time," Susan E. Gerber, MD, an assistant professor in the Department of Obstetrics and Gynecology, Northwestern University in Chicago, and one of the co-authors of the study, told me.
"In all likelihood," she adds, "This is a multi-factorial phenomenon. While it is unclear why it would be on the rise, we cannot exclude the possibility that gender discrimination plays a role."
Tony Lo Sasso, a professor and senior research scientist in the health policy and administration division, for the school of public health, University of Illinois at Chicago, another co-author, tells me while gender discrimination is a possibility, "it doesn't ring true," because there is too much room for other, unexplained probabilities, such as specific work arrangements, for the reduced salaries for women.
"We should be cautious in trying to ascribe explanations which are essentially unobservable things, not observed by us," Lo Sasso says.
Lo Sasso and Gerber agree that many variables are involved, such as specific work-life arrangements among men and women, and lifestyle choices, generally, that go into the mix of what occurs on pay day for work and family balance. In some ways, they are living it. They are married.
Gerber says there are areas in their study's data collection that did not account for all the subtleties in physician practice styles that could account for some of the salary differences, and hence, she says, there is need for further study. For instance, "on call" preferences may not have been picked up (in their study) and are likely reflected in compensation imbalance," she says.
There are also other reasons for the pay differences that could simply be the result of negotiations between physicians and their office management. "Newly trained physicians typically have no experience in contract negotiation, and it is possible that there is a gender disparity," Gerber says.
Still, she notes: "I cannot explain why that would have increased over time."
Gender gaps exist through a wide variety of settings, and there is a "wide spectrum of individual preference in changes in workplace settings or environment," Lo Sasso says.
In looking at their data, Lo Sasso and Gerber and their other co-authors note that other previous studies have been inconclusive about pay difference reasons, and "no clear conclusion on this issue has been reached."
New York State is home to more residency programs and more resident physicians than any other state. The sample included 4,918 men and 3,315 women, and more than 62% of physicians responded.
The salary discrepancies were revealed somewhat in the study and survey respondents. There were more women who planned to devote fewer than 40 hours per week to patient care, and a lower proportion of women who planned to devote more than 50 hours per week to patient care. Women also had a larger representation than men in lower-paying specialties, for instance, 13.9 percent of women were in pediatrics, versus 5 % of the men. Women also had lower average starting salaries than mean for nearly all specialties
As they began their study, the authors thought an explanation for the pay differences could be the increased number of women in primary care practice. However, while the number of female physicians in primary care has indeed been rising, they say, there have been proportionately a decreasing percentage of female physicians having chosen to enter primary care fields.
The study did not include possible scenarios that could reveal more of the differences in salaries. For instance, the study did not include the questioning of respondents about marital and family status.
Indeed, Lo Sasso says, the survey findings may come down to "women making these tradeoffs, willing to give up the less tangible aspects" of physician work, such as salary, for a work-life balance.
Maybe. But maybe not so fast, according to his wife.
"There are certainly demographic changes that affect career choices, and younger generations have different goals as far as a work life/home life balance," says Gerber.
"However, most other studies have demonstrated a similar impact of this demographic shift on both genders rather than on just women," she adds. "Both male and female trainees are increasingly likely to seek employment opportunities with flexibility in scheduling, as opposed to the old 'solo practice' model," she says, noting her experience in the practice of obstetrics and gynecology.
Regardless, there has to be further, detailed study into what they have begun to find, the authors say, opening the door for "new considerations for medical institutions and policy makers."
Future research would benefit from a "more detailed understanding of the specific job characteristics," Gerber says. In that way, it could be determined whether "this compensation disparity truly reflects differences in the jobs themselves, or other forces at play in the labor market."
In the wake of healthcare reform, it is more important than ever to know more about the physician labor force, says Lo Sasso, not only for physicians themselves, but overall patient care.
Ardis Dee Hoven, MD, chair of the American Medical Association, told the House Judiciary Committee this month that the medical liability system is "broken" and "irrational." After her testimony, the House, in bipartisan fashion introduced a measure that would reform the medical liability system. But Hoven concedes she has no idea when such a measure might be realized as law.
Hoven is a specialist in infectious disease medicine and internal medicine based in Lexington, KY. She has been a member of the AMA board of trustees since 2005, and in June 2010 began serving as AMA chair. With broad experience on many physician-related issues, she says she has testified several times before Congress, but never before the Judiciary Committee. Recently, she was appointed to the National Advisory Council for Healthcare Research and Quality and has served on numerous AMA boards, including the practicing physicians' advisory board.
Days after her January 20 testimony calling for "meaningful" medical liability reform, Hoven told me she thought members of Congress heard her message all right, but she didn't offer predictions what they would do. It was interesting that she was invited to speak at one of the first hearings of the 112th Congress. Of all the issue before it, Congress was ready to listen to doctors complain about medical liability: Why?
"Several people have commented to me: you were invited to speak and this is the first time they've met in this Congress," Hoven told me. "What does that mean? I think it means that, I hope this correct, meaningful medical liability reform is back in a place it should be and we can make some progress on this."
"The cost of medical liability related issues," she says. "There are more definitive numbers now. We have a much better understanding. Doctors were talking for a long time about defensive medicine, but nobody would listen to us. The other piece is the public."
Unlike the past, she insists, "the public recognizes and thinks that the medical liability system is a costly system and dos impact patients as well. You have public concern now, which nobody had paid much attention to before. You have dollars attached to that, and I think people are looking at (medical liability) in a different light than they used to before."
For one thing, the Republicans in the House are digging deep into President Obama's healthcare reform and doing whatever it takes to get rid of it. Whatever they do, however, a potential trap door awaits: the Senate, led by Democrats.
As the political scenario unfolds, there stands the AMA, which truly wants medical liability reform, and has wanted it for years. So the organization is moving toward whatever party curries favor, and vice versa. If it's the Republicans, so be it. And besides, the polls show, physicians generally aren't exactly thrilled with many aspects of healthcare reform.
In her testimony before the House committee, Hoven called the current medical liability system increasingly irrational and in need of reform. Then she toted out figures from reports showing that the current system is patently unfair: to physicians, and patients. Over the years the AMA has been tweaking their message to change the liability system. Their latest argument: it hurts patients.
Nearly 61% of physicians aged 55 and older have been sued. A majority of claims field against physicians lack merit, as 64% of liability claims that were closed in 2009 were dismissed or lacked merit, Hoven told the committee. On average, 95 medical liability claims were filed for every 100 physicians, she said.
The threat of malpractice claims drives up healthcare cost by at least $70 billion to $126 billion each year, according to a 2003 Department of Health and Human Services study, Hoven says, because physicians are forced to practice defensive medicine. And patients don't win out, she says, because those harmed by negligence really don't get the rewards; that goes to the attorneys and courts.
For too long the public hasn't understood the meaning of medical liability reform and what it means to them, she says. In terms of medical liability, she says there is an acknowledgement by the public that "it just impacts the cost of healthcare."
"So, you've got public concern now, which nobody really paid much attention to before, and now you've got dollars and figures attached to it, and I think people are looking at it in a different light," she says.
The AMA harps on changes that were made in medical liability in Texas and particularly California. The AMA supports reforms based on California's Medical Injury Compensation Reform Act of 1975 (MICRA) that caps non-economic damages at $250,000. While premiums generally were raised an astronomical 945% nationwide between 1976 and 2009, premiums in California increased 261 % -- less than one third of that amount.
"We've got good pilot studies on this. Look what happened in California," Hoven says. Changes have proven to be "cost effective. This stuff really works. I think that is the environment we find ourselves in right now. There is good documentation now. They cannot fly in the face of facts."
It's interesting scenario, this politics business, the shifting of positions, aiming for a middle ground, finding a piece of the "puzzle," as she calls it. But that's some of the very reason the AMA had been criticized over time, in part, for what some described as limp support of healthcare reform and its failure to win concessions in areas such as the "doc fix."
"The AMA was on record from the get-go with healthcare reform that medical liability reform be part of the whole thing," Hoven says. "It has to be part of it. You can't separate this and do carve-outs and make it all work together."
Many have thought meaningful medical liability reform should have been part of the healthcare reform issue, as well, and there has been too much tepidness on the part of physician representatives, the AMA included.
With her testimony before Congress, the AMA sees its move toward medical liability reform as happening at the right time and place.
Although Republicans are interested in dismantling healthcare reform, generally, Hoven concedes that medical liability reform "can be dealt with as a stand-alone, in some ways that's better. When you try to bind this in, I'm afraid it could get buried in something or marginalized. The administration has gone on record in supporting medical liability reform."
"Part of this is driven by the Republicans taking over the House," she adds. "We have been asking all members – Democrats and Republicans to do it," Hoven says of medical liability reform. "There is a lot of push now, as we talk about the Affordable Care Act," she says.
After her testimony, she says she was taken aback by some "theatrics" among members of Congress, but overall, she felt she got a fair shake by the committee. When I asked her about prospects for legislation, she said, "I have no idea. I could not tell from that hearing one way or another."
By January 25, however, a bipartisan bill was introduced to include what co-sponsors David Scott, D-GA, and the committee chairman, Lamar Smith, R-TX, called reforms to fix the "broken medical liability system, reduce healthcare costs and "preserve" patients' access to medical care. Another co-sponsor was Rep. Phil Gingrey, MD, (R-GA). The AMA and 100 other medical and physician organizations then sent a letter to the lawmakers, supporting the proposed Help Efficient, Accessible, Low-cost, Timely Healthcare (HEALTH) Act of 2011.
Maybe there's a reason the name is so cumbersome.
There is a "long road" ahead, for whatever prospects for change takes place, Hoven said before the bill was introduced. "You want this to be taken care of before 2012," she says, noting another political benchmark: the presidential elections.
The enrollment for meaningful use initiatives has begun, and for physicians that means a slew of requirements that must be met to gain the financial rewards attached. You are forewarned: don't forget about quality.
Before anyone starts counting their dollars, or wondering what went wrong, researchers Jane B. Metzger and Jared M. Rhoads for CSC, a technology and healthcare company, did some investigating. They spent time "deconstructing" the core measures to meet the meaningful use requirements, especially in terms of "quality" reporting data.
They looked at the necessary information that has to be documented by large medical groups, in particular. Metzger, principal for emerging practices for CSC, based in Falls Church, VA, says that in looking at many levels of meaningful use requirements, they found "hidden functional requirements. "
Hidden? "We call these hidden because they aren't immediately apparent from viewing the list of Stage 1 requirements for eligible professionals," Metzger says. "Stage 1 is largely focused on data capture."
As a result, physicians in large groups should include a wide scope of quality issues in documenting their meaningful use initiatives, Metzger says.
"A minimalist approach to documenting this information just to meet the meaningful use threshold will not provide sufficient information for quality reporting," says Metzger and Rhoades, a senior analyst for CSC, outline their concerns in a white paperPhysician Quality Reporting - The Hidden Requirements of Meaningful Use." In particular, they refer to Stage 1, the requirements for 2011 and 2012, in which "health systems and medical groups need to perform a detailed analysis" of data for quality measure reporting.
The quality provisions within meaningful use data gathering may be complex, but that is to be expected, Metzger says. "Given the orientation of the program as an investment in improving health care, the inclusion of quality reporting in meaningful use is not surprising," they write. "In a health system or medial group, a careful analysis of quality reporting must precede final decisions about how to approach Stage 1 meaningful use for EPs (eligible professionals)."
Metzger says that while she is not predicting how physician practices may be impacted by the meaningful use quality requirements, she notes there is enough complexity in the requirements that should make physicians be concerned and take notice.
In December, the Office of the National Coordinator for Health Information Technology (ONC) and the Centers for Medicare & Medicaid Services released documents shedding light on what physicians and hospitals must do to qualify for EHR incentive payments under the HIECH Act. To quality for incentives, physicians and hospitals must be using "certified EHR technology" in a "meaningful manner." Enrolment for the meaningful use incentives began January 3, 2011.
There is confidence among healthleaders that they will achieve meaningful use within the government's push for electronic health systems by 2016. In a recent HealthLeaders Media Intelligence Report, E-Health Systems, Opportunities and Obstacles, 90% of healthcare leaders say they'll achieve meaningful use from the governmental push for electronic health systems by 2016.
In the meantime, 60% of physician leaders say they are satisfied with the overall functionality of their systems. Of the respondents, 46% cited lack of financing or resources as the greatest challenge of implementing e-health systems, and about a quarter are still struggling to overcome physician resistance to electronic health systems.
On its face, the medical record information required for the set of measures in meaningful use may seem simplistic, Metzger says. But it is much more complicated, she says, to include determinations, for instance, "if the recommended care was given or desired health outcome achieved."
"One of the points of our (white paper) is that any EP or medical group working to meet Stage 1 requirements needs to look at the specifics as they pick the measures they will use to meet the quality reporting requirement," she says.
For physicians, the bottom line is this: "Health systems and medical groups need to gain a detailed understanding" of what is required, especially for quality measures, Metzger says.
Months ago, the American Board of Internal Medicine proposed sanctioning 139 physicians for passing along and receiving test questions from a test preparation company.
While many physicians feared the sanctions would cost them their jobs, it now appears dozens of the physicians cited won't be held for sanctions the ABIM initially sought.
As the process began, I was wondering if the ABIM officials were over-reaching in their inquiry, and it certainly seems they did. Initially, it reached back more than 20 years to find alleged violators. The board talked tough.
That tough talk is ebbing and now there appears to be reconciliation. In some cases, recommended sanctions have been rescinded, in the words of the ABIM president Christine Cassel, the ABIM president and CEO, acknowledged in a statement to me.
Meanwhile, Drew Wachler, an attorney representing 40 physicians, says the ABIM has allowed his clients to resume their careers, by shifting course, in part. Still, he says, he hopes ABIM will revise its procedures, and that remains to be seen.
The controversy over the testing began when the ABIM cited the 139 physicians in June for improper conduct over the testing. The board took steps to strip board certification of many physicians for periods ranging from one to 5 years. The ABIM also sent what some have dubbed "shame on you" letters to about 2,700 physicians who took the test. These doctors were not accused of wrongdoing, but the ABIM said the doctors should have known what was going on.
Aside from the test takers, the major target of the investigation was Arora Board Review, a New Jersey test-preparation course. The principal of Arora Board Review, being sued by ABIM has surrendered his certificate to perform the tests. Arora Board Review shared information garnered from physicians who took the ABIM test with other would be test takers for years, according to ABIM.
Wachler, one of the many attorneys representing physicians caught up in the ABIM probe, says that in many cases ABIM has shifted from its original position of outright sanctions "in a way that will allow these doctors to continue their careers."
Wachler, based in Royal Oak, MI declined to discuss the specific allegations involving his clients, nor the ABIM's exact determination of their cases. Throughout the legal process, Wachler says that it's been his goal to reach an "alternative resolution" with the ABIM following the initial charges against his clients. Besides preserving each physician's career, he sought to "minimize consequences of licensure, maintenance of staff privilege employment and participation with third party payers."
It appears that ABIM had sought multi-year suspensions in many cases, according to sources. In some instances, ABIM has sought community service from the physicians, although that has not been detailed. Regardless, there is certainly anger among some physicians over the length and breadth of the investigations, the penalties, how physicians were targeted, and for the kind of infractions involved.One attorney wrote to HealthLeaders Media that he was able to get his client's matter resolved. "It appeared to me that the ABIM people did not review the evidence before (issuing) their letters," the attorney wrote.
The appeals have certainly dragged out, in some cases, for months. Without characterizing the length of the appeals, most of the physicians who received recommended sanctions arising from the investigation "have pursued appeals through ABIM's standard robust, three-stage appeal process," says Cassel, the ABIM president.
"Some have been resolved and some are ongoing," Cassel said of the cases. "Each appeal involves unique facts and circumstances."
Some recommended sanctions have been affirmed, she adds. "In a few instances, recommended sanctions have been rescinded." Cassel also did not elaborate. "In any event, individual proceedings are confidential," she says.
"The recommended sanctions and appeals process reflect ABIM's commitment to maintaining the integrity of the board certification process and fulfilling ABIM's obligation to the public" Cassel says.
As for Wachler, he hopes to see some changes within ABIM procedures as the organization weighs potential disciplinary actions, and seems reconciliatory.
"Once we began working with ABIM they have been consistently sensitive to attempts to resolve matters on a case-by-case basis that would balance their view of what happened, but also recognize that many of these doctors are exceptional individuals who have a lot to offer society," he says.
Wachler acknowledges he has not agreed with every aspect of the ABIM position.
Wachler is hoping that ABIM will implement changes to its appeals process and regulatory procedures in the wake of the current investigation. Wachler says he wants to continue "constructive work with ABIM to reach a resolution for each client that will not jeopardize their career."
That hope, however, rests with a conclusion of the appeal process, whenever that may be.
On the face of it, it almost sounds like some CIA operation: "The Proactive Office Encounter Approach."
But it's not clandestine, and there's the rub. The Southern California Permanente Medical Group's patient care system, dubbed POE, appears to reflect what healthcare reform is all about, with designs on improving quality and establishing data to back up what they do, working toward a clean slate of transparency.
The POE system allows physicians to begin focusing on preventative and chronic care needs of patients almost as soon the patients step inside the door of their offices, whether the conditions were reasons behind the visit or not. The system uses, in the medical world parlance, "standardized workflows" and "sophisticated information technology" to achieve its outcomes. Whatever The Southern California Permanente Medical Group calls it, the system is about carrying out preventative care.
Since its inception, POE has contributed to sharp improvement in the group's clinical quality performance, in areas ranging from colorectal screening to blood pressure control, says Michael Kanter, MD, regional medical director of quality and clinical analysis for The Southern California Permanente Medical Group. It is the physician's group for Kaiser Permanente members in Southern California.
Clinicians, labor partners, and health care professionals and administrators work collaboratively to develop the process, in which electronic medical records are important components. Even before a patient's visit to the physician's office, staff works to identify "gaps in care" for particular patients as their histories become better known.
"One thing to keep in mind is every time a patient with high blood pressure comes in for a visit, even if they are not coming in for a blood pressure check, it is another opportunity to monitor and speak with them about their blood pressure no matter what department they are going to since every department is documenting patient care gaps," Kanter says. "This is also a demonstration of what we refer to as complete care, which is providing every aspect of care to our patients throughout their life cycle."
In instances where patients have high blood pressure, they may be placed on medication and begin an ongoing monitoring process. Also, they may referred to a hypertension clinic, and also begin health education classes and instruction. Proper nutrition and exercise programs are also established. The idea is to get the blood pressure to an appropriate level.
"Since we've implemented this new way of practicing, we've seen many cancers detected earlier and found cases of undiagnosed hypertension, and we have some of the best blood pressure control rates in the country," Kanter says.
The conclusions drawn from an analysis of data compiled by POE show an improvement in clinical strategic goals and in "closing care gaps" at every opportunity. Some of the improvements from 2006 to the second quarter of 2009 include:
• An 18.5% increase in patients screened for colorectal cancer, from 52.5% to 71%
• A 17% increase in the number of patients counseled to quit smoking from 53% to 68%.
• A 12.2% increase, from 70.5% to 79.6% in controlling high blood pressure for patients aged 18 to 85.
• A 9.3% increase in the percentage of patients given a retinal screening test from 61.6% to 70.9%
While individual physicians, departments and medical centers have previously implemented various programs to address patient care needs, of course, Kanter sees a difference in his staff does by, again, closing those "preventative and chronic care gaps."
Closing the "care gaps" – isn't that what every physician wants to do? Kanter agrees. In "most physician offices, they do not have complete access to all the relevant information about a patient," he says
In many instances, a primary care doctor would refer a patient to a dermatologist, but that dermatologist would not know, for instance, she needed a mammogram, Kanter says. Under the proactive encounter, "each patient contact presents an opportunity to remind the patient that she needs a mammogram," Kanter says.
"The idea is to get patients the tests and/or other preventative measures they need regardless of where they enter the Kaiser Permanente health system," Kanter adds.
Overall, patients have been receptive and have not felt the added information would be intrusive, he says.
"Patients are particularly impressed when they visit a physician or other provider who is not their primary care physician and are offered a flu shot, or a mammogram" Kanter says. "They might expect their primary care physician to have that information, but are particularly grateful when they get reminders from receptionists and others in specialists' offices. They are impressed to see how much information their primary care doctor or specialist has at his or her fingertips."
Kanter is excited about the possibilities. I keep thinking about the quality initiatives being launched under healthcare reform, and many of the plans are wrapped around the idea of detecting health issues involving patients before they become full-blown problems. And that's what the POE is all about. Kanter says the POE is working for physicians, too.
"Physicians like POE because it allows them to do what they were trained to do: talk with patients, diagnose issues and treat them," Kanter says.
