Friday, September 20, 2013

Khullar on Carrots and Sticks

New York Times writer (and medical student) Dhruv Khullar discusses how, "Medicine is More than Carrots and Sticks".

Here is the opening:
“Did you take it out yet?” my supervising physician asked me, referring to the urinary catheter I placed in a patient several days before. “You know they’re keeping tabs on that now?”
I did know. We had recently discussed performance metrics during morning rounds, and were taught that prolonged urinary catheterization caused many hospital-acquired infections. Hospitals were now being penalized for that sort of thing.
Several months before, I had attended a conference where there was a heated discussion about whether to tie reimbursements to how well physicians managed hemoglobin A1c levels – a marker of blood sugar control in diabetic patients. Some argued doctors would pay closer attention to diabetes control. Others thought they would simply select healthier, more compliant patients to make their jobs easier.

Suddenly, a stately gentleman stood up and the room fell silent. I recognized him as one of the most distinguished faculty members at my medical school, a legend that physicians across the state consulted on their most difficult cases.

“What on earth are we teaching these young doctors?” he asked, exasperated.

He stressed that a physician’s responsibilities — to avidly manage diabetes or blood pressure, to promptly remove a urinary catheter, to ensure patient compliance with medications — come not from incentives, but from a sacred duty we assume upon entering the profession. Overemphasizing the former while underemphasizing the latter, he argued, does a disservice to the medical profession and to our patients...
Yet all the "pay for performance" incentives are leading to precisely this kind of sterile, "cookbook" medical care.

This is one of the disturbing facets of American medicine under ObamaCare that I also discuss in my recent PJ Media piece, "How Big Medicine Will Affect Patient Care".