I had the pleasure of spending an entire day with physicians at the Washington State Medical Association (WSMA) annual conference in Seattle on Saturday, October 12.
In addition to the fantastic speakers who talked about medicolegal issues, technology, and population health, I also heard about policy development with the House of Delegates and new legislative issues at the state and federal level.
Here are my take-aways from the experience.
Attending the WSMA conference was extremely rewarding. I was privileged to attend as a healthcare professional and was one of the few non-physicians in attendance.
In total, over a dozen practitioners from all walks of life and specialties shared their perspective with me about the healthcare industry and the future of the MD profession. A common theme in every interaction was the strong motivation to care for patients in their local communities, and to creatively help under-served individuals. This mirrors the challenges and focus I have observed in my work with non-MD healthcare practitioners.
The most interesting highlights for me at this conference were:
Physician Burnout and Suicide
A strong emphasis throughout the day was an epidemic of physicians who experience overwhelm on the job. We heard about this topic in several legislative issues and from nearly all of the speakers.
The rate of physician burnout is growing every year, and it affects not only currently practicing doctors but also those who are newly entering the field. MDs face mounting pressure to achieve high productivity, high quality, low error rate, and to generate a high volume of patient visits. Under pressure to perform with limited control, physicians are an increasing danger of experiencing a professional and personal crisis.
Unfortunately, a significant number of doctors choose to leave the field of medicine. Those who remain tend to muscle through it, or to cut back their hours. Ultimately, experts predict this will lead to a huge shortage of physicians in the next few years. No practical solutions were suggested for how to solve this problem.
Physician suicide is another topic that was mentioned often. It is estimated that 400 doctors die by suicide each year. We heard some discussion about current mental health services which are available to physicians (the Washington Physician Health Program and the Washington Medical Commission). There seemed to be an equal sentiment of support and criticism of the current available services.
From what I observed, the root causes for physician burnout, depression, and suicide appear to stem from 3 things:
- A lack of support from peers, employers, and regulatory agencies;
- Humiliation, shame, and demoralization during the investigation of any violation, even if it is found to be untrue; and
- Victimization from a lack of any control over the practice of medicine, an inability to defend themselves, and a ruined reputation for even minor infractions.
At breakfast, I sat next to a gentleman named Dr. Ken Bachenberg, a retired anesthesiologist who has worked with a team of doctors to develop a tool called The KavuMD™ Project (an initiative of the Physicians’ Wellness Alliance). This program allows doctors to receive discreet mental health support and is similar to one that is successfully being used in Oregon by hundreds of physicians. Dr. Bachenberg hopes that the KavuMD pilot program will help more physicians to find balance between productivity and quality of life.
Newly elected WSMA president William Hirota, MD attended the First-Time Attendee breakfast and was very welcoming. Halfway through the day, I had a chance to speak to WSMA past president Tom Schaaf, MD, MHA about burnout and the support that is available to physicians.
Evaluating Product Safety
A fantastic pain management physician who works in Emergency Medicine spoke to me about the opioid epidemic.
She also talked about the problem of in-office product sales and how difficult it can be to operate a profitable practice without resorting to nontraditional means. In her opinion:
“Doctors are concerned about how to survive; they don’t want to be accused of an ethical violation, but reimbursement rates are so low that it’s tempting to sell products like everyone else.”
She said that patients can become confused about the validity of nutritional supplements or other products that physicians are selling — including cannabinoids (CBD) — for which there is very little longitudinal research (see Current Psychiatry Reports paper).
When evaluating a product, this doctor recommends that patients should ask 4 questions:
- Is the product safe?
- If yes: Can you afford it?
- If yes: Is there enough data to prove its effectiveness?
- If yes: Does it improve your condition?
She thinks patients should be wary of any nutritional supplement products that claim to “cure” diseases, and to evaluate based on research… not on flashy marketing.
Another practitioner told me that the specialties which most frequently sell in-house products include:
- Dermatologists (skin care products)
- Plastic Surgeons (beauty regimens), and
- Optometrists (eyeglasses and contacts).
“Private labeling” of products, especially skincare, is a booming business. One doctor told me,
“Practitioners can slap a label on anything and make it appear exclusive, despite the fact that it is not a unique formulation. They don’t always tell patients that there are plenty of cheaper alternatives on the market.”
A few doctors told me that it is very common for physicians to sell products such as skincare creams, eyeglasses, and podiatry devices even if these are not necessarily indicated for every patient.
This conflict of interest seems to be an open secret in the medical community, even though everyone I spoke to indicated they believe it is unethical (especially when physicians promote Multi-Level Marketing products). “Good luck finding anyone in these practices who doesn’t push products to their patients,” said one doctor wryly.
On the other hand, it was wonderful to hear that so many practitioners are strongly in favor of ethical decision-making. Every doctor I spoke to believes that product sales should not be sold in a practitioner’s office. Only one doctor said he agrees that selling from a practitioner’s office is not ethical but added that “doctors sell in their office so often, it would be difficult to stop it altogether.”
(The sale of products by a physician is an ethical violation of a number of medical associations’ Code of Ethics, which can be found here.)
Ethics of Self-Referral
Obstetrics is another specialty which has the potential for unethical sales practices. One family doctor shared his concern about obstetricians who encourage every pregnant mother to get an ultrasound — despite the fact that an ultrasound is not indicated for every pregnancy (something that surprised me).
I was also surprised to hear that family physicians can serve as the primary practitioner for prenatal care and birth in exactly the same capacity of obstetricians for a normal birth.
Family doctors tend to refer mothers for an ultrasound less often than OBs. But unlike family practitioners, nearly all obstetricians own an ultrasound machine, which is an expensive investment. While it is certainly a useful diagnostic tool, multiple ultrasounds are not indicated in a healthy pregnancy and could even pose risks. When the need to see ROI (Return on Investment) on the purchase expensive equipment clouds a practitioner’s decision to self-refer for extra services, this could be construed as a kickback. The physician I spoke to considers over-reliance on ultrasounds to augment profits as a financial conflict of interest.
Employment Over Ownership
I also enjoyed hearing physicians’ point of view about being employed versus owning an independent practice.
A 3rd-year medical student told me that many of his classmates are planning to join a hospital or clinic system once they graduate, because they want stability and a regular paycheck. He said very few of his classmates are interested in entrepreneurship.
But the employment option is not for everyone. Several practitioners who were employed for years have decided to start their own business. They say they are motivated by:
- a desire to have more control over their schedule,
- to make clinical choices independently, and
- to give back to their community.
Independent owners seem to have a very strong need for both altruism and autonomy, although this trend seems to be changing as older physicians retire. The pressure to keep up with government regulations, EHR and interoperability standards, insurance billing, and practice management headaches is causing more physicians to leave private practice. I believe that this trend will eventually reverse, but it will require an objective look at the changing patient landscape and a strategic future outlook.
Insurance Rate Disparity
I spoke with several physicians about the disparity in insurance reimbursement. Larger practices can negotiate a higher rate for the same service as a smaller practice, even though the quality of care is the same. This results in a huge income discrepancy because of the differences in insurance contracts.
One ER doctor shared her concerns about physicians who shift to a concierge payment model. She believes that cash-based services cater to patients who can afford services out-of-pocket and generates a higher profit for physicians, but in her opinion this is unethical because it limits access for patients with insurance coverage limitations.
Many doctors mentioned the frustration of insurance company dictating the terms of their clinical decision-making. In spite of their professional responsibility to care for patients using a variety of tools and treatments, many doctors feel pressured to follow a prescribed path as directed by their patients’ insurance plans.
Another physician told me:
“Medicare reimbursement is at the same level as it was in the 1990s, because more individuals utilize it and the rates remain capped. Insurance selects which physicians a patient can pick. A practice will live or die based on contracts. Twenty to 30% of patients will leave when their insurance contract ends, and that one change can ruin the practice.”
Doctors who accept Medicare are in a moral conundrum; the more Medicare patients they accept, the lower their profit. Many practices that accept Medicare are basically breaking even.
A few doctors said they do not expect this problem to improve anytime soon.
(You can read my thoughts about adjusting to a changing market in What Does it Take to Develop a Triple Niche?)
We heard from 5 different speakers during the conference.
At lunch, WSMA’s Legislator of the Year award was given to Rep. Paul Harris, R-Vancouver of the 17th District of the Washington State House. He gave a rousing speech about his efforts to curtail a recent measles outbreak in Clark County (where I live) and to promote the importance of medical doctors’ contributions in the state.
We also got a real treat with a talk from Rep. Kim Schrier, MD of the 8th district.
As the first pediatrician in Congress, Rep. Schrier updated us on several key initiatives in Washington DC that are happening despite the media’s attention on impeachment. There’s a lot of positive change going on behind the scenes that has the potential to greatly improve health quality and access through legislative efforts.
New Medical Technology
The third speaker, Rubin Pillay, MD, PhD, wowed us with many examples of new technology in the healthcare industry, including gadgets that are emerging on the market. His presentation was entitled Healthcare 3.0: How Technology is Driving the Transition to Prosumers, Platforms and Outsurance.
Specialties which are most likely to be disrupted by technology are:
- Radiology (because of computer imaging interpretation),
- Dermatology (AI diagnosing skin conditions), and
- Pathology (computerized review and recommendations).
Dr. Pillay talked about “pro-sumerism” as the next phase in healthcare, where patients are technology-enabled producers of care. He said that technology is starting to compete with physicians for consumer health decisions, and it is growing at an exponential pace.
He also mentioned the evolution of insurance to “outsurance” – where rather than paying into a system that mitigates against ill health, this new system would reward patients for good health.
Another insurance concept is Pay-As-You-Live, which rewards policy holders based on their behavior. For example, Sweden has rolled out a program where drivers are sent cash when they follow traffic rules. It was so popular that they now use a lottery system to determine which drivers are paid. In the US, good driving habits are rewarded with products like IntelliDrive® by Travelers Insurance.
“InsureTech” is the use of new technology to decrease costs. For example, a policyholder can decrease their annual premiums by using a toothbrush sensor that can tell if she or he is regularly using good oral hygiene protocols.
A few of the many devices Dr. Pillay mentioned include:
- WIWE heart rate bio-monitoring
- Babylon Health (an online Primary Care Physician app that uses artificial intelligence)
- Steth IO, the Smartphone Stethoscope
- Defibrillator drones that can be dispatched to save a patient suffering from cardiac arrest
- Pharmacy dispensing units which are being used in South Africa like an ATM machine
- Philips Sonicare FlexCare Platinum Connected toothbrush with sensors and Bluetooth technology to reveal missed spots
- AliveKor is a “medical-grade EKG”
- EyeQue optometric testing products that can be done at home
- Embrace2 by Empatica is a wearable watch for epilepsy management
- PillCam the “colon exam in a capsule” by Medtronic
Despite the hype, many of these new products cannot adequately assess a patient’s health. For example, a heart rate monitor that has only 1 lead will not provide the same diagnostic information as a clinical 3- or 5-lead monitor. Virtual dermatology skin assessments and bio-alerts may work too well and create panic for a patient, rather than relying on the expertise of a physician.
When patients rely on self-administered tests instead of consulting a medical provider, they could miss out on the expert diagnostic evaluation and input of a trained clinician. This can be very dangerous for health outcomes.
Dr. Pillay recommended that physicians can “lead the charge” and steer the conversation about of these new tech tools, rather than passively waiting for technology to guide patient decisions.
Medical Documentation Risks
The fourth speaker was Elizabeth Leedom, JD, who talked about medicolegal issues, especially the risks when using electronic health records (also called EHRs—which was the focus of my post-graduate training). Her talk was entitled Top 10 EHR Pitfalls.
Ms. Leedom talked about “clicktation,” which is over-selecting options in a patient’s record even if it didn’t happen. In her words:
The old saying “If it wasn’t documented, it wasn’t done” should now be “Much of what is documented may not have been done.”
She mentioned a study of physician behavior in which there was a huge discrepancy between what was actually verified on patient exam, and what was documented in the chart. Between 46% and 61% of systems that were documented as having been evaluated by the physician were never actually heard or observed, according to the study. (source: JAMA) This “documented but not done” problem can result in huge settlements for the prosecution.
Another great quote was:
“In ‘EHR,’ the ‘E’ doesn’t stand for ‘Electronic’; it stands for ‘Eternal’.”
Ms. Leedom recommended that physicians refrain from using the word “unfortunately” in charting, as this is a red flag for plaintiff lawyers.
She recommended using secure EHR systems for patient communication and refraining from texts or personal email.
Patients should also not be added as “friends” on social media, because the physician’s posts could be used in litigation.
Doctors need to be aware of the patient’s perspective during documentation. Many patients are upset when the physician hides behind a screen during the visit. It is helpful to spend the first half of a visit speaking directly with the patient, and then transitioning with a statement like “Excuse me, I’m going to put this information in your health record now.”
Population Health Challenges
The final speaker was none other than the President of the American Medical Association (AMA), Patrice Harris, MD, MA, who spoke on Physician Leadership and the Urgency of the Moment in Medicine. It was really impressive to hear from the first female African-American president of the AMA.
Dr. Harris spoke about the ways in which the AMA is poised to take a more vocal stance on legislative issues regarding patient equity, technology, diversity, and community engagement.
In her talk, Dr. Harris discussed the work that the AMA is doing to promote population health awareness and childhood health impacts from abuse and neglect.
There was some discussion about racial disparity in medical school training. For example, dermatological conditions do not present in the same way for a Person of Color as it would in a Caucasian or Hispanic patient. This disparity affects care, because practitioners are not necessarily able to determine problems.
I noticed that very few of WSMA’s attendees are members of the AMA. Unfortunately, I had trouble finding a current estimate of the AMA’s membership numbers; their latest annual report only stated that it has “increased membership for the eighth year in a row.” Yet this is unclear, since membership appears to be dropping despite efforts to engage new physicians.
The Future of Medicine
One of my biggest take-aways from this conference was that medicine is undergoing a big transformation right now.
I came away from this event with mixed emotions about the future of healthcare. Doctors may be committed, but they are not seeing a wage increase that can sustain them with cost of living increases. It is not as financially worthwhile to enter the medical profession as a family practice or pediatric physician, and this is unfortunate; these doctors earn less than any other specialty, even though they are the most needed if the current trend continues.
I also noticed that the majority of attendees were either:
- older physicians who are nearing or past retirement age, or
- new MDs who are prepared for fast-paced employment in a large healthcare system.
Very few physicians in attendance appeared to be in mid-career; the vast majority were over 55 years old or under 25, which seems to align with the projected physician shortage.
Along with many who attended the conference, I am concerned about the degree to which physicians feel overwhelmed in their profession.
Doctors are important to the future of medicine. They are human beings first, and many of them are passionate about caring for their patients appropriately. But this passion can be difficult to maintain with the pressure of fulfilling the expected regulatory standards, productivity levels, and patient satisfaction scores.
Based on what I observed, I am encouraged to see that practitioners are committed to giving their patients evidence-based, high-quality care. The WSMA attendees seemed to care deeply about serving patients’ needs and are doing what they can to maintain a high ethical and professional standard.