Here’s a doctor’s health tip for patients that I’ll bet you haven’t heard before.

If you’re a patient who walks into a hospital for an elective procedure of any kind–surgery, or a diagnostic test–and you find out that Joint Commission reviewers are on site, reschedule your procedure and leave. Come back another day, after the reviewers have left.

Why? Because every single person who works there will be paying a lot of attention to Joint Commission reviewers with their clipboards, and scant attention to you.

The Joint Commission has the power to decide whether the hospital deserves reaccreditation. Administrators, doctors, nurses, technicians, clerks, and janitors will be obsessed with the fear that the reviewers will see them doing something that the Joint Commission doesn’t consider a “best practice”, and that they’ll catch hell from their superiors.

For you as a patient, any idea that your clinical care and your medical records are private becomes a delusion when the Joint Commission is on site. Their reviewers are given complete access to all your medical records, and they may even come into the operating room while you’re having surgery without informing you ahead of time or asking your permission.

Perhaps physicians and nurses have an ethical duty to inform patients when the Joint Commission is on site conducting a review. Right now, that doesn’t happen. Does the patient have a right to know?

Unintended consequences

How did any private, nonprofit organization gain this kind of power? Why do American healthcare facilities pay the Joint Commission millions each year for the privilege of a voluntary accreditation review? It’s a classic tale of good intentions, designed to improve healthcare quality, that turned into a quagmire of unintended consequences and heavy-handed regulation.

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When you walked into the voting booth on Tuesday, November 6, did you do so with a feeling of calm certainty that the man who would get your vote for President was unquestionably the best choice, or even the only possible choice?  Did you feel confident that your candidate’s political party fully supports your political views as well as your personal values?

For many physicians, I suspect that the answer to those questions was not a resounding “yes”.  Perhaps more so than in any previous election that I can recall, there were elements in each party’s platform that many thoughtful physicians might have a hard time accepting.  The extreme left and right wing contingents within the Democratic and Republican parties argue for wildly different policies, but does either of them truly represent the best interests of our profession or our patients?

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In my hospital’s preoperative area, upright on her bed, sat an unhappy middle-aged lady who needed an operation to treat complications from her previous bariatric surgery.  She hadn’t lost weight and clearly was feeling discouraged about practically everything.  She was physically uncomfortable, couldn’t even keep down her own saliva because her lower esophagus was obstructed, and was in tears.

As her anesthesiologist, I came to evaluate her prior to surgery.  In fairly short order, I got her a tissue and a warm blanket, listened to her tale of woe, and finished my pre-anesthetic examination.  Nothing special.  At the end, she said,  “You’re so nice.  Were you a nurse before you were a doctor?”

Ouch.

No, I told her, I wasn’t.  Never a nurse; always a doctor.  She looked surprised.

And that little narrative may help to explain why we (physicians as a group) are having so much trouble with public relations, and  with the onslaught and success of mid-level caregivers who want to practice medicine without a license.  Their PR is better than ours because their PR task is easier:  patients already think mid-level health care personnel, especially nurses, are basically nicer and more sympathetic than we are.

Just look at the recent coverage of Hurricane Sandy.  News reporters on radio, TV, print, and online repeatedly and justly praised the heroic efforts that nurses made during the evacuation of patients from dark, flooded hospitals, and showed photos and video clips of nurses hand-ventilating premature infants.  But not once did I hear a mention of the attending physicians and residents who were no doubt working right alongside the nurses, let alone the respiratory therapists, orderlies, and all the other personnel.  Nurses got all the credit in the public’s view.

Anesthesiologists and nurse anesthetists represent perhaps the most visible part of the physician/mid-level conflict, but other physicians are at risk as well.  The American Academy of Family Physicians (AAFP) has recently made public its opinion that nurse practitioners shouldn’t run medical homes, but the Affordable Care Act supports independent practice for nurse practitioners–including admitting privileges to hospitals–just as it supports independent practice for nurse anesthetists.

The latest unbelievable turn of events is Medicare’s decision in favor of nurse anesthetists practicing interventional pain medicine without physician supervision.  Just so we’re clear, this means that a nurse anesthetist with no special qualification other than Medicare’s blessing can bill Medicare for performing invasive pain management procedures that physicians ordinarily train to do with four years of medical school, at least four years of residency, and a fellowship.  These are procedures so risky that my hospital wouldn’t consider me qualified to do them despite my MD degree and anesthesiology residency, because I haven’t taken advanced training in interventional pain management.

What are we going to do to turn around this public perception that doctors are curt, mean, and unsympathetic? And that nurses are always better, kinder, and maybe even smarter?  And can do everything doctors can do, just as well?

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“Everybody has needs,” Governor Jerry Brown told the physicians and medical students who filled a Sacramento banquet room on April 17.  “But needs turn into rights, which turn into laws, which turn into lawsuits.”

The governor was breaking the news that physicians can look for little help from state government in raising payment rates for California’s Medicaid program, Medi-Cal, despite the fact that they are already among the lowest for any Medicaid program in the country. The budget deficit is severe, he said, even with drastic cuts that have already been made to schools, the state university system, and services for people in need.

Governor Brown addressed the physicians (myself included) who had made the trip to Sacramento as part of the California Medical Association’s 38^th Annual Legislative Leadership Conference.  For anyone who cares about incentives for physicians to see Medicare and Medicaid patients, nothing he said was good news.  If payments to physicians continue to decline, more of them will stop accepting these patients, and we can expect to see even more physicians leaving the profession in frustration.

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If Dr. Ezekiel Emanuel gets his wish, tomorrow’s physicians won’t deserve to be paid as well as physicians today because they won’t be as well trained.

Dr. Emanuel, a brother of Chicago Mayor Rahm Emanuel and a chief apologist for the Affordable Care Act, is the lead author of a startling opinion column in the March 21 Journal of the American Medical Association.  He argues that there is “substantial waste” in the current medical education system, and—in a time when medicine gets more complex every day—advocates cutting the training period for young physicians by no less than 30 percent.

Dr. Emanuel’s plan would reduce both the time spent in medical school and in residency training, which (as every physician knows from experience) is the period of three to seven years that a new graduate physician spends learning to practice a specialty.

Many people don’t realize that residents already receive less training than they used to, because stringent limits have been set on the amount they are permitted to work.  Since the duty hour rules were rewritten in 2003, residents are limited to 80 hours a week in the hospital, which includes overnights on call when they may be asleep (what the rules refer to as “strategic napping”).  First-year residents, or interns, as of 2011 aren’t allowed to work more than 16 hours at a stretch.

Many senior physicians are concerned that today’s residents aren’t seeing enough patients. Evidence suggests that board examination scores are on the decline in fields from neurosurgery to pediatrics, as reported in the Accreditation Council for Graduate Medical Education (ACGME) Bulletin in 2009.  The American Board of Internal Medicine reports that the passing rate for first-time exam takers slipped from 94 percent in 2007 to 87 percent in 2010.  Unfortunately there’s no evidence that residents are using their increased off-duty hours to pursue either knowledge or sleep.  There’s no proof that patient care has improved, or that medical errors are fewer.

Now Dr. Emanuel thinks that even this amount of training is too much.

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