Feet First

“It is much more important to know what sort of a patient has a disease than what sort of a disease a patient has.” - Sir William Osler

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    Monday, February 06, 2012

    My flight home from Australia included Moneyball as one of the featured movies. In this film Brad Pitt plays Billy Beane, the general manager of the Oakland A's baseball team. He is faced with the challenge of putting together a winning team on a very tight budget. Fortunately he meets Jonah Hill's character Pete, an Econ nerd recently graduated from Yale, who believes he can find undervalued baseball players by analyzing their stats. For example, if a player does not have a great batting average but often gets on base via walks, that player is more likely to score (although his low batting average causes him to be undervalued). Billy hires Pete to help him find these undervalued players. Although they meet a lot of resistance at first, Pete's theory proves to be correct.

    In the course of the film we learn via flashbacks that Beane was drafted out of high school as a promising baseball player. He never lived up to his early promise and eventually quit the sport to become first a baseball scout and then general manager. His experiences give him a very clear-eyed view of professional sports. He does not find baseball romantic; in fact, immediately after the climax of the film in which the A's set a new League record, we see Billy Beane explaining to Pete that he isn't interested in setting records or winning World Series rings. What he wants is to change the game. Left unanswered is the question, is he changing it for the better?

    Today at work I sat through a very dispiriting meeting and was irresistibly reminded of Moneyball. The issue is that The Firm has to reduce the cost of patient care. We are at risk of losing several insurance contracts, as we're being told that we as a group are simply too expensive. We, the primary care doctors, have been divided into "pods" and told that we will be meeting monthly to analyze our practice habits; the meeting today was for the pod leaders. (I'd make a "Pod People" joke here, but it is simply too close to the truth to be funny.)

    We were handed sheets of paper listing the number of studies and lab tests each of us had ordered in the past year. This included EKG's, echocardiograms, radiologic studies, neurologic studies and so forth. Our "efficiency score" was also included. We were told that the doctors in general are undercoding patient diagnoses. The higher you code, the sicker the patient and the better your efficiency score is (but if you overcode, woe betide you! You will be cast into the seventh circle of Hell - meaning the Feds will sue your sorry ass off.)

    Nothing on these sheets of paper said anything about patient satisfaction... or doctor satisfaction, for that matter. Nothing about the pleasure we take in treating three generations of one family, or congratulating a patient on their retirement or a grandchild's marriage, or in saving somebody's life. Nothing, in other words, about the romance of medicine. Our performance was boiled down to a handful of statistics presented to us by a clear-eyed, hardbitten MD in charge of numbers. Now to be fair I know this guy to be a great doctor, one of the Founding Members, who really knows what he's doing. And I also know that he's right and we have to be more efficient in what we do. But today was a new emotional low for me.

    I come from a medical family and I often think back to the stories my mother has told me. Her father and his brother ("Uncle Doc") were a dentist and a doctor respectively. They lived in the same small Southern town and shared office space. In that time and place tobacco was the main cash crop. The farmers were flush with cash once a year, after the tobacco auctions, and that was when they paid off their accounts. My mother remembers them coming in: "They'd say 'How much do I owe ya, Doc?' and they'd pull a wad of bills out of their overalls that could choke a horse." My grandfather carried them on account the rest of the year, knowing they were good for it.

    Obviously this billing method has its weak points. But as I sit through these meetings belabored with statistics and ICD-10 coding, I often find myself visualizing that 1940's office and wishing I worked there instead of here. At least no one there was reduced to a statistic.

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    You should submit this to something for publication. Very well-written, if depressing! I feel the same way about the practice I'm currently in as it's prohibitively expensive for most.

    By Blogger Pisser, at February 21, 2012 at 8:43 AM  

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