Category Archives: compare education and medicine

Learning from the Past? An Analogy between Compulsory Public Schools and Health Insurance*

The U.S. Senate’s failure to either repeal or repair the Affordable Care Act (Obamacare) means that the existing law, its strengths and flaws, will be around for the immediate future. A half-century ago, President Lyndon Johnson signed amendments to the Social Security law that the then Democrat-controlled House of  Representatives and Senate passed with large majorities. Thus, Medicare became the law of the land in 1965 for Americans 65 and older and Medicaid for the very poor. It was a single payer system of what was then called “socialized medicine.”

The first enrollee for Medicare was former President Harry Truman. Truman had initially promoted health insurance for all in 1945 and 1949 as had President Franklin Delano Roosevelt before him and President John F. Kennedy after him. So it took decades to get health insurance for the elderly.

 

Zelizer-Medicare.jpg

 

For those under the age of 65, however, health insurance was largely managed by private companies with prices set by the market. Even though most democracies in the world already had national insurance for all, the plans were funded differently (e.g., Britain, Netherlands, and Australia). Not until 2010–nearly a half-century later–when President Barack Obama signed the Affordable Care Act did the U.S. provide ways for millions of uninsured Americans under 65 to get health insurance.

The Affordable Care Act aimed at the 48 million Americans without health insurance in 2010. That number of uninsured Americans fell to 28 million in 2016, a drop (the highest ever) from 18 percent to 10 percent uninsured. Uninsured poor Americans in 31 states got Medicaid. Still there were defects in Obamacare that both Democrats and Republican legislators saw needed correcting.

Neither the bill passed by the House in 2016 and the bills that failed in the Senate in 2017 corrected the major flaws and even threatened to double the numbers of uninsured. With the recent Congressional debacle over health care bills, Obamacare remains intact but still millions of Americans under the age of 65 cannot afford market-driven prices for insurance.

To recap then: between the mid-1930s to 2017, nearly nine decades, old and young, economically comfortable and poor Americans have slowly gained health insurance in increments but Medicare for all or universal health care–is still in the distance. Although a majority of Americans polled (53 percent) say they want a single-payer plan, that would take a unified U.S. Congress and a determined President who could shove that ball yard-by-yard over the goal line. When that will happen, I surely do not know.

Affordable health care covering all Americans is, I believe, similar to the slow but steady incremental progress of tax-supported public schools that moved from private tutors, tuition-paying academies, and “Dame schools” in the 17th and 18th centuries to property owners being taxed, voters authorizing the “common” public school before the Civil War, and states later passing compulsory attendance laws in the late-19th and early 20th centuries (see here here, and here). Today, free public schools in the U.S. enroll over 50 million children and youth between the ages of 4 through 17 (depending on the state) in over 13,000  districts housing over 100,000 schools. The process of insuring that all boys and girls will go to school took many decades just as health care has in the 20th and early 21st centuries.

This is the analogy I use in this post. But historical analogies are dicey.

Uses of the Past

When policymakers, practitioners, and public school students ask about the usefulness of history they want guidance from the past to avoid making mistakes now; some even want predictions. Invariably, historians disappoint them.

Most historians believe that the past can surely inform current policy but extracting direct “lessons” and making confident predictions, while playing well on cable news, last little longer than the 24-hour news cycle and are often, there is no other word, wrong (see here and here).

So historians of education, for example, (and I include myself in that group) argue that even if “lessons” cannot be extracted from the past, policymakers and practitioners can surely profit from looking backward when, say, earlier generations of well-intentioned reformers worked hard to improve schooling. These scholars say that they can aid contemporary policymakers by pointing out similarities and differences between previous and current situations (i.e., analogies). Finally, historians can alert policymakers to what did not work, what might be preferable and what to avoid under certain conditions.

In historians offering their knowledge of how previous generations approached the problems of the day and crafted solutions, they can inform contemporary, serious reformers as they wrestle with a different context from their cousins a half-century to century ago.

The Spread of Tax-supported Public Schools

Beginning in colonial years, proceeding through the Revolutionary decades and responding to the social and political reform of the early 19th century, funding public schools in a mostly rural nation was seen as crucial to the political, social, and cultural health of the new nation. Reformers such as Thomas Jefferson, Horace Mann, and Noah Webster in these years spoke often of creating Americans who knew and performed their civic duties, understood the Bible, could read and write to get jobs, improve their moral character, and create a republican society that Americans prized. Yes, more than two centuries ago, there were multiple (and conflicting) purposes for schooling the young (see here, here, and here).

Slowly, the idea of tax-supported public schools took hold in New England spread to the Midwest but barely penetrated the pre-Civil War South. In rural and urban areas, primary and grammar schools grew. After the Civil War, more and more parents voluntarily sent their sons and daughters–racially segregated, however, by law until the 1950s–to school (see here and here).

Not until the early decades of the 20th centuries had all states passed  Compulsory attendance laws mandating parents to send their children to school. The ever-shifting but crucial purposes for schooling the next generation in a democracy required everyone to pay taxes and send their children to school.

By the middle of the 20th century, kindergartens, junior high and senior high school had been added to the age-graded elementary school. Increased graduation rates meant that the high school diploma became common. While the purposes for public schooling shifted from time to time (e.g., dropping Bible study, increased attention to job preparation) and while a private school K-12 sector grew slowly–about 10 percent of public school enrollment now–going to school became the dominant experience for children and youth.

By the end of the century, reformers called for all students to go to college (although most of higher education both public and private required families to pay tuition) bringing into daily conversation the question of whether youth would go 16-plus years to tax-supported institutions.

The point of this brief sprint through history of tax-supported schools and their purposes in a democratic society is that much time was taken and incremental steps occurred to make tax-supported public schools a virtual right for every U.S.family.

I believe a similar process is at work in providing universal health care as well.

______________________

*I thank Beverly Carter for suggesting this analogy.

 

 

 

 

Advertisements

Leave a comment

Filed under compare education and medicine, school reform policies

All Doctors Should Teach (Paula Cohen)

I have written often about the cluster of occupations that make up the “helping” professions: teaching, clinical medicine, nursing, therapy, and social work. These professionals help students, patients, and clients learn and become healthy. They are all teachers albeit in different settings.

Most important, these “teachers” in helping professions are totally dependent upon their students, patients, and clients to learn and get healthy. Regardless of the degree earned, annual income, and social status, these professionals cannot reach their goals without the cooperation, compliance, and involvement of those being helped.

Those who recognize this inherent dependency of professionals upon whom they serve have occasionally recommended that all physicians, nurses, therapists, and social workers become teachers before they enter the other helping professions. Here is one such recommendation for those seeking to become physicians.

Paula Marantz Cohen is dean of the Pennoni Honors College and distinguished professor of English at Drexel University and the author of Jane Austen in Scarsdale or Love, Death and the SATs. This post appeared in The American Scholar, September 18, 2012

 

My daughter, Katherine Penziner, wrote the essay that follows in response to my last column. She is spending a few years teaching in Southwest Arkansas as part of the Teach for America program. She plans eventually to go to medical school.

Every aspiring doctor should be required to teach a year of high school science. First, there is nothing more grueling than standing up, day after day, in front of hormonal and angsty teenagers who are having trouble controlling their attitudes. The emotional toll teaching takes can be exhausting–a perfect training ground for the taxing years of medical school we premeds are always hearing about. Still, a good day of teaching makes you feel good about yourself, and your students.

But what makes teaching most valuable for an aspiring doctor are the communication skills that must be developed in order to convey information to people who don’t yet have the vocabulary to engage fully with a concept. I firmly believe that the principles of chemistry and physics I teach to 15- and 16-year-olds are inherently exciting when the delivery is right.

That delivery is the crucial element missing when people complain of doctors’ bedside manner. Doctors who do not put their patients at ease are generally not bad people. It’s hard for me to believe that my friends who are in medical school now could alienate their patients–they are great communicators. However, there is a difference between the communication of facts and the explication of them. The gap between communication and explication is precisely the point at which the doctor-patient relationship can disintegrate fastest.

On tests in college and, I’m guessing, in medical school, you answer questions for professors, people who already know the answers. Why tell them what they already know? The truest test is if a doctor can give the answer to those who have no idea what hemoglobin is, could not guess the function of the gallbladder, and have never heard of the nephron.

In a recent article about health care in rural areas, a woman commented that poor black Americans might not trust doctors that don’t look like them. I can imagine that in the Mississippi Delta a black patient might be skeptical that white doctors could truly understand their situation, socially and economically. But though skin color can’t change, the vocabulary doctors use can.

I often use words in the classroom that my students don’t know. But I also make sure to either provide plenty of context for them to figure out the meaning, or clearly define them. I’ve seen students shut down when they don’t understand what I’m saying.  But with the right explanation, I’ve seen my weakest students grasp a concept.

Similarly, doctors must explain what they are doing to patients without alienating them with the vocabulary they use. I’ll never forget going to the dentist when I was very young and being frightened when he didn’t explain what he was doing. For years, that experience made going to the dentist into an ordeal.

Patients can develop a basic understanding of their illness and their treatment with the guidance of their doctors.  Good teachers can make a difference between success and failure in students’ lives. Doctors, if taught to be good teachers, can be the difference between health and sickness, and even life and death.

 

 

 

2 Comments

Filed under compare education and medicine

How Technology Integration Has Altered Doctor/Patient Care in Hospitals (David Rosenthal, M.D. and Abraham Verghese, M.D.)

Over the past few years, I have compared physicians and teachers because even with so many differences in preparation and the nature of their work, they share two core principles. Both professionals belong to helping professions where their success, in part, is dependent upon the patient and the student. And success, however defined, depend upon each professional developing close relationships with their patients and students. The degree to which labor-saving devices have increased the efficiency of both physicans and teachers in carrying out their daily work, there are, nonetheless, tradeoffs that have become apparent as professionals practice in hospitals and schools.

The following article, “Meaning and Nature of Physicians’ Work,” appeared in the New England Journal of Medicine, November 16, 2016. To see citations, click on footnote number in NEJM article.

….Typically in our field, internal medicine, residents arrive at the hospital at 7 a.m., get sign-outs from nighttime residents, and conduct “pre-rounds” to see patients they have inherited but don’t know well, before heading to morning report or attending rounds. Attending rounds often consist of “card-flipping” sessions held in a workroom, frequently interrupted by discharge planning and pages, calls, and texts from nurses and specialists. Finalizing discharges before noon can feel more important than getting to know new patients. Increasingly, the attending physician doesn’t see patients with the team, given the time constraints.

No longer are there paper charts at the bedside. The advent of the electronic era, while reducing the time required for tracking down laboratory or radiology results, has not substantially changed the time spent with patients: recent estimates indicate that medical students and residents often spend more than 40 to 50% of their day in front of a computer screen filling out documentation, reviewing charts, and placing orders. They spend much of the rest of their time on the phone coordinating care with specialists, pharmacists, nutritionists, primary care offices, family members, social workers, nurses, and care coordinators; very few meetings with these people occur face-to-face. Somewhat surprisingly, the time spent with patients has remained stable over the past six decades.1

The skills learned early by today’s medical students and house staff — because they are critical to getting the work done — are not those needed to perform a good physical exam or take a history, but rather the arts of efficient “chart biopsy,” order entry, documentation, and sign-out in the electronic age. When a medical team gets notice of a new admission, it seems instinctive and necessary to study the patient’s record before meeting him or her. This “flipped patient” approach2 has advantages, but it introduces a framing bias and dilutes independent assessment and confirmation of history or physical findings.

In short, the majority of what we define as “work” takes place away from the patient, in workrooms and on computers. Our attention is so frequently diverted from the lives, bodies, and souls of the people entrusted to our care that the doctor focused on the screen rather than the patient has become a cultural cliché. As technology has allowed us to care for patients at a distance from the bedside and the nursing staff, we’ve distanced ourselves from the personhood, the embodied identity, of patients, as well as from our colleagues, to do our work on the computer.

But what is the actual work of a physician? Medical students entering the wards for the first time recognize a dysjunction, seeing that physicians’ work has less to do with patients than they had imagined. The skills they learned in courses on physical diagnosis or communication are unlikely to improve. Despite all the rhetoric about “patient-centered care,” the patient is not at the center of things.

Meanwhile, drop-down menus, cut-and-paste text fields, and lists populated with a keystroke have created a medical record that (at least in documenting the physical exam) at best reads like fiction or meaningless repetition of facts and at worst amounts to misleading inaccuracies or fraud. Given the quantity of information and discrepancies within medical records, it’s often impossible to discern any signal in the mountains of noise. Yet our entire health care system — including its financing, accounting, research, and quality reporting — rests heavily on this digital representation of the patient, the iPatient, and provides incentives for its creation and maintenance.3 It would appear from our hospital quality reports that iPatients uniformly get wonderful care; the experiences of actual patients are a different question.

It’s clear that physicians are increasingly dissatisfied with their work, resentful of the time required to transcribe and translate information for the computer and the fact that, in that sense, the work never stops. Burnout is widespread in the workforce, and more than a quarter of residents have depression or depressive symptoms.4 In response, health care leaders have advocated amending the “Triple Aim” of enhancing patients’ experience, improving population health, and reducing costs to add a fourth goal: improving the work life of the people who deliver care.

A 2013 study commissioned by the American Medical Association highlights some of the factors associated with higher professional satisfaction. Perhaps not surprisingly, the investigators found that perceptions of higher quality of care, autonomy, leadership, collegiality, fairness, and respect were critical. The report highlighted persistent problems with the usability of electronic health records as a “unique and vexing challenge.”5

These findings underscore the importance of reflecting on what our work once was, what it now is, and what it should be. Regardless of whatever nobility inhered in the work of physicians in a bygone era, that work was done under conditions and quality standards that would now be unacceptable. We practice in a safer and more efficient system with measurable outcomes. Yet with the current rates of burnout, our expectations for finding meaning in our profession and careers seem largely unfulfilled.

We believe that if meaning is to be restored, the changes needed are complex and will have to be made nationally, beginning with a dialogue that includes the people on medicine’s front lines. Perhaps the greatest opportunity for improving our professional satisfaction in the short term lies in restoring our connections with one another. We could work on rebuilding our practices and physical spaces to promote the sorts of human connections that can sustain us — between physicians and patients, physicians and physicians, and physicians and nurses. We could get back to the bedside with patients, families, and nurses. We could get to know our colleagues from other specialties in shared lunchrooms or meeting spaces.

In addition, we believe that in the coming years, the U.S. medical community will have to rethink the human–computer interface and more thoughtfully merge the real patient with the iPatient. We have an opportunity to radically redesign electronic health record systems, initially created for fee-for-service billing, as our organizations shift toward bundled payments, capitation, and risk sharing. Perhaps virtual scribes and artificial intelligence will eventually reduce our documentation burden.

But technology cannot restore our professional satisfaction. Our profession will have to rebuild a sense of teamwork, community, and the ties that bind us together as human beings. We believe that will require spending more time with each other and with our patients, restoring some rituals that are meaningful to both us and the people we care for and eliminating those that are not.

Solutions will not be easy, since the problems are entangled in the high cost of health care, reimbursement for our work, and obstacles to health care reform. But we can start by recalling the original purpose of physicians’ work: to witness others’ suffering and provide comfort and care. That remains the privilege at the heart of the medical profession.

Leave a comment

Filed under compare education and medicine, school leaders

How Measurement Fails Doctors and Teachers (Robert Wachter)

Robert M. Wachter is a professor and the interim chairman of the department of medicine at the University of California, San Francisco, and the author of “The Digital Doctor: Hope, Hype, and Harm at the Dawn of Medicine’s Computer Age.This post appeared in the New York Times on January 16, 2016

 

Two of our most vital industries, health care and education, have become increasingly subjected to metrics and measurements. Of course, we need to hold professionals accountable. But the focus on numbers has gone too far. We’re hitting the targets, but missing the point.

Through the 20th century, we adopted a hands-off approach, assuming that the pros knew best. Most experts believed that the ideal “products” — healthy patients and well-educated kids — were too strongly influenced by uncontrollable variables (the sickness of the patient, the intellectual capacity of the student) and were too complex to be judged by the measures we use for other industries.

By the early 2000s, as evidence mounted that both fields were producing mediocre outcomes at unsustainable costs, the pressure for measurement became irresistible. In health care, we saw hundreds of thousands of deaths from medical errors, poor coordination of care and backbreaking costs. In education, it became clear that our schools were lagging behind those in other countries.

So in came the consultants and out came the yardsticks. In health care, we applied metrics to outcomes and processes. Did the doctor document that she gave the patient a flu shot? That she counseled the patient about smoking? In education, of course, the preoccupation became student test scores.

All of this began innocently enough. But the measurement fad has spun out of control. There are so many different hospital ratings that more than 1,600 medical centers can now lay claim to being included on a “top 100,” “honor roll,” grade “A” or “best” hospitals list. Burnout rates for doctors top 50 percent, far higher than other professions. A 2013 study found that the electronic health record was a dominant culprit. Another 2013 study found that emergency room doctors clicked a mouse 4,000 times during a 10-hour shift. The computer systems have become the dark force behind quality measures.

Education is experiencing its own version of measurement fatigue. Educators complain that the focus on student test performance comes at the expense of learning. Art, music and physical education have withered, because, really, why bother if they’re not on the test?

At first, the pushback from doctors and teachers was dismissed as whining from entitled and entrenched guilds spoiled by generations of unfettered autonomy. It was natural, went the thinking, that these professionals would resist the scrutiny and discipline of performance assessment. Of course, this interpretation was partly right.

But the objections became harder to dismiss as evidence mounted that even superb and motivated professionals had come to believe that the boatloads of measures, and the incentives to “look good,” had led them to turn away from the essence of their work. In medicine, doctors no longer made eye contact with patients as they clicked away. In education, even parents who favored more testing around Common Core standards worried about the damaging influence of all the exams.

Even some of the measurement behemoths are now voicing second thoughts. Last fall, the Joint Commission, the major accreditor of American hospitals, announced that it was suspending its annual rating of hospitals. At the same time, alarmed by the amount of time that testing robbed from instruction, the Obama administration called for new limits on student testing. Last week, Andy Slavitt, Medicare’s acting administrator, announced the end of a program that tied Medicare payments to a long list of measures related to the use of electronic health records. “We have to get the hearts and minds of physicians back,” said Mr. Slavitt. “I think we’ve lost them.”

Thoughtful and limited assessment can be effective in motivating improvements and innovations, and in weeding out the rare but disproportionately destructive bad apples.

But in creating a measurement and accountability system, we need to tone down the fervor and think harder about the unanticipated consequences.

Measurement cannot go away, but it needs to be scaled back and allowed to mature. We need more targeted measures, ones that have been vetted to ensure that they really matter. In medicine, for example, measuring the rates of certain hospital-acquired infections has led to a greater emphasis on prevention and has most likely saved lives. On the other hand, measuring whether doctors documented that they provided discharge instructions to heart failure or asthma patients at the end of their hospital stay sounds good, but turns out to be an exercise in futile box-checking, and should be jettisoned.

We also need more research on quality measurement and comparing different patient populations. The only way to understand whether a high mortality rate, or dropout rate, represents poor performance is to adequately appreciate all of the factors that contribute to these outcomes — physical and mental, social and environmental — and adjust for them. It’s like adjusting for the degree of difficulty when judging an Olympic diver. We’re getting better at this, but we’re not good enough.

Most important, we need to fully appreciate the burden that measurement places on professionals, and minimize it. In health care, some of this will come through advances in natural language processing, which may ultimately allow us to assess the quality of care by having computers “read” the doctor’s note, obviating the need for all the box-checking. In both fields, simulation, video review and peer coaching hold promise.

Whatever we do, we have to ask our clinicians and teachers whether measurement is working, and truly listen when they tell us that it isn’t. Today, that is precisely what they’re saying.

Avedis Donabedian, a professor at the University of Michigan’s School of Public Health, was a towering figure in the field of quality measurement. He developed what is known as Donabedian’s triad, which states that quality can be measured by looking at outcomes (how the subjects fared), processes (what was done) and structures (how the work was organized). In 2000, shortly before he died, he was asked about his view of quality. What this hard-nosed scientist answered is shocking at first, then somehow seems obvious.

“The secret of quality is love,” he said.

Our businesslike efforts to measure and improve quality are now blocking the altruism, indeed the love, that motivates people to enter the helping professions. While we’re figuring out how to get better, we need to tread more lightly in assessing the work of the professionals who practice in our most human and sacred fields.

10 Comments

Filed under compare education and medicine