5 ms·

No, I'm talking about 99% of docs 99% of the time. It's a job. It's a great job sometimes, but it's paperwork most of the time. For every hour we spend rounding

No, I'm talking about 99% of docs 99% of the time. It's a job. It's a great job sometimes, but it's paperwork most of the time. For every hour we spend rounding in the morning - when we're given at best 2/3 of the time we need to actually do the bare minimum, and half the time we need to really talk to people - we spend another 1-2 hours (minimum) in a windowless room doing a pile of paperwork notating the hell out of the morning's visits. I won't mention the X additional hours doing bullshit like wrangling with insurance companies and home healthcare and calling the nurse to very-politely-because-we're-all-a-team-here find out why my STAT EKG on last night's chest pain didn't get a fucking EKG. No one is passionate about paperwork in windowless rooms and workplace political wrangling. No one. But that's what it is most of the time, because it's a job. A real world job, with TPS reports (heh) and never enough printer paper to go around. But, hey, if you want to buy the hype, go for it.

mjevans 8y ago
Would being a doctor be better in a system where there was /only/ a choice of either single payer or bring your own all-cash payment? (No 'insurance' at all.)
- arkades 8y ago
  I don't know, to be honest. I know a lot of docs blame insurance for this, but I've worked in health policy and insurance - the problems are bigger than that. A lot of the documentation is an attempt to create "quality standards". I like that in theory, and it's independent of what kind of payment mechanism is used, but ... docs will have a riot if we're held accountable for final outcomes ("This guy has had 30 docs in 20 years, smokes like a chimney despite my repeatedly trying to get him to stop, and I'm getting my wallet drained because he had a heart attack?"). Alternatively, process measures ("Did you put everyone with high cholesterol on a statin?") kill autonomy, require documentation, destroy nuance (there's a good reason I don't want this patient on a statin) and also calcify medicine (advances in medical knowledge occur faster than Medicare updates its performance metrics). Unfortunately, "quality care" is also a PR move to cut costs. Create enough metrics over enough things docs have no control over, and a documentation slip-up becomes a good reason to ding us our reimbursement. This documentation is also a way to cut government and insurance budgets: they want the information for their programs, but don't want to pay for anyone to convert unstructured medical notes into structured data. Therefore, it becomes an unfunded mandate plopped onto physician's heads. That's not going to go away, unless all insurance - public and private - go away. All-cash payment removes documentation because there's no one to be accountable to. There's no central party trying to track your outcomes. But... I like the idea of tracking performance. I like the idea of encouraging quality care. I wouldn't mind if we could divorce quality metrics from centralized payors, and put the cost burden of data entry onto the party using and benefiting from that data rather than physicians. Some of the paperwork headache won't go away regardless. Primary Care docs spend most of their time doing bullshit paperwork tasks. As often comes up on HN, an employer won't let you bring your own chair to work - unless you get a doctor's note. Family med guys write stupid notes every single day, and it occupies a significant percentage of their workday. It's disheartening, and it's not going anywhere. Another big thing that's happened is social work. Every issue that society doesn't want to deal with rolls down to healthcare: the homeless, the mentally ill, the uninsured, eventually land in an emergency room. That means we're the central clearing house for social services. Psychiatry - especially ER psychiatry - spend probably as much of their time (or more) networking with social work and the state trying to secure Medicaid and housing for patients than they do addressing their mental health needs. It's work that needs doing, but man is it heartbreaking to train to be a physician just to spend your day trying to arrange housing. Lastly, even a single payer system has incentives to deny services. That's still a cost borne by the system. Accordingly, docs will still find themselves fighting paperwork battles with the insurer to justify a course of treatment - they'll just be doing it against a single bureaucracy instead of several.
  - mjevans 8y ago
    That's a little outside of the specific question I was asking, so I feel like an addition is warranted; I'll try to return to the main topic where possible as well. My outside knowledge is that a medical facility focuses on: diagnosis, confirmation of diagnosis, selection of treatment along with annotations about EXCEPTIONS to standard treatment, finally actual treatment. I'd like for doctors to focus more on the keen observation and decision parts and would not mind automated transcription of doctor / patient interactions to be reviewed and possibly have a summary forward (but not replacement of actual data) added by other staff. That might be an opportunity to hire/train other types of staff and gain experience in a more concrete way; much like the source article wants to make it easier for potential experts to grow in to a job. If there's a typical outcome given an input it's important to document the decisions that affected the selection of non-generic courses of action - exceptions are things that should be known in the future. That's something that any worker should do. The NTSB, as seen in a different recent hacker-news linked article, has excellent postmortems, even for incidents which only came close to being disastrous. A cascade of failures and lack of good decision processes seem to be the typical cause and review with recommendations on how to prevent them from occurring in the future is good. An honest mistake or poor circumstances for otherwise good people are worthy of overlooking and avoiding in the future. Lack of training can be identified and refresher courses or other supplementary training can improve the situation for everyone. Much like making sure someone is addressing problems in their job and growing to accommodate the required work. Though there might be a bad fit for a job; either someone not able to do the expected work of an individual in that position, a job that's poorly defined and/or not broken up in to manageable units of work, or a worker that is a bad actor to some degree. All of those defects are situations that review and recommendations for remediation should address and resolve. In your specific case, I believe having a single payer system would improve the outcome related to the above considerations. Affected individuals would still be covered by 'the system', good doctors would not be burdened by specific negative outcomes that happened to occur under their care, and bad workers of any type would be removed. The actual outcome of individual patients shouldn't factor in to compensation. However addressing that in detail is clearly off the main topic. I think it is both ethical and practical to recognize and classify cases that are bad fits for a given worker and to attempt to route them to someone that is a proper fit; while providing the best intermediate care and transition possible. Also of note is that for a 'single payer' system the costs SHOULD be divorced from the actual treatment; though might be a considered criteria when a given standard of treatment is selected.
Aeolun 8y ago
It’s a pretty sad thing we have to describe such a soul destroying environment as par for the course for a job though.

mjevans 8y ago

Would being a doctor be better in a system where there was /only/ a choice of either single payer or bring your own all-cash payment? (No 'insurance' at all.)

arkades 8y ago
I don't know, to be honest. I know a lot of docs blame insurance for this, but I've worked in health policy and insurance - the problems are bigger than that. A lot of the documentation is an attempt to create "quality standards". I like that in theory, and it's independent of what kind of payment mechanism is used, but ... docs will have a riot if we're held accountable for final outcomes ("This guy has had 30 docs in 20 years, smokes like a chimney despite my repeatedly trying to get him to stop, and I'm getting my wallet drained because he had a heart attack?"). Alternatively, process measures ("Did you put everyone with high cholesterol on a statin?") kill autonomy, require documentation, destroy nuance (there's a good reason I don't want this patient on a statin) and also calcify medicine (advances in medical knowledge occur faster than Medicare updates its performance metrics). Unfortunately, "quality care" is also a PR move to cut costs. Create enough metrics over enough things docs have no control over, and a documentation slip-up becomes a good reason to ding us our reimbursement. This documentation is also a way to cut government and insurance budgets: they want the information for their programs, but don't want to pay for anyone to convert unstructured medical notes into structured data. Therefore, it becomes an unfunded mandate plopped onto physician's heads. That's not going to go away, unless all insurance - public and private - go away. All-cash payment removes documentation because there's no one to be accountable to. There's no central party trying to track your outcomes. But... I like the idea of tracking performance. I like the idea of encouraging quality care. I wouldn't mind if we could divorce quality metrics from centralized payors, and put the cost burden of data entry onto the party using and benefiting from that data rather than physicians. Some of the paperwork headache won't go away regardless. Primary Care docs spend most of their time doing bullshit paperwork tasks. As often comes up on HN, an employer won't let you bring your own chair to work - unless you get a doctor's note. Family med guys write stupid notes every single day, and it occupies a significant percentage of their workday. It's disheartening, and it's not going anywhere. Another big thing that's happened is social work. Every issue that society doesn't want to deal with rolls down to healthcare: the homeless, the mentally ill, the uninsured, eventually land in an emergency room. That means we're the central clearing house for social services. Psychiatry - especially ER psychiatry - spend probably as much of their time (or more) networking with social work and the state trying to secure Medicaid and housing for patients than they do addressing their mental health needs. It's work that needs doing, but man is it heartbreaking to train to be a physician just to spend your day trying to arrange housing. Lastly, even a single payer system has incentives to deny services. That's still a cost borne by the system. Accordingly, docs will still find themselves fighting paperwork battles with the insurer to justify a course of treatment - they'll just be doing it against a single bureaucracy instead of several.
- mjevans 8y ago
  That's a little outside of the specific question I was asking, so I feel like an addition is warranted; I'll try to return to the main topic where possible as well. My outside knowledge is that a medical facility focuses on: diagnosis, confirmation of diagnosis, selection of treatment along with annotations about EXCEPTIONS to standard treatment, finally actual treatment. I'd like for doctors to focus more on the keen observation and decision parts and would not mind automated transcription of doctor / patient interactions to be reviewed and possibly have a summary forward (but not replacement of actual data) added by other staff. That might be an opportunity to hire/train other types of staff and gain experience in a more concrete way; much like the source article wants to make it easier for potential experts to grow in to a job. If there's a typical outcome given an input it's important to document the decisions that affected the selection of non-generic courses of action - exceptions are things that should be known in the future. That's something that any worker should do. The NTSB, as seen in a different recent hacker-news linked article, has excellent postmortems, even for incidents which only came close to being disastrous. A cascade of failures and lack of good decision processes seem to be the typical cause and review with recommendations on how to prevent them from occurring in the future is good. An honest mistake or poor circumstances for otherwise good people are worthy of overlooking and avoiding in the future. Lack of training can be identified and refresher courses or other supplementary training can improve the situation for everyone. Much like making sure someone is addressing problems in their job and growing to accommodate the required work. Though there might be a bad fit for a job; either someone not able to do the expected work of an individual in that position, a job that's poorly defined and/or not broken up in to manageable units of work, or a worker that is a bad actor to some degree. All of those defects are situations that review and recommendations for remediation should address and resolve. In your specific case, I believe having a single payer system would improve the outcome related to the above considerations. Affected individuals would still be covered by 'the system', good doctors would not be burdened by specific negative outcomes that happened to occur under their care, and bad workers of any type would be removed. The actual outcome of individual patients shouldn't factor in to compensation. However addressing that in detail is clearly off the main topic. I think it is both ethical and practical to recognize and classify cases that are bad fits for a given worker and to attempt to route them to someone that is a proper fit; while providing the best intermediate care and transition possible. Also of note is that for a 'single payer' system the costs SHOULD be divorced from the actual treatment; though might be a considered criteria when a given standard of treatment is selected.

Aeolun 8y ago

It’s a pretty sad thing we have to describe such a soul destroying environment as par for the course for a job though.