{"id":476,"date":"2009-12-09T21:07:00","date_gmt":"2009-12-10T01:07:00","guid":{"rendered":"http:\/\/blog.cmhughesmd.com\/?p=476"},"modified":"2009-12-09T21:07:00","modified_gmt":"2009-12-10T01:07:00","slug":"an-interview-with-thomas-russell-for-health-affairs","status":"publish","type":"post","link":"http:\/\/blog.cmhughesmd.com\/?p=476","title":{"rendered":"An Interview With Thomas Russell for Health Affairs"},"content":{"rendered":"<p><a href=\"http:\/\/healthaffairs.org\/blog\/2009\/12\/07\/an-interview-with-thomas-russell\/#more-3087\">Health Affairs Blog link to full interview.<\/a><\/p>\n<p>John <span>Iglehart<\/span>, one of the Founders of Health Affairs posts an interview with surgeon and retiring Executive Director of the American College of Surgeons. There are quite a few pleasantly surprising <span>moments<\/span> in the interview, <span>which<\/span> I&#8217;ll bullet here, but you can go read on your own.<\/p>\n<ul>\n<li>Q. I would assume that more than a few surgeons regard such activity as an intrusion into the independent practice of medicine.  Is there a generational difference among surgeons in their willingness to cooperate or at least participate in these kinds of initiatives?<br \/>Russell: Absolutely.  The younger surgeons have trained in an environment in which they to expect that the  quality of care they deliver will be measured and evaluated, so they don\u2019t really have any difficulty participating in these activities.  It\u2019s some of the older physicians who entered practice in a more autonomous era who struggle with these new forms of oversight.<\/li>\n<li>First, let me say that the surgical community is not homogeneous, and they\u2019re all over the map on reform.  The College has a split membership.  Some surgeons think that the status quo is just fine and that greater oversight and accountability are unnecessary. They view them as intrusions into the autonomy of a sovereign profession, while others are all in favor of reform.<br \/>There is at least one matter on which I think we mostly agree, and that is the fact that we have to do something to fix our broken payment system. So, the number-one change that I would like to see emerge from the health care reform debate is fundamental, long-term improvement in how physicians are paid, so that they really are being paid for providing cost-effective, high-quality services.<\/li>\n<li>Iglehart: Would that mean, according to your vision, an abandonment of the fee-for-service payment model and going to an alternative model, or some kind of a hybrid?<br \/>Russell: I recently addressed a large group of surgeons and asked them whether they are paid a salary, and most of them raised their hands. Throughout the nation, more surgeons are becoming salaried professionals. Most academic surgeons as well as those in integrated delivery systems\u2014such as the Mayo Clinic, Geisinger, Kaiser, and many others, including Veterans Affairs\u2014are on salary. So are doctors who are employed by the VA. I think it\u2019s safe to say that more than 50 percent of the nation\u2019s physicians are paid a salary.  And, some of the happiest doctors whom I\u2019ve met are the salaried ones because they don\u2019t have to deal with the hassles of malpractice insurance, including the high premiums they pay, or coding, or any of the other administrative burdens that confront physicians who are in private practice and reimbursed through the complicated fee-for-service system. <\/li>\n<li>We also need to look in a very thoughtful, ethical way at rational \u2013 I\u2019m not using the word rationing, I\u2019m using the word \u201crational\u201d\u2013ways to improve end-of-life care.<br \/>In addition, the medical and surgical professions need to develop protocols for the best ways to approach diseases.  We need policies about when scans, such as a CTs and MRIs, are indicated, and to make sure they are not unnecessarily repeated by another physician.  And we must develop standardized ways of treating diseases so that every health care professional involved in coordinating a patient\u2019s care is addressing the condition in the most cost-effective way that follows the scientific evidence.<\/li>\n<li> For instance, I think that the Number One way to help patients avoid frivolous trips to the ER is to educate them about where they should turn to receive appropriate care for nonemergency conditions and to make certain they have access to primary care physicians. [We do a poor job of <a href=\"http:\/\/cmhmd.blogspot.com\/2008\/08\/international-comparison-access.html\">getting people into PCPs<\/a>&#8211; cmhmd]<\/li>\n<li> Here\u2019s how this maldistribution of surgeons has arisen.  About 80-90% of medical school graduates who pursue surgery as a specialty begin their residency training in general surgery.  After five or six years of residency, and at ages 32 to 34, many pursue additional training in a fellowship that will allow then to focus on just one type of disease or organ that general surgeons treat and operate on. That is to say, they become super-specialized in breast surgery, minimally invasive surgery, bariatric surgery, cardiac surgery, or cancer surgery.  So they\u2019re taking themselves out of the pool of professionals who can perform the broad range of general surgery procedures. And, most of this highly specialized surgery is performed in large cities, so these surgeons are not typically accessible to rural patients.<\/li>\n<li>  Organized medicine and many Republican legislators have long argued in favor of capping awards for noneconomic damages, but I don\u2019t believe the nation will ever reach a consensus on that proposal, although a few states have implemented the limits.  I think instead more efforts should be made to educate, in this case surgeons, about how to avoid or better manage risk by staying within their scope of practice.  Communication with the patient and his or her family throughout the surgical experience is also key to helping these individuals understand why there was a negative outcome. When a mistake is made, apologize, if you practice in a state that has passed legislation providing legal protections for saying, \u201cI\u2019m sorry.\u201d<br \/>Very important, too, is for the profession to develop evidence-based best practice protocols and for physicians to follow them closely.  In my era, we objected to this form of standardization and called it \u201ccookbook medicine.\u201d But, as calls for accountability have increased, lawmakers should consider setting policies that protect physicians who adhere to professionally developed protocols. In these cases, if a patient sues because of a bad outcome, the physician can respond with a legitimate defense:  \u201dLook, I followed the protocol that we all agreed was best practice.  I\u2019m sorry for the bad outcome, but a bad outcome does not equal malpractice. [Except <a href=\"http:\/\/cmhmd.blogspot.com\/2009\/11\/how-to-reform-broken-medical.html\">for this<\/a> and people like <a href=\"http:\/\/cmhmd.blogspot.com\/2009\/11\/evidence-based-medicine-and-reform.html\">Bernadine Healy, who should know better<\/a> -cmhmd]<\/li>\n<\/ul>\n<p>Thanks to Mr. Iglehart and Dr. Russell for the informative interview.<\/p>\n","protected":false},"excerpt":{"rendered":"<p>Health Affairs Blog link to full interview. John Iglehart, one of the Founders of Health Affairs posts an interview with surgeon and retiring Executive Director of the American College of &hellip; <a href=\"http:\/\/blog.cmhughesmd.com\/?p=476\" class=\"more-link\">Continue reading<span class=\"screen-reader-text\"> &#8220;An Interview With Thomas Russell for Health Affairs&#8221;<\/span><\/a><\/p>\n","protected":false},"author":1,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"sfsi_plus_gutenberg_text_before_share":"","sfsi_plus_gutenberg_show_text_before_share":"","sfsi_plus_gutenberg_icon_type":"","sfsi_plus_gutenberg_icon_alignemt":"","sfsi_plus_gutenburg_max_per_row":"","footnotes":""},"categories":[108,92,47,85],"tags":[],"class_list":["post-476","post","type-post","status-publish","format-standard","hentry","category-health-care-reform-debate","category-organized-medicine","category-physician-income","category-practice-variation"],"post_mailing_queue_ids":[],"_links":{"self":[{"href":"http:\/\/blog.cmhughesmd.com\/index.php?rest_route=\/wp\/v2\/posts\/476","targetHints":{"allow":["GET"]}}],"collection":[{"href":"http:\/\/blog.cmhughesmd.com\/index.php?rest_route=\/wp\/v2\/posts"}],"about":[{"href":"http:\/\/blog.cmhughesmd.com\/index.php?rest_route=\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"http:\/\/blog.cmhughesmd.com\/index.php?rest_route=\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"http:\/\/blog.cmhughesmd.com\/index.php?rest_route=%2Fwp%2Fv2%2Fcomments&post=476"}],"version-history":[{"count":0,"href":"http:\/\/blog.cmhughesmd.com\/index.php?rest_route=\/wp\/v2\/posts\/476\/revisions"}],"wp:attachment":[{"href":"http:\/\/blog.cmhughesmd.com\/index.php?rest_route=%2Fwp%2Fv2%2Fmedia&parent=476"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"http:\/\/blog.cmhughesmd.com\/index.php?rest_route=%2Fwp%2Fv2%2Fcategories&post=476"},{"taxonomy":"post_tag","embeddable":true,"href":"http:\/\/blog.cmhughesmd.com\/index.php?rest_route=%2Fwp%2Fv2%2Ftags&post=476"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}