Robert M. Wachter, MD is Professor and Associate Chairman of the Department of Medicine at the University of California, San Francisco, where he holds the Lynne and Marc Benioff Endowed Chair in Hospital Medicine. He is also Chief of the Division of Hospital Medicine, and Chief of the Medical Service at UCSF Medical Center. He blogs regularly at Wachter’s World.
Bob Wachter, MD
There are tens of thousands of policies in Medicare's policy manual, which makes for stiff competition for the "Most Maddening" award. But my vote goes to the policy around "observation status," which is crazy-making for patients, administrators, and physicians.
I sometimes explain to medical students that they are entering a profession being transformed, like coal to diamonds, under the pressure of a new mandate. "The world is going to push us, relentlessly and without mercy, to deliver the highest quality, safest, most satisfying care at the lowest cost," I'll say gravely, trying to get their attention.
In the past, neither hospitals nor practicing physicians were accustomed to being measured and judged. Aside from periodic inspections by the Joint Commission, hospitals did not publicly report their quality data, and payment was based on volume, not performance.
These should be the best of times for the patient safety movement. After all, it was concerns over medical mistakes that launched the transformation of our delivery and payment models, from one focused on volume to one that rewards performance. Yet I’ve never been more worried about the safety movement than I am today.
I was recently speaking to the clinical leaders of a mid-sized hospital, and a senior administrator posed the question, “should we require our doctors and nurses to get flu shots?” The answer, I said, is yes, and it isn’t just to prevent the flu.
The debate over pay for performance in healthcare gets progressively more interesting, and confusing. And, with Medicare’s recent launch of its value-based purchasing and readmission penalty programs, the debate is no longer theoretical.
Emerging evidence suggests that patients and their surrogates frequently engage in massive denial when it comes to prognosis near the end of life. While understandable – denial is often the way that people remove the “less” from “hopeless” – it can lead to terrible decisions, with bad consequences for both the individual patient and society.
Senior attendings like to quip that the medical students seem to be getting younger every year. They’re not. But the attendings on the wards of American teaching hospitals actually have gotten younger.
Like waiting outside the Vatican for the puff of white smoke, the nation sits on edge awaiting the Supreme Court’s ruling on the Affordable Care Act.
Two cover stories in this week’s Time magazine debate a provocative question: Is America in decline?