For the record, the Soapbox family is not crazy about going to the US for medical care, but our eldest daughter (let’s call her “Missy”) has some serious health issues (I blame it on Mr Soapbox’s gene pool) and her GP refused to book the necessary appointments with specialists because—get this—“there were too many cooks in the kitchen”!
So we followed in the footsteps of Mr Soapbox and our younger daughter “Mini” and set out for the Mayo Clinic in Rochester, Minnesota.
We got off to a less than auspicious start. I kicked over Missy’s hot chocolate in the airport lounge, our plane was late and they lost our luggage. Luckily Ms Soapbox and Missy are easy going souls and rolled with it. OK, Missy rolled with it, Ms Soapbox fretted until the bags showed up at midnight.
After an initial hiccup (Missy’s “intake” doctor was on vacation and appointments that should have been pre-booked were not) her cardiologist sorted out her appointments overnight. These ranged from baseline tests to assessments with a number of specialists.
Some specialists were able to see Missy within a couple of days, but others, specializing in more complex cases, were booked 3 weeks out. Not good.
That’s when we became “checkers”.
The “checker” system
Thousands of patients flow through Mayo each day. Most have appointments scheduled outside of the “anticipated” window of five to eight business days. This wreaks havoc with hotel reservations, return flights and life in general and would be a colossal problem but for the fact that the minute they get their appointment schedules everybody starts shifting them around.
The Mayo booking process allows a patient to “check in” with a doctor hours or even days in advance of their scheduled appointment and hang around in the waiting room in the hope that the doctor can squeeze them in. Sounds goofy but it works.
In Missy’s case this meant foregoing breakfast (twice) on the chance the doctor could see her—he did.
Too many cooks?
Missy’s cardiologist was stunned by our GP’s belief that involving specialists would result in “too many cooks in the kitchen”. The Mayo model is based on the collaborative efforts of a number of specialists working as a team to deliver the best results for the patient.
His comment: “There’s no such thing as too many cooks in the kitchen”. The real challenge is to ensure that all of the “cooks” are communicating effectively. That’s where Mayo Apps come in.
All of the Mayo doctors work off the same page (literally) and have done so for decades.
About 100 years ago Dr Henry Plummer, one of the original partners, created the “unit record”—a single file that records everything related to a patient’s care—physician notes, lab reports, surgical dictations, correspondence, appointment schedules, X-rays, ultrasounds, CT and MRI scans, echocardiograms — you name it, it’s all in the unit record.
In 2005 the unit record went electronic. Not only is the record instantly accessible to all of the doctors who record their findings immediately after each appointment, it’s instantly accessible to the patient who’s downloaded the Mayo app to her iPhone or iPad. A sign of trust given the US is one of the most litigious nations in the world.
The Mayo app is secure as human nature will allow…you guessed it, the waiting room is abuzz with conversations like this: Wife: It looks like you’re leaking protein. Husband: I’m leaking what???
What Alberta can learn from Mayo
Harvard economist, Jeffrey Sachs says “Good health requires seamless connections among the family doctor, specialists, hospitals, diagnostic units and others. Instead we have a horrendous maze of separate organizations, insurers, and providers, each on its own accounts and information systems. The result is waste, fraud, and abuse of hundreds of billions of dollars each year.”*
Mr Sachs was talking about US but the “horrendous maze” is springing up in Alberta as well, particularly since the government agreed to underpin private concierge clinics and diagnostic clinics with a publicly funded safety net.
It doesn’t have to be this way. We can develop a healthcare system powered by collaboration and “seamless connections” by learning from those who do it best.
The Mayo’s motto is “The needs of the patient come first”. This is expressed in its priorities which include Allow time for questions. Anticipate the patient’s needs and Go the extra mile.
The Alberta Medical Association also has a motto—Advocating for Patients First—but fails to take it to heart. The “one ailment per visit” rule allows doctors to pad their incomes at the expense of their patients. GPs abandon their patients once they’re put on the wait list where they may languish untreated for years.
Trust me, a patient knows when her doctor is merely giving lip service to “patients first” or going the extra mile. It’s time for the AMA to step up.
Electronic Medical Records
Alberta Health Services has been working on a province-wide Electronic Health Record (EHR) system since 1999. By 2010 roughly 2,600 physicians or 50% of the “eligible community physicians” were using the system.**Very little progress has been made since then.
Missy spent days schlepping from MRI clinic to X ray clinic to specialists’ offices gathering up her medical records because her GP was not electronically connected to anything.
The Mayo Clinic converted 6.2 million patient files (some dating back to 1907) to electronic records in 2005. It continues to update its files by 350,000 patients a year (the system now contains 8 million electronic patient files). Surely Alberta Health Services can finish the job it started in 1999 and convert the records of 3.9 million Albertans to an electronic system accessible to all including the patient.
What the Soapbox family learned from Mayo
We learned something we already knew but couldn’t access in Alberta:
- Medicine is a personal service. It begins with listening to the patient and creating a relationship based on trust.
- Human health is a complex thing. Specialists see what they are trained to see; when they collaborate their collective efforts are far superior to their individual contributions.
- This is the 21st century. It’s easier to collaborate electronically.
And on a personal note, after living together in a hotel room for eleven days, Ms Soapbox and Missy learned that they don’t need much personal space as long as there’s something half decent on TV.
*“How Not to Make America Great” by Jeffrey D Sachs, Esquire April 2013, p 86
** Government of Alberta Backgrounder dated May 14, 2011
Alberta already has Netcare. All diagnostic tests – labs and radiology – hospital discharge summaries and pharmaceutical prescriptions are uploaded onto to it. So any physician you are seeing can have a look to see what’s been done. Physicians who operate with EMRs in their own office do not upload onto Netcare (with perhaps the exception of prescriptions) and nor should they. Do you really want the details of every visit you make to your physician made available to every healthcare worker in the province? Alberta loosened the rules for sharing of medical information years ago, so that physicians can easily share information with each other for patients in their care. Also, if you park yourself in any specialists office for two days without an appointment they will likely see you.
The Mayo Clinic puts on a good show, but the results aren’t always as dazzling.
I’m more familiar with the Mayo App than Netcare but my review of the Health Information Act indicates that an Albertan’s health information is available to a small army of people, not all of whom are healthcare workers. The HIA makes our health information available to “authorized custodians”, defined as doctors, nurses, pharmacists, nursing home operators, Alberta Health Services, hospital boards, community health councils and the Minister of Health Fred Horne and his department(!!) and their “affiliates”, defined as the custodian’s employees, volunteers, contractors and students. The only person who doesn’t have an automatic right to her health information is the patient. So yes, I wouldn’t want the details of my doctors visits to be available to this cast of thousands. Instead of ditching the Mayo App idea I’d suggest we amend the HIA by narrowing the definition of authorized custodians and affiliates starting with the elimination of the Health Minister and his department from the definition of “authorized custodian”.
The reason I liked the Mayo App was that we could access the doctor’s records in real time. As a result we could ask questions and participate more fully in the process.
I’m not so sure the “checker” system will work in Alberta. The best I’ve been able to accomplish is to be put on the “call in case of cancellation” list. I tried phoning to see where I was on the list and was told to stop bothering the staff. But who knows, it’s worth a try.
I am struggling to try to figure out why the Alberta system is so different in reality as compared to the Mayo system. The Mayo system is based on a not for profit model, while at least part of the Alberta system is. Mayo doctors are paid a salary, while many Alberta doctors bill the system for each visit/procedure. I am always reminded of the adage of “Be careful what you measure/reward” and think of the Russian example which measured the production of typewriters by weight …which resulted in very heavy typewriters.
Presently the Alberta system rewards its doctors financially by seeing as many patients as possible, which encourages the limiting the issues to one per visit and discourages allowing time for questions or the building of a personal relationship. Meanwhile the Mayo doctors already know how much money they are making and instead, focus on doing a thorough investigation of the patients before them (including accepting checkers that they don’t receive extra money for). Money is not the driving force in Rochester but it appears to be in Alberta. Is it because the rates per visit are so low, doctors need to ensure they maximize their billing time to help cover overhead such as rents, assistants etc (unlike the Mayo doctors who are part of the complete team)? Or is it because Alberta doctors are almost viewed as personal corporations, whose primary objective is to maximize profits?
There appears to be a big gap in the two cultures, as Mayo actually walks the talk. Do we suggest all medical personal, including doctors become employees of the provincial government, with access to offices etc.? That may start to create the Mayo emphasis on patients rather than money. Then if some doctors wanted to set out on their own, they could direct bill patients for all expenses with no ability for the doctor or patient to get reimbursed by the province. They would also be responsible for all overhead and would truly be private.
Lastly, I feel the need to comment on the gene pool theory advanced by Mrs. Soapbox. While I agree both daughters inherited the brainpower and good looks of Mrs. Soapbox (thank goodness), they appear to have also inherited some of the less stellar genes, which can be traced back two generations on that side of the tree!
Roy, I think you’re right, the compensation model is a key driver of behavior and the Mayo “on salary” model is more conducive to “go the extra mile” behavior than the “fee for service” model that encourages doctors to rush through appointments or default to one ailment per visit or focus on more lucrative services and ignore the less lucrative ones.
A recent article in the Edmonton Journal (Apr 8, 2013, online) set out the range of compensation paid to doctors depending on their specialties. And while I understand (sort of) that specialists merit higher compensation than generalists, the rationale behind why some specialists make so much more than others or indeed why all specialists should make so much more than the generalists escapes me.
In 2010-2011 the gross annual income for doctors practicing family medicine averaged $316,335, for general surgery it went up to $513,969 and for ophthalmology it hit $943,916. Doctors deduct their overhead expenses which the AMA says ranges from 40 to 60% but which a national study says is closer to 25%. (??) None of this is transparent because doctors, for the most part, are independent contractors operating their own private businesses. There must be a mechanism to ensure that they’re not double or triple billing AHS for their services but I don’t know what it is or if it’s effective at eliminating fraudulent billing. Add to this the possibility of additional compensation through the Alternative Relationship Plans and it’s all very opaque.
All I know for certain is that I’ve been treated by both types of doctors, the ones who “go the extra mile” and the ones who are so busy hustling me out the door that I barely have time to get my coat off, let alone state my (one) ailment.
PS. I take it back. You have a wonderful gene pool.
The national study to which you refer averages ALL physicians’ overhead expenses. Keep in mind that many physicians work out of hospitals and apart from paying someone to do their billing paperwork, don’t actually have overhead expenses. Also keep in mind that many rural physicians enjoy offices owned and paid for by the communities they work in (don’t blame them; it’s a good way to attract doctors to places where the work is hard and the hours are long). Then keep in mind that the gross annual income for “family medicine” includes walk-in clinics, a model effective in treating non-emergent but acute illness (your bladder infection, say) and in maximizing billings, but not so effective in providing continuity of care.
Now think about those of us practising real family medicine, where we know our patients and we talk to them and we are honestly trying our best. Not many of us are billing $300K/year. Not many of us stick to the “one-problem-per-visit” rule, even though we may advertise it (but please, do remember that waiting room time is exactly the same as exam room time: if you book a short appointment to deal with one issue and you expect to deal with five, something has to give). We know that medical care is more complicated than that. And most of us are paying a nurse and a receptionist and a clerk as well as rent and supplies and a ton of professional fees…while your short appointment pays somewhere in the neighborhood of thirty-five bucks. So while I’d love to spend all the time in the world with every single patient every single time, I also want to be able to keep my office open so that said patients actually have a family doctor to visit. Sometimes economic reality rears its ugly head.
And finally, well, sure, illness doesn’t work 9-5. But physicians aren’t illnesses, we are human beings, and we get tired and sick and have families and sometimes need to look after ourselves too. And that’s a good thing. People put their lives in our hands every single day. You don’t really want someone who hasn’t slept making those decisions.
Oh..not finally. Most family physicians are not GPs. Family Medicine is a recognized specialty with its own College and a full two-year residency. The general license has been gone since, oh, 1993…
It’s great to hear from someone “inside the tent”. There is so little information out there about physician compensation that most of us just assume that our family doctor is well paid. However as you rightly point out a statistical survey can be very misleading, particularly in the case of family medicine. I’ve never understood why physicians who practice family medicine should fall at the lower end of the compensation spectrum when they’re the ones who need the broadest understanding of medicine in order to deal with whatever comes in through the door.
I understand that the AMA has set up a committee to address compensation issues. I would hope that family medicine practitioners will have an opportunity to make their case for a more equitable distribution of the pie. Given the emphasis on keeping people healthy at the outset by preventing chronic disease or failing that, addressing it early, surely it would be wise to train more physicians in family medicine and ensure they’re well compensated. If we can’t get it right at the front end, it will only get worse at the back end.
Thanks for your comment, Alberta Family Doc, and welcome to the Soapbox.
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Mmmm… I wonder if this is Susan’s husband?
It was the gene pool comment that gave us away, eh? 🙂 (Thank god Mr Soapbox has a sense of humour!)
Reading the Soapboxes ‘ posts on the Mayo Clinic makes me think why is it so difficult for Americans to have more of those. It seems a good model and apparently it works. I personally think that having doctors on salary would be much better but the issue is money. The real issue is not the service, the quality of care …etc. The issue is money and our system is deteriorating because doctors want to be free to make more money and they no longer support the existing system. On the other hand the existing system is being deliberately sabotaged because our supreme ayatholas cannot see anything other than their neo-con model that calls for competition and privatization. So the two together are dragging the system into oblivion and in the meantime no one really knows what to think of it all. Of course the doctors do not go against the existing system but they also do not support it. So the slow sliding to nothing seems acceptable. They did the same with the nurses where they were all along silent about supporting them.
The reason to me why this Mayo model does not take off in the US and apparently is not at all in the horizon for Alberta politicians, is the individualism that we have so carefuly pampered in the last 30 years. In the US for example people are no longer poor, they are milionaires in waiting and in Canada, we have embraced celebrity culture to levels I thought impossible in a much more balanced society in the late 70s and 80s. Now the conversation is ‘to make it’ which of course today no longer means a house and a car and a vacation abroad every year. It means an enormous house, as many cars as possible, boat, and a jet helps a lot to avoid the so called airports that look more to me like doctors office’s waiting rooms with drinks and food available.
Well I hope that Missy is doing better and also that Susan does not go around kicking people’s hot chocolates. As far as the checkers, I do not know if I want any more electronic gadgets but I would be very happy if the laws changed so that doctors do not keep us slaves of their prescriptions every three months. This is where they make the easy money and takes the place for others that need to see a doctor. I am not so sure a lot of them actually want to see patients just judging by the way they talk to the walls saying nothing of consequence while in my case, I then had to ask if there was any problem or not as a result of an important test that took me half a day to complete. DOUGHHH
You’re absolutely right Carlos, the reason the Mayo not-for-profit model hasn’t taken off in the US (or Canada for that matter) is money. The doctors who work at the Mayo Clinic have given up lucrative careers in the private sector in exchange for the opportunity to practice medicine in a state-of-the-art facility with the best clinicians or to conduct independent research without constraints imposed by drug or equipment manufacturers. In both cases the “salary question is settled and the business office takes care of the fees; all they have to think about is getting the patient well.” (The Doctors Mayo, p 422).
Patients coming to the Mayo are, for the most part, insured under the typical employer HMO and PPO plans although the Mayo does take “charitable” cases as well (I have no idea how this works).
The Mayo’s state-of-the-art facilities are funded by wealthy benefactors. Ironically this is a situation we’re seeing develop in Alberta as well as the PC government abrogates its responsibility to provide basic services and calls upon wealthy Albertans to fill in the gap. Just look around your community to see how many hospital wings bear the name of Brett Wilson or some other philanthropist. Thank god they’re prepared to step up, but even the philanthropic well will run dry if the government taps it too often.
Your comments in your last paragraph mirror the frustration of so many Albertans. I was pleased to see that the Liberal MLA, David Swann wrote to the Alberta Medical Association telling them that it was time for the AMA to live up to its motto–Patients First. He also publicized the issue on his blog. Here’s the link: http://www.davidswann.ca/blog/. It will be interesting to see if the AMA responds.
Thank you for the David Swann’s blog. I did not know he had a blog. I will for sure visit it. He is one of those individuals like Taft that somehow were not able to ‘make it’ politically when they had all the qualities for excelence. It is unfortunate.
One thing you mentioned in your post that astonished me and I meant to make a comment is the issue of access to health records. The government makes a big deal about privacy and then in the end all of the Health ministry employees have access to these records. Why even Fred Horne has that access. What does that information have to do with his job? That is quite something. This is actually bogus.
Yes the Mayo Clinic is for people that are truly interested in health or somehow go there to have an opportunity to do some research without big brother right behind telling them what drugs have to be sold to make HUGE profits. I do not know anything about the Mayo Clinics history but I bet it is known in the US as a socialist Institution. In my view the same model would not work in Canada because the mentality that doctors care about patients is vanishing very quickly. I predict that soon we will have no model at all just like we do not have a understanble structure for anything else. The model now is ‘If you have the money you can get around most obstacles and if you have no empathy you can be a good predator without much consequence’. This is the same model that took all of Latin America where they are today and trying to get out of it, and also most of Africa. In Latin America thanks to the American foreign policy that decimated their infant democracies in the late 50s and early 60s and in Africa because in the 60s and 70s they were taken over from the European colonies by leaders educated in East Germany, China and Russia who proceeded to completely destroy economies that worked way way better than their communist structures. They also expelled all the whites born there and replaced them with East Germans, Russians and Polish people that came in to just send some money back to their decrepit economies that could not even produce enough bread for their citizens. Years after this madness was completed and the countries were basically bankrupt the same leaders announced that it was of course because the whites had left and taken everything with them!!! 🙂
What does this have to do with our health care system? Maybe nothing but it is the process of desintegration of existing structutures to be replaced with dogmatic ideological models without any concern for the consequences and without any proper planning to avoid total collapse.