By David Albert Newman
August 3, 2010
This post discusses a very strong point of interest of mine: quality over quantity health care treatment.
This article shows the Canadian Medical Association (CMA) advocating pay for performance based upon quantity of patients treated.
A piece rate system (pay for performance) based upon the QUANTITY of patients treated is NOT a good solution. That rewards expedient performance. That is the problem with the current health care system: patients are treated TOO quickly by doctors when they finally see them after waiting for too long and the patient ends up with suboptimal care.
The solution: pay for QUALITY of CARE measured by LESS FREQUENT follow up appointments and/or fewer hospitalizations from conditions that could have otherwise been treated sooner or better.
Quality over quantity better manages the health care operations bottleneck: waiting times. I have studied this in my MBA Operations Management course about queuing theory and line balancing to manage the bottleneck by adding resources to equalize a system flow.
We need to adopt a new model of health care that I have coined: Think. Consult. Reflect. Act. (TCRA).
Doctors rely too much upon their own knowledge and skill rather than consulting a peer for his or her thoughts and a second opinion. That is extremely rare in professions.
The consult may take more time up front BUT in the long run the patient may recover with fewer repeat contact points to the health care system.
This is important since while many doctors think they are infallible, they are like the rest of us: they make mistakes AND their mistakes are often more serious due to the nature of their work of treating human beings who are ill, either acutely or chronically, and who may be getting worse.
It's time to change the culture of doctors to REQUIRE that they consult UNLESS IF and ONLY IF the diagnosis and treatment is very routine.
The current system BEFORE a negative change to a piece rate system of pay for performance relates to my poor health care treatment when I had ulcerative colitis in my mid-teens that almost killed me (I went to hospital at 98 lbs at 5' 10" tall and I was there for a week or so). This family physician not only did not diagnose my ulcerative colitis, he provided medication that moved food through my body faster since he thought I had an ulcer. That exacerbated the already chronic diarrhea that was dehydrating me and leading to my rapid weight loss. Thus, he broke the rule of non-malfeasance in the duty of care for me as the patient.
As for my mental health care, I was diagnosed incorrectly during 2000. I can't recall if the doctor was a psychiatrist or a psychologist, but based upon talk therapy, he must have been a psychologist since psychiatrists rarely perform talk therapy; rather the psychiatrist is a pharmacologist toward mental illness treatment.
During 2000, the psychologist stated that my long dead grandmother did NOT have schizophrenia even though she had finally been diagnosed with schizophrenia by a very prominent Winnipeg psychiatrist when she was quite old; how can a subsequent psychologist make a differential diagnosis about a relative, my grandmother, who had been dead for years and then extrapolate to me that I also did not have schizophrenia even given my paranoid behaviours of my wall posters staring at me and persecuting me? I was treated for anxiety with medication that controls the heart rhythm. This too is an act that broke the rule of non-malfeasance in the duty of care for me as the patient.
That is a SERIOUS error since I suffered for 5 more years before being hospitalized three times during 2005 where I finally received the diagnosis of schizophrenia (with depression and anxiety as a result since I could not recover properly and I had no idea at the time before diagnosis what was wrong with my brain, along with the following reality). I had lost all jobs, I had no positive cash flow income, I almost lost my house, and I almost killed myself since I was highly suicidal. The EI system funds ran out and then they came back at me for not properly declaring the little side income I did earn in my poverty.
I would have been gone and not only my family and friends would have lost me; I believe in myself and my ideas and the world would have lost those too.
The underlying problem in my case for both the family physician and the psychologist: no peer consult and over confidence in their knowledge and skills to properly diagnose completely ignoring me, the patient, and the input from me and my family. The CMA does have one thing correct: the patient MUST be the center of care. That is the whole point of the health care system.
I think the Hippocratic Oath needs to be recalled by all medical doctors regardless if they are a general practitioner or a specialist. This patient was almost killed twice by insufficient and inappropriate medical treatment and it is not only my goal, it is my moral duty, to minimize that same occurrence for other patients who may be too ill to fight for their human rights of proper health care treatment in Canada and elsewhere in the world.
David Albert Newman, CGA, CIA, ACCA (UK), B. Comm. (Hons.) with Distinction
"Anything is possible if we let our mind wander away from standardization towards creativity."
From 17 years old to 29 years old, I had chronic insomnia wherein I had two weeks of restful sleep. The family physician response was to tell me to eat a snack such as toast and to drink milk before bed and to not stay in bed. He eventually prescribed an anti-depressant which did little for me at the time. He wanted to "chase away the depression". He sent me to my first psychologist and that individual concluded that I was too sensitive a person and he told me to read books to learn relaxation. That was the first and last time I saw him. I wound up addicted to sleeping pills, alcohol, and drugs even though I told my family physician this and he acknowledged it was not good for sleep, but he offered no solutions (thus, the need to self-medicate to sleep since my mind raced from high dopamine levels later rectified by Olanzapine prescription which slowed the world down and eased information overload).
ReplyDeleteI have briefly described in another blog post the negligence by ignorance of counseling services--either not directly provided by my psychiatrist and psychiatric nurse or by them stating there was no help in Manitoba, that CMHA Winnipeg could not help me, and that I would be institutionalized for the rest of my life--which also includes a brief referral to a third psychologist recommended by my psychiatrist and psychiatric nurse. The third psychologist essentially found no interest in my desire for cognitive behavioural therapy, most likely to not poach another doctor's and nurse's patient.
As we have seen, I was bounced around the mental health care system until I was treated by the psychiatric nurse and psychiatrist who over medicated me that made me appear stiff and zombie like to keep me as a captive patient by a steady flow of appointments and high dosage prescriptions. CMHA counseling and medication reduction (but not elimination) was my enabler.
In between my first and third psychologists is the story that is shown above of error by my second psychologist as it is the most impactful and memorable of extreme medical negligence relating to schizophrenia non-diagnosis and non-treatment by phantom diagnosis of my dead grandmother.
My next blog post, which I will work on for a bit of time, will be more positive exploring CMHA Winnipeg relaxation techniques that helped me. It is good to remember the past, but at the same time I must be mindful of the present and the future since that is where my destiny resides.
ReplyDeleteThank you again for posting my thoughts and experiences. This goes a long way to becoming a mental health advocate to help others who are suffering from both poorly treated and untreated mental illness and who are not being empowered to realize their full creative abilities.
I had ulcerative colitis and I was lactose intolerant yet the family physician prescribed milk as a treatment for insomnia? Dilemma?
ReplyDeleteA creative thought spurred by mental illness creativity: Einstein's time dilation is the human behaviour of anticipation. Note that when you have seen an image, you recognize it faster. In terms of memory, faster means slower stimulus rate when perceiving the stimuli. Thus, when reconciling reality of faster recognition and perceptive reality, Einstein’s differential memory integrated anticipation AND foresight before events occurred (fast pattern recognition). This slowed time for Einstein when he thought which he coined time dilation. He then saw at the speed of light in his ideas. As such, he could then apply ultimate abstract thought.
ReplyDeleteUPDATE: I have verified that the psychologist during 2000 who said my long dead grandmother did not have schizophrenia-when in fact she did-and then used bias and applied that phantom diagnosis to me is in fact a psychiatrist. Thus, he was the first psychiatrist that I saw.
ReplyDeleteTook me time to read all the comments, but I really enjoyed the article. It proved to be Very helpful to me and I am sure to all the comments here It's always nice when you can not only be informed, but also entertained I'm sure you had fun writing this article.
ReplyDelete