Physicians as Stewards of Health Resources

Doctors are people.  While I want all physicians to rise above and be totally selfless in helping those in need, I know that all people work within a broader milieu and are sensitive to incentives, economics and the metrics on which they are judged.  As part of the health care consolidation that is ongoing in our society, doctors are increasingly employees of large organizations rather than private professionals answering only to their patients.  That tendency in healthcare to organize more effectively is necessary as medicine is increasingly a team sport that requires many different professionals, using complex equipment often available only in sophisticated facilities, working together.  Large organizations can often combine these resources more effectively.  However organizations that are large can also lose the focus on the individual who is in need of care.  It can lead to systems in which health professionals are judged more on their effective use of organizational resources and their contribution to the well-being of the organization, rather than the well-being of the patient.  Ultimately, because physicians and all health professionals are people, judging them as stewards of health resources rather than as fierce advocates for their patients puts them at risk to be less focused on the values and needs of the specific individual they are helping in the moment. 

Two articles this week shed light on this issue.  In the Journal of the American Medical Association, an article entitled “Guidelines, Online Training Aim to Teach Physicians to Weigh Costs of Care, Become Better Stewards of Medical Resources.”  It intermingles two points, benefit to the patient and benefit to society, as if they were the same and those two related but critically different points can result in danger for patients.  Lowell E. Schnipper, MD, chair of the American Society of Clinical Oncology’s Value in Cancer Care Task Force speaks of the need to raise physician awareness of the financial effects of medical care on their patients.  That is critically important as the physician must know their patient, and must know the factors that will affect that patient’s care.  Financial considerations are an important part of anyone’s life and a doctor must be sensitive to those factors.  Schnipper however later states, “The dollar amount isn’t the driver; it’s the degree of benefit the patient and society get.”  That statement makes me nervous.  A doctor’s focus must be on the benefit the patient receives and not the benefit for society.  Doctors who are “stewards of medical resources” rather than stewards of their patients’ needs and values can harm the trust needed between a doctor and patient. 

Dr. Charlotte Yeh voices my own fears quite well in her article “Nothing is Broken: For an Injured Doctor, Quality Focused Care Misses the Mark” published in Health Affairs.  She tells her own story of being in an accident, then taken to the ER and ultimately admitted.  She felt alone, isolated, and ignored.  She did not feel cared for.  At one point, after being in the Emergency Room for 14 hours, a physician said to her, “There’s no medical reason to admit you but if you can’t walk, we’ll just have to.”  That callous statement made her feel embarrassed and guilty.  Yet the physician was following medical scientific protocols and trying to be a good steward of the expensive resource of a hospital admission.  Dr.Yeh laments the “uneven nature of my care, marked by an overreliance on testing and a narrow focus on limited quality metrics” and states that it “fostered an inattention to my overall well-being.”  She points out that patient-reported outcomes are critical and that the “North Star” guiding all care must be “providers using any means possible to know the patient, hear the patient, and respond to what matters to the patient.”

If I, as a patient, believe that my physician is more focused on a broader societal good, and not as much on my own benefit, then I will not have the trust I need in the physician.   Part of that trust is a physician understanding the financial impact of any care on me and my family.  There is a slippery slope however in focusing on societal and organizational goals rather than the patient and family goals.  It could lead to physicians thinking more about the society and deciding, for example, that it is not worth helping a healthy alert 80 year old get the care needed, as his or her life expectancy on a cost benefit analysis would not bring enough value.  If you practiced in a prison setting, a focus on being a steward of societal resources could cause you to decide that someone serving a life sentence should be allowed to die of disease because the price to society of both the cost of care and the cost of maintaining that person in a prison is too high.

 

I say all this as a person who works, and has worked for the past twenty-five years in some very large organizations.  I have built and managed many of the policies and programs of those organizations.  Yet I have always done so with the knowledge that any metric, any policy, and any organizational design will not fit 100% of all the people they are meant to impact.  I design these with the knowledge, and the proviso that smart people, using judgment, must be allowed to override the process in order to help a person in need.  I do this design work in the hope that caring health professionals will battle the design when they must to maintain the sacred patient trust that is part of being a Health Professional, and especially part of being a Physician.  I want the dynamic tension that comes from caring people, with different frameworks of healthcare, occasionally arguing for different approaches because that leads to better results for all.  Once, when I was Chief Medical Officer of an organization that covered 11 million lives, I was called because a 9 year old girl needed a type of therapy for a rare cancer that was not approved under the medical policy of the health plan for that particular cancer.  It was covered for other types of cancer however no one had foreseen the potential of using it for the particular rare cancer this young girl suffered from.  The mother of the patient had been fighting with the health plan for three weeks before it came to my desk.  I immediately approved payment for the treatment, called the mother directly and listened to her cry with relief.  Money was a factor and this family could not have afforded the treatment had it not been covered.  I was later taken to task by my organization for going against the medical policy.  I still wear that decision, and the price I paid organizationally, as a badge of honor. 

While doctors are people, and will work towards incentives as people, I still want the practice of medicine and all health professions to be callings; sacred missions to help people and not just jobs.  People are able to rise above their own incentives and their own concerns if they are trained and imbued with the responsibility that a calling entails and given the proper protection if they fight the system.  What is needed is more education to physicians about all aspects of a patient’s life impacted by illness, including finances.   What is needed is a culture in which doctors are encouraged to know their patients, and care more about their patients, and not necessarily the broader society.  Physicians must be given the tools and time to return to the caring role they traditionally have held.  A physician should be focused on listening to the patient, learning who they are and what their values are, and following a solemn oath to be true to the patient’s needs and values while practicing the best scientific care in partnership with that patient.  Only then will physicians be true stewards of the trust that their patients place in them. 

More on the VA System

I want to thank those of you who commented, in a variety of venues, on my blog post on the VA system.  The Health Assistants I work with brought valuable perspective from having loved ones who receive their care from the VA in their comments.  In that post, I spoke of my work consulting for the VA system in the 1990s.  During that era, Dr. Kenneth Kizer, as the Undersecretary of Health in the Department of Veterans Affairs implemented reforms that improved quality, access and efficiency.  I was an admirer of Dr. Kizer and his efforts at that time. This week, in the New England Journal of Medicine, Dr. Kizer in collaboration with Dr. Ashish Jha, wrote about restoring trust in VA Health Care.  Their analysis and suggestions are ones that should be followed.  They point to three main causes of the health care problems now besetting the VA Health System.  “…an unfocused performance-management program, increasingly centralized control of care delivery and associated increased bureaucracy, and increasing organizational insularity.”  They propose a few first steps. 

1. Refocus its performance-management system on fewer measures that directly address what is most important to veteran patients and clinicians – especially outcome measures.
2. Conceptualize access to care in terms of a “continuous healing relationship” drawing on modern information and communications technologies to facilitate caregiver-patient connectivity and that uses personalized care plans to address patients’ individual access needs and preferences. 
3. Engage in more private-sector health care and form learning and improvement partnerships with outside entities, while making performance data broadly available. 

To the three that they mention, I would add one that would be required even before starting – leadership of the quality that Kenneth Kizer brought to the organization in the 1990s.  

VA Health Care, Good Intentions, and Unintended Consequences

In the mid-1990s, I had the experience of consulting for VISN (Veterans Integrated Service Network) 11 of the VA system which includes Michigan, Indiana and parts of Illinois.  I was asked to help them develop a strategy to bring more primary care to communities that had no VA facilities. Even then, the problem of access to care, and especially access to high quality primary care, was seen as a major issue for veterans.   I visited communities in northeast Indiana and helped the VA system develop options to either build a contract system to use independent primary care doctors as an arm of VA care, or to actually have VA employed doctors work in community based outpatient facilities with the major VA medical centers reserved for referrals from those community based practitioners.   My job was to deliver the options in a way that could facilitate decision making and be made operational.  The experience I had was consistent with the revelations now receiving media coverage and congressional scrutiny.  I saw excellent clinical care and horrendous service which significantly limited access to care. 

I am not the only one to recognize that these problems are not new.  A Wall Street Journal editorial entitled “The VA’s Bonus Culture” starts by saying “It must feel like Groundhog Day at the Veterans Affairs Office of Inspector General.  On Wednesday it issued an interim report – its 19^th since 2005 – documenting excessive wait times at VA hospitals.”  The lack of public attention to all of the previous reports is a sad fact. I will not attempt to explain it except to say that there is constant competition for public attention as problems are plentiful.  That is part of our contemporary world. 

The persistent nature of the problems is the result of a flawed system of flawed incentives.  I don’t doubt that the implementation of the current VA system was done with the best intentions.  In the 1980s and 90s, there was a persistent belief amongst the architects of this system that the effective use of technology, and the use of state-of-the-art electronic medical records would result in a better quality of care. The belief ran that these approaches in turn would drive ‘care efficiency’ by instituting best-practice protocols embedded in the use of this technology. This ‘efficiency’ would allow for more care to be given to more veterans at a lower cost and in a timely manner.  Twenty years ago the VA system also instituted the use of specific metrics in assessment of its employees to properly reward those who met their metrics and punish those who did not.  The career-advancement incentive for these VA professionals became the following of proper protocols and meeting their “numbers” rather than an incentive system based on individual patient progress, veterans’ satisfaction with their care and improved quality of life for people using the system. Again, I do not question the good intentions of those who instituted this system, but looking at the current situation of the VA in turmoil and with my thirty years of experience in the world of Health Policy, I can confidently point to these efforts as inadvertently leading to the major underlying problems of VA healthcare.

We are now seeing the logical consequence of a system designed and executed poorly.  In individual VA networks and hospitals, this poor incentivization made it so that the administrator who challenged this system was likely to be replaced while the one who accepted it as is and perpetuated its broken bureaucracy was likely to be promoted.  Of course, back then the elected officials in the legislative and executive branches did not know that computers would not be the entire answer, and that the incentives they put in place would drive creativity of the wrong type – creativity in manipulating the system to gain raises, bonuses and promotions with little regard for the care of the patient.  We have now found ourselves with a system that was never designed to expose and correct resulting problems or respond to the changing needs of veterans.

Health care, even when consistent with best science and greatest public policy, is greatly affected by the context of our lives that make each of us unique: our values, our beliefs, our family, our culture, our finances, and our work.  Inflexible systemic ‘solutions’ in the provision of care, curated either by government or by private industry, can handcuff us to programs and policies that, though driven by a desire to improve the world, end up creating incentives that bear little relationship to those initial good intentions.  We need small solutions built for each person carried out by people whose only incentive is tied to how they help that human being in their care. We need to acknowledge that part of the responsibility of health care providers is to be caring and compassionate to all aspects of the lives of their individual patients.  Illness is isolating and being thrown into a big bureaucracy only adds to the isolation.  No person, let alone our veterans, should walk through illness alone.  When on the actual battlefield, it is sometimes said that you do not fight for country, or for your cause, but for your buddy next to you.  When you spend time at a VA facility, broken as its administrative system may be, you see the buddy system in full force as veterans stand outside, share stories and experiences, and remember the tremendous camaraderie of their unit, and their team. If only the system were built to incentivize its workers to more fully appreciate the importance of those stories, experiences, and camaraderie in the implementation of care.

All answers, especially large scale answers, always have unintended consequences and any answer we develop today in reaction to this crisis is likely to have flaws. We need to build a system that is flexible and able to innovate on the go as we learn more about the unique ails and lives of our soldiers. We need people, our medical professionals and administrative staff, to be trained and incentivized to be interested in what is best for individual veterans.  We need a system that assesses all VA employees on the human connections they make with veterans and their families and on their successes in helping our veterans access the care they need and deserve. We need professionals who listen and make themselves part of the military unit that provides care. 

Programs to lower cost and improve quality of care must be driven by individual patient needs, as determined by patients and health professionals working together.  The sacred trust of a caring relationship cannot thrive in a world that tries to shoehorn people into systems that fail to adjust and innovate to the changing science, changing values, changing populations, and changing realities of the people being served. Illness is a battlefield and, as healthcare providers, it is our duty to make those battling illness feel as though we have their backs.  Let’s build dynamic, flexible systems that acknowledge all the veterans’ needs including the need to have someone they trust at their side. 

Transitions of Care

Americans have a tendency to overcomplicate. The cartoonist, Rube Goldberg, satirized that tendency in the 1920s and 1930s with his intricate designs of complicated inventions contrived to serve simple purposes.  His legacy lives on through the Rube Goldberg Society.  Unfortunately, the Rube Goldberg devices we create in the health care system are often not quite so amusing. 

A classic example of a Rube Goldberg device 

It is helpful to think of Rube Goldberg devices when we evaluate different issues related to patients who have to go from home, to inpatient hospital stay or to outpatient “day” surgery (which can easily last more than a day) and then back to the home.  These types of “transitions” of care used to be relatively easy.  The patient would be in the hospital longer than today, with all the harms of hospital borne infections and all the benefits of prolonged recovery times.  The primary care physician would visit the patient daily and provide stability through the transitions. The transitions were handled by a single professional who saw the patient as the focus of their attention, regardless of where the patient was being treated, and who truly walked the patient through the difficulty of those transitions.  Admittedly this was inefficient and possibly less medically sound than our current use of focused hospital professionals. 

Today, we find ourselves in a world of hospitalists, surgeons, facility based procedural specialists and primary care specialists who never leave their offices.  Communication is supposed to be driven by improving electronic medical records and other technologies rather than by professionals actually talking to each other.   After all, professionals talking to one another is considered to be inherently inefficient and very hard to fit into tightly scheduled calendars.  This leads to problems in transitions which leads to high readmission rates and poor quality of care when people go through those transitions.   It leads to people feeling alone and abandoned as they traverse the various sites of care that modern medicine demands.  People leave the hospital and don’t keep follow up appointments with their doctors.  They never fill the prescriptions that they need.  Problems fester when they should be evaluated rapidly because patients and families don’t know who to call.  Complications that could be simply treated if found early are missed and turn into major problems. 

The medical profession recognizes this problem and a recent editorial in American Family Physician addressed it.  The authors of the editorial stated:

“The effectiveness of hospital-based care transition programs is unclear.  Although some programs reduced 30-day re-hospitalization rates, a systematic review found that no single intervention is reliably helpful, and successful readmission programs generally occur only in single institutions.  However, it seems that programs that focus on the whole patient rather than a specific diagnosis are more successful in reducing readmissions.”

The italics are mine.  Are we losing this whole patient, and more importantly whole person focus?  I fear we are.  The authors of this editorial do not suggest going back to primary care physicians seeing their patients when they are in the hospital.  They know that those days are gone.  They are not suggesting longer hospital stays as they recognize the dangers both medically and fiscally of going back to that system.   

The editorial sees better electronic communication between the facility’s doctors and the primary care doctors as one way to solve the problem with more standardized systems to nudge primary care doctors to automatically contact their patients from 24 to 72 hours after discharge.  To their credit, the authors mention the need for more communication between the hospital based professionals and the outpatient based professionals as the transitions occur.  However they do not address the transition from the patient’s point of view, as the patient and their family travel alone through the illness journey. 

Even in the “good old days”, a critical piece of the puzzle was missing, which was a “diagnosis” of the home environment and how that may or may not be conducive to healing.  However it was much less of a factor as people left the hospital much later in their recovery than in today’s world and the family doctor tended to know more about the person’s home life as they often treated the entire family and knew their patient over time.  Today that home and social diagnosis is a critical missing piece to the puzzle of better managing transitions. 

I worry that in trying to create solutions that are systems based and are designed from the doctors’ point of view the health care system may be missing the very human issues involved in maximizing care and recovery.  Are we are trying to create Rube Goldberg devices using modern technology when something much simpler is needed?  Perhaps the issue is that we need a person, much like the primary doctor of old, to be with the patient as they take their journey through the health care system.  That person need not be a doctor.  Perhaps we need a new profession that combines certain aspects of social work, nursing and insurance consulting to help people through all those issues, either medical, social, or financial no matter where they are in the health care system and the health care continuum.  We have been building such a group of professionals at Accolade and we hope others will follow our lead in developing a profession to help a person through all of the transitions in as simple a manner as possible.  

How Well Do Doctors Listen and Care? – Measuring Quality that Matters to the Patient

For many years, health care systems, government and insurers have attempted to measure the quality of care delivered by individual physicians.  In health systems, the main methods used to evaluate doctors rely on the mining of the medical record and patient surveys.  The article by Weiner and Schwartz published in the April issue of the Journal of General Internal Medicine, points out the challenges of these current methods and suggest another option of directly observing the encounter between a doctor and a patient.  The current methods, the authors rightly point out, are flawed.  In the article they state:

“Neither captures an array of performance characteristics including clinical attention to symptoms and signs while taking a history or conducting a physical examination, accurate recording in the medical record of information obtained during the encounter, evidence based communication strategies for preventive care counseling, and effective communication behavior.”

They do not comment on two other modalities used to measure physician quality and that is mining medical claims data and standardized patient forms used mainly to document activities for insurers and regulators, such as informed consent forms before surgeries and forms meant to inform about privacy and confidentiality laws.  These two are even more flawed than the use of medical records and surveys and yet many millions of dollars are spent each year just to manage the use of these claims databases and the flow of the attestation forms.  These two, admittedly inferior techniques are the main ones used by payers and regulators who turn to medical records and survey tools only rarely as the costs of these types of reviews tend to be high

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Therefore we have four data sets, all of them admittedly flawed which we currently use to measure physician quality.  The direct observation, in this article accomplished by unannounced standardized patients and in other articles by this team by the use of audio recordings of patient visits, is a tremendous step forward as this fifth type of dataset can potentially be the most powerful of all.  When the work of Wiener and Schwartz and others who are pursuing this more direct evaluation methodology is reviewed in total, it points to a few truths so obvious that they rise to the point of being profound.  The following truths are my interpretation alone and are not part of the work cited.

• Just because patients sign a form, that does not mean they understand what they signed and that the communication of the contents of the form actually occurred.  More often than not, for example,   HIPAA forms are given to patients as they first register at a practice or a facility by a clerk who does not explain the form of even understand it him or herself. 
• A claims data base, which is a financial record used for billing and reimbursement purposes, is often not an accurate measure of what really occurred during a patient visit.  While useful for macro purposes, it is much less useful for assessment of individual practitioners.
• Big data clarifies big trends and hides small differences.  It is often the small differences that matter to the individual patient. 
• Patients don’t know what they don’t know so surveys devolve into popularity tools rather than true assessment tools of good clinical skills, listening and assessment quality, and abilities to truly understand the context of a patient’s life that is critical to their ability to carry out recommendations, follow advice, and change destructive behaviors. 
• To assess listening, you have to listen.  Weiner and Schwartz, in their numerous studies over a decade demonstrate this repeatedly.

Only focusing on evidence based algorithms and value as measured by cost benefit analysis devalues the professional art, which may arguably be the most important part of medical practice.  Ultimately, the quality of a physician, and of any health professional, is dependent upon their ability to see and understand their patient as a unique individual, and then apply the appropriate best practices in the context of that person’s life and values.  The truly gifted practitioners do this as an art form, applying science at a very high level while always testing to ensure that they are bringing value to the patient, in the physical, social, emotional and even financial realms.   We have to measure that professional ability and develop the right methods to do that effectively and consistently.  

The Economic Need for Improving Patient Decision Making

As the New York Times says, “It’s back.” Healthcare spending, which had moderated for the past few years, is beginning to rise once again.  The rise in healthcare spending is being driven by more visits to doctors’ offices, more hospitalizations, and more prescription medication use.

Healthcare spending can be thought of as having two components: a unit cost component (such as the cost of an office visit or a day in the hospital) and the volume of services (such as the number of office visits or days in the hospital). The volume of services is driven by the number of people using healthcare services and by the number of services each person receives. If it is successful, the Affordable Care Act, will increase the volume of services by increasing the number of people with better access to the healthcare system.  That will drive a national increase in healthcare spending. There is, however, an opportunity to impact the volume of services by decreasing the number of unnecessary services each individual receives. In studies that were initially done by the RAND Corporation – and have been replicated over and over – researchers found that as much as one-third of medical costs are unnecessary.

Each individual service in healthcare is driven by doctors’ and patients’ decisions. While many see medical decision-making as being a physician endeavor, the truth is that patients make many more decisions than doctors. Think about all the decisions made in relation to health and healthcare:

Who Makes the Decisions?
	Doctor	Patient
Staying Healthy	NO	YES
Deciding to Seek Medical Help	NO	YES
Diagnosing	YES	YES
Treating an Illness	YES	YES
Complying with Therapy	NO	YES

Many of the projects and demonstrations that are part of the Affordable Care Act are focused on physician decision-making. However, influencing patient decision-making can have a profound positive effect, in terms of better quality care and lower costs. When you gain people’s trust, respect their values and beliefs, and help them to come to better decisions, the result is lower costs -- often dramatically lower costs --, and better care. In addition, patients end up being happier with their care experience, which in today’s world is otherwise an experience filled with fear and confusion.

How is this done? There is not one answer -- and I would not be so arrogant as to suggest that there is. When you look at the innovations (including our own efforts at Accolade) in the area, they have certain commonalities. I would divide them into the following categories:

• Building patient – professional trust early
• Understanding and accounting for the dynamic nature of illness, rather than approaching it as a unique disease at a single point in time
• Understanding the isolating nature of illness and the power of having a trusted professional at the ill person’s side
• Taking people’s beliefs and values into account and affording them the respect they deserve
• Understanding the social, psychological, economic and spiritual nature of illness
• Giving health professionals the time, systems and training to truly engage with patients and families and not only to treat the disease pathology

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So while the Affordable Care Act will, we hope, give more people access to insurance and may increase the volume of services, we at Accolade are dedicated to making sure that each individual we help makes decisions that are the most likely to be necessary and helpful. In that way, we can minimize unnecessary services and lower the total cost of care in the process. 

Trust, Money and the Physician’s Role

Should a discussion of healthcare costs ever enter the exam room? Should doctors be rewarded for focusing more on costs when seeing patients?   A recent viewpoint article in the Journal of the American Medical Association (JAMA) entitled “Health Reform and Physician-Led Accountable Care” suggests that primary care physician-led accountable care -- with proper incentives for physicians to focus on lowering unnecessary costs -- may be the answer to the healthcare cost dilemma. I read this article and shared many of my fellow bloggers’ opinions: This is a wonderful advance in our national discussion -- and yet, in other ways, I was also frightened by some of the implications. I cringe somewhat when I think of physicians being responsible for the costs of the care they are recommending for me as a patient. I worry that the imperative to lower costs, and the financial incentive to do so, will subvert the focus that a physician should have on the patient’s well-being – and, in so doing harm the sacred trust that should define the physician- patient relationship.

The authors start out by saying: “Even though most adult primary care physicians may not realize it, they each can be seen as a chief executive officer (CEO) in charge of approximately $10 million of annual revenue.” That alone was enough to scare me. When I walk in to a doctor’s office, I want that doctor to be concerned about my life, my problems, my symptoms, and my concerns --not the running of a 10–million-dollar-a-year business. I want my abdominal pain, my chest pain or my fear of dying to be foremost in his or her mind, and not the desire for a return on investment. I do want my physicians to think of cost when it is important to me, as the patient. If I, for one second, believe that their commitment to help me is being influenced by some other concern, the trust that I must have in them – the trust I need for the therapeutic relationship to work -- is undermined.

And I am not alone. In that same JAMA article, the authors noted that “Physicians see opportunities every day to improve quality and lower costs, but in a recent survey reported that they should not be expected to play a central role in controlling costs.” I understand that attitude. Doctors are in the business of managing the uncertainty of illness, and if they are to work with patients to manage that uncertainty, the patient must trust that physicians’ total focus imperative is on helping them, not on the costs to the system.

Patients feel the same way. In a February 2013 Health Affairs article, researchers from the Rand Corporation ran focus groups asking if cost should enter into medical assessment and treatment. That article, “Focus Groups Highlight That Many Patients Object to Clinicians’ Focusing on Costs,” found that “the majority of participants were unwilling to consider costs when deciding between nearly comparable options and generally resisted the less expensive, marginally inferior option.” The authors identified a number of “barriers” for this unwillingness to discuss costs -- and all of them were related to the need to trust that their physician will do what is best for them, in the context of their lives. From a patient’s point of view, putting their doctor at financial risk to save money can undermine that necessary trust.  Patients want physicians to spend time with them and they fear that an emphasis on cost and efficiency will limit that time. 

At Accolade, we have developed a system that involves health assistants -- who are evaluated and rewarded almost solely on their ability to understand the people in need, and to help them fulfill their needs in the context of their life and their values. The true paradox is that when you focus on what people want and need, and take the time to build trust and address those wants and needs, you save money. As that trust forms, health assistants can help people manage the uncertainty of illness and help educate them to the fact that sometimes higher quality means lower costs.

Physicians know how to save money by making care safer and more personal, but most of the systems that attempt to incent primary care physicians to achieve savings, and make them the “CEO” of the healthcare dollar, have the unintended consequence of potentially eroding trust. Physicians are dedicated, smart, focused individuals who take on a priestly, sacred responsibility for their patients. Anything that may erode that trust is unlikely to improve care, save money and achieve our societal goals.