How Healthy is the State of Women in Medicine?

Let’s start with some numbers.

In a 2011 Health Affairs Article, LoSasso et al concluded, “In 2008, male physicians newly trained in New York State made on average $16,819 more than newly trained female physicians, compared to a $3,600 difference in 1999.”

A 2013 study in Academic Medicine re-examined the pay gap for new doctors to see if the trend had changed, but unfortunately they reached a similar conclusion as the 2011 study.  The authors wrote, “….we observed a substantial gender difference in salary that was not fully explained by specialty, academic rank, work hours, or even spousal employment. These findings suggest that salary disparities in academic medicine exist even in cohorts hired recently and that these disparities arise early in the course of a career.” Read More

An Interview with Dr. Shona Johnson, a junior doctor at Royal Berkshire Hospital in Reading, England

 

Dr. Shona Johnson, a junior doctor at Royal Berkshire Hospital in Reading, England, sat down with Doctors Council (DC) to discuss the ongoing strike actions of nearly 50,000 junior doctors in England.

The term “junior doctor” refers to qualified medical practitioners who are working while engaged in postgraduate training, anywhere from 5 to 8 years out of medical school.

The interview has been edited for length and readability.

DC: Welcome Dr. Johnson and thanks for sitting down. So you’re a junior doctor. Can you tell us what the strike is about and how long it’s been going on?

SJ: It’s a reaction to a new junior doctor contract that has been put forward by Jeremy Hunt, who is the Secretary of State for Health. It’s changing a lot of things about the current contract, which was last changed in 2008. Since 2013, the BMA (British Medical Association) have been in talks with the Government about what to change, including pay structures. In 2014, the process stalled because there are 23 points in the new contract they couldn’t agree upon. Throughout 2015 they used a mediation agency to try to work through it, but out of those 23 points, the Government refused to budge on 22. Those covered what constitutes normal working hours, how people should be paid, how hours should be monitored by hospitals and what safeguards should be put in place to prevent doctors from working 90 hours a week, among other things. But those are the main ones people are worried about.

 

DC: So it’s about additional working hours without pay?

SJ: Pay is a secondary point. It does affect our pay, but it’s more that they want us to cover more hours in the week and not provide more doctors to do it. So they’re actually spreading the work more thinly, and changing rotas [schedules] and creating gaps in rotas. And the fear is that doctors will be so overworked and tired that they’ll start making mistakes and patients will be put at risk.

 

DC: Does that include weekend hours, in terms of procedures as well as availability of your GP [primary care physician]?

SJ: There’s no plan to extend weekend GP services further than they already are; there’s no funding to do that. In terms of hospital doctors, which is what I am: Currently there are 60 social hours, 7am-7pm M-F; and then outside of that you get an additional pay supplement, a system called banding, so if you’re in a specialty where you do a lot of nights or weekends like A&E, which I’ve done a lot of, you’re banded in a higher category in which you might get additional pay to compensate for unsocial hours. There are different levels of banding – 1A, 1B, 1C – depending on how many extra hours you do. And under the new contract, they want to expand social hours to be 7am-10pm M-Sa, so there would now be 90 social hours in the week.

So you could be working a Saturday evening and be getting paid the same as a Tuesday morning. And it’s not only that, it’s that you have to provide normal working day services even on that Saturday as well as on a Sunday, but there’s no extra doctor to cover that 8 hour shift – the rota just has to be fiddled around to fit everything in.

DC: So it’s demanding more time as well. About how many junior doctors are on strike?

SJ: It’s difficult to give a precise number. There are over 53,000 junior doctors in the UK, and about 45,000 are members of the BMA, which were the only ones who were balloted to strike. 98% voted to strike. The total on any given strike depends on who’s providing emergency hospital cover, plus who’s on annual or maternity leave. But it’s several tens of thousands. The strike is only in England: Wales’ and Scotland’s governments have rejected the contract. But England remains [the Health Secretary] Jeremy Hunt’s domain.

DC: What has the public mood been toward the strike? And it’s most accurately described as number of strikes, correct, since the strikes have mostly been a day or so, and then back to work?

SJ: There have been 4 strikes now. In January, there was a 1-day emergency cover only strike, and then in February a 48-hour “emergency cover only” strike, with similar 48-hour strikes in March and recently on the 7th-9th of April. On the 26-28th of April there is the first planned full strike, where the junior doctors won’t be providing emergency cover either. That will be the 5th one.

But in terms of public support, it was quiet at first. I think the whole issue with the contracts and even people being balloted for industrial action, people weren’t made aware of it in the media really, and it wasn’t until the second strike in February that people began to really take notice. It was after that second one that Jeremy Hunt said they would impose the contract. More newspapers got involved then – it depends which newspaper you read to determine what you believe –  

DC: As ever with the fantastic British press…

SJ: Exactly. Some of it has been really positive, some of it has been not so positive. There have been quite a few scaremongering ones, talking about how being on strike is reckless and putting patients at risk, but there’s a good amount of patient support, on each strike at most of the hospitals there have been picket lines in the mornings, and there have been lots of people honking as they go past. There has been an NHS choir and their song made it to #1 on the charts in December. There’ve been members of the public positing on Facebook and other social media sites with their support, with placards things like that. From the patient side, support is quite good, but it’s difficult to see it because it’s not as positive in the media as a whole.

DC: How has the strike affected you or your colleagues, with respect to sharing responsibilities or shifting the burden of work?

SJ: From my hospital in Reading, the support of the consultants [ed: most nearly “attending physicians”] has been incredible. For example, I’ve worked in A&E in Reading, and there are 15 A&E consultants, and they all said, when the ballot went out, we encourage people to vote and they would support any strike action. In Intensive Care, consultants were coming in on their day off to cover so junior doctors didn’t feel like they couldn’t go on strike. The nursing support has been really high as well – really good. And I think that’s mutual, because the Government are also trying to stop nursing bursaries [scholarships] for students as well.

DC: How do you respond to people who criticize you for cancelling procedures or putting patients at risk?

SJ: In terms of putting patients at risk, we’ve made people aware they shouldn’t be at any risk: junior doctors have been providing emergency services cover. But aside from that, we work as part of a team, we’re not the be-all and end-all, there are consultants, associate specialists, nursing staff, physios and pharmacists, they’re all working together to support people so we can go on strike and patients will be safe.

When the first couple of strikes happened in January and February, people were a bit worried, and there were reports of people not going into A&E when the strikes were happening because they were afraid. But there are still amazing people there working, it’s not like the wards or A&E are being left uncovered; any operation that has been postponed or canceled is an elective operation; it’s not life or limb-saving operations that are being cancelled.

So I understand that if you’ve been on a waiting list for 6 weeks it’s frustrating and a bit upsetting, but the whole point is that if we just stop now and let everything happen with this new contract, patients are likely to be at risk in the future and that’s what we’re trying to prevent – so it’s the long term benefit really.

DC: What do you anticipate for the next stage of the campaign, and what does victory look like for the junior doctors?

SJ: That one’s a difficult one, because I don’t think anyone wants to do the full walkout [in late April]. But the threat of imposition is the worst thing… it’s like they don’t trust us to know what’s best, and they don’t trust the BMA to sit down and be reasonable and negotiate. The imposition is the worst thing, because we feel like collateral damage, that we’re undervalued.

The first sign of victory would be to stop the threat of imposition, to sit down and actually negotiate these last bits of the contract. I don’t necessarily think that there will not be a new contract at all, but we need to sort out the things that concern us, like the removal of safeguards to make sure doctors aren’t working 100-hour weeks. There’s not at the moment a replacement for those types of safeguards we have right now.

DC: It seems like the government isn’t backing down easily. How are other trade unions and community groups helping you apply pressure and win for your patients?

SJ: There has been some great support from other unions. Black cabs in London have a huge union, and they’ve supported picket lines in London, getting people to places so that they can strike. The Royal College of Nursing is behind the Junior doctors, and in fact all of the Colleges in Medicine, completely apart from the BMA, they set out curriculum and things like that, they’ve written letters to the government and are encouraging members of the public to write to their Members of Parliament and post them on Facebook and so on.

DC: We’re here in New York City. Where can Doctors Council members go to help and support you?

SJ: A good place to start is the BMA website, www.bma.org.uk, they have links to some of the statements from the Colleges, the contract itself, if you want to know more detail, and infographics explaining some of the numbers to make it clearer. There’s a lot of hashtags on Twitter and things like that to share around.

DC: Great, so spreading the word is important. There hasn’t been much media coverage on this in the U.S., so this has been really useful. Anything else you’d like to add?

SJ: It’s difficult, because there’s lots of different prongs people are upset about. The newest thing, the BMA have asked for a judicial review of the contract, and the government recently released their Equality Impact Statement regarding the contract, and the major issue is it’s quite discriminatory towards women particularly. Throughout the review it sort of says, “any adverse affect towards women is justified by the ends” – that’s another way women are being particularly affected. And there are slightly more female junior doctors overall, while in certain specialties, something like 72% of registrars in Pediatrics are female, 75% in OB/GYN. And those specialties are quite hard to recruit to and to retain staff in already, so if women are going to have to leave, because they can’t afford to have their families, what does that mean to the safety of children and pregnant women? These are all questions we are putting forward in our actions – that it’s about the future of patient safety and our healthcare system in Britain.

The End of Fee For Service? 

If there was any doubt that the fee for service model of health care payments is on its last legs, CMS’ launch of the Comprehensive Primary Care Plus on April 11th should end them.  The goal of the plan is to avoid the old fee-for service problem in which interventions, as opposed to the health of the patient, were incentivized by the payment model.  The new plan, according to Politico, tries to incentivize physician practices to keep the patients healthy without tying their revenue to specific medical tests or procedures:

“They will be required to give patients 24-hour access to care and information, and to meet various metrics for managing and coordinating care. Otherwise, though, they can treat their patients just about however they want, and their reimbursements will no longer depend as heavily (and in some cases not at all) on the protocols they follow or tests they administer. They will receive more money up front, and if they help keep their patients healthier, they can receive extra money on the back end.” Read More

Metric Movement

Has the metric movement gone too far in Medicine, as Robert M. Wachter suggests in a New York Times Opinion Piece?

“… the measurement fad has spun out of control. There are so many different hospital ratings that more than 1,600 medical centers can now lay claim to being included on a “top 100,” “honor roll,” grade “A” or “best” hospitals list. Burnout rates for doctors top 50 percent, far higher than other professions. A 2013 study found that the electronic health record was a dominant culprit. Another 2013 study found that emergency room doctors clicked a mouse 4,000 times during a 10-hour shift. The computer systems have become the dark force behind quality measures.”

Or in the words of Dr. Don Berwick, former head of the Centers for Medicare & Medicaid Services:

“Stop excessive measurement: I don’t mean that we should stop measuring. Indeed, I celebrate transparency in every form. How else can you learn? But we need to tame measurement. It has gone crazy. Far from showing us our way, these searchlights training on us, they blind us. …. I vote for a 50 percent reduction in all metrics currently being used.”

A HealthAffairs Blog post that discusses the call for measures that matter asks a key question about that movement:

“Yet defining the measures that matter is complicated because we often gloss over an important question — measures that matter to whom?”

At Doctors Council we have noticed that debates over metrics are often debates over power and control.  It is not the idea of measurement that offends doctors–Dr. Berwick is right: “How else can you learn?”—rather, it is the fact that the measurements feel separate from the work of doctoring.  They feel disconnected from the healing process, and are often experienced as an add-on that takes time and energy away from the work at hand.

This feeling that the patient and provider are there to serve the metric  is captured by Craig Bowron, MD who writes in KevinMD

“Without a hint of hyperbole, it’s clear that many physicians feel that their primary task is to satisfy the electronic chart, so as to satisfy the system. When you’re done with that, you might see if you can figure out what’s wrong with the patient and how to fix it. All these “innovations” in the business of medicine have made direct patient care much more difficult.” 

As we noted in a previous Doctors Council blog, while there is value in reporting the numbers, the question is debated if  the practice of medicine has become too focused on numbers and as a result, the autonomy of doctors is being eroded or lost.  In addition to doctor autonomy, there is also the concern if the medical profession has become good at quality assurance as opposed to quality improvement.

Rather than the doctors serving the metric, the metrics need to serve the patients and doctors.  Therefore the solution is not some sort of technical fix; rather it is a question of involving patients and physicians in the creation of the metrics.  This is hard for doctors to do on their own, and gets to a key question: How can doctors come together collectively to shape the institutions in which they practice?

 

What’s in a Name?

What is a safety net hospital?  The Institute of Medicine’s 2000 report America’s Health Care Safety Net: Intact but Endangered – define a safety net hospital as:

“Those providers that organize and deliver a significant level of health care and other health-related services to uninsured, Medicaid, and other vulnerable patients. “

They go on to explain the idea of a core safety net provider

“These providers have two distinguishing characteristics: (1) by legal mandate or explicitly adopted mission they maintain an “open door,” offering access to services to patients regardless of their ability to pay; and (2) a substantial share of their patient mix is uninsured, Medicaid, and other vulnerable patients.”

New York has its own definition of a safety net hospital.  The state uses the percentage of business generated by Medicaid to define a safety net hospital. The threshold is 35% of all patients and 30% of inpatients.  There is also an exception offered on a case by case basis.

This definition leads to a rather strange situation.  According to the Institutional Cost reports filed with the New York State Department of Health  of the 187 statewide hospitals 149 are safety net institutions.  Of the 47 New York City hospitals 42 are safety net institutions. Of course what is at stake here is money.  One example is DSRIP–the 6 billion dollar program whose “primary goal of reducing avoidable hospital use by 25% over 5 years.”   To be eligible for DSRIP funds a hospitals needs to be a safety net provider. 

Given New York City’s Health + Hospitals mission not to turn anyone away and its financial hardships it is hard not to wonder if all 42 hospitals deemed safety net hospitals by the state of New York are equally deserving of funds.

Safety Net Hospitals Being Squeezed by Wrong Measures?

Safety net hospitals are having a harder time in the new health care funding landscape- this is not news.  One of new truths is Value Based Purchasing (VBP). VBP promises to reimburse hospitals based on the value of care  as opposed to simply providing a fee for services rendered. Safety net hospitals serve patients with a lower socioeconomic status and uninsured patients (especially undocumented patients who are not covered by the Affordable Care Act).  Is it fair to grade these hospitals on the same curve as better financed hospitals who treat patients with private insurance?

Teresa Coughlin and Adele Shartzer wrote a very important and thorough post at the Health Affairs blog, The Challenges Of Rewarding Value Over Volume Without Penalizing Safety-Net Hospitals , that outlines both the research and policy proposals that address that complicated problems that value based purchasing creates for safely net hospitals.

Much of the research focuses on the Hospital Readmission Penalty Program (HRPP) which penalizes hospitals, based on a complicated algorithm, up to 3% of Medicaid payments for excessive readmission rates.  As Coughlin and Shartzer explain “in essence for selected medical conditions (including heart failure, …), it penalizes hospitals whose risk-adjusted 30-day Medicare readmissions rate are greater than the national average.”

Coughlin and Shartzer pose the question that is becoming a daily reality and fear at many safety net hospitals:

“While the HRPP penalties may not be appreciably higher at safety-net hospitals, by eating into their already thin profit margins, they could potentially limit these hospitals’ ability to implement the very changes needed to reduce readmissions. This begs the question: Is there a way to lessen the adverse impact of the HRPP penalty on safety-net hospitals without tacitly endorsing lower quality care for vulnerable populations?”

The first question is how much socioeconomic status explains the difference in readmission rates at different hospitals.

One study that looks at New York City (NYC) Hospitals concluded that socioeconomic status (SES) had a minimal impact on readmission.  The study by Blum, Egorova, Sosunov, et al, concluded “We examined whether inclusion of a measure of community SES, in NYC, in the 30-day CHF models impacted hospital-level profiling. The impact of the community-level measure of SES on 30-day CHF readmission models was small. As such, even in NYC, where differences in SES status are stark, inclusion of this measure had minimal impact on hospital-level RSRR.”

On the other hand Gilmen and his team conclude in a 2015 Study  “Taken together, these results indicate that safety-net hospitals are providing better health outcomes than other hospitals yet are more likely to be penalized under a program that intends to improve and reward high performance.”

Another  study that looks into the role SES plays in readmission rates is a 2015 work by Sheingold et al “Understanding Medicare Hospital Readmission Rates And Differing Penalties Between Safety-Net And Other Hospitals.”  They are specifically trying to answer the policy question- should safety net hospitals be graded on a different scale because of the special challenges for their patients and communities- by trying to understand what the data says about the difference in readmission rates between hospitals. 

What is interesting in this study was how much remains unknown about what causes discrepancies in readmission rates. 

According to Sheingold et al “In this study we found that patient characteristics, including clinical and socioeconomic factors, explained approximately 60 percent of the observed differential in readmission rates between high- and low-DSH hospitals. Consistent with previous research,7 we found that a substantial share of the differential was due to unmeasured factors. The results from our second set of analyses suggest that one of these other factors may be differences in the quality of care across hospitals.”

Sheingold et al also found that “The data suggest that at least in the first few years, safety-net hospitals did not have disproportionately high penalties, compared to other hospitals.”  

We can draw a few tentative conclusions from these studies.  First SES does play an important role in grading readmission rates of hospitals.  What is less clear is how that difference plays out given the funding algorithm used by HRPP. 

Yet when one takes a step back from the specific policy question involved in HRPP, we find ourselves with a question on social values.  If SES effects readmission rates more at safety net hospitals what are we doing to address that inequality at the level of patient care? This is a question that gets played out in the details of federal and state Medicaid policy.  One such battleground is exactly how a safety net hospital is defined.

 In the next blog we will look at how the definition of a safety net hospital becomes an important political fight in addressing that very question.

 

Addressing Racism to Improve Population Health

Mary Bassett’s M.D., M.P.H, Commissioner, New York City Department of Health and Mental Hygiene, experience as a young doctor and researcher in Zimbabwe continues to frame her perspective as a doctor today.  In an honest and powerful TedMed talk she discusses her regret at not speaking out more on the structural inequality that framed the early years of the AIDS epidemic in Africa.   She experienced hands-on the frustrating distance between the one-on-one care she was providing to the best of her ability and the larger forces that affected her patients.  It inspired in her a determination to not be quiet, but rather to speak out in the face of the large structural forces that determine the health of populations.

For Dr. Bassett this now means, among other struggles, an honest confrontation with racism in medicine. In a previous blog post we highlighted her comments in a JAMA editorial  #BlackLivesMatter — A Challenge to the Medical and Public Health Communities in which she takes the lessons learned in Zimbabwe and applies them legacy of racism in the United States.  At the core of her vision is the belief that doctors have an ethical responsibility to address the structures of power that affect the health of the patients.  As she wrote in JAMA:

“Should health professionals be accountable not only for caring for individual black patients but also for fighting the racism — both institutional and interpersonal — that contributes to poor health in the first place? Should we work harder to ensure that black lives matter?”

At a recent CUNY forum: “Dismantling Racism in the NYC Health System,” she explained how choice replaced genetics in understanding health disparities:

“We went from [a belief in] genetic inferiority to saying black people make bad choices. I don’t think anyone decides, ‘I want to live in a neighborhood with really bad housing, or poor air quality,’” she said. “Nobody says, ‘I really prefer a neighborhood where there is only fast food available.’ … These are not personal choices. These are a lack of choice.”

Or as she wrote in the American Journal of Public Health  “To frame chronic disease risk as a consequence of ill-conceived personal choices and inadequate medical care is a modern day version of hand washing to prevent cholera: not wrong but tragically misguided.”

This is the background for Dr Bassett’s understanding of the 2014 Summary of Vital Statistics which was recently released.  She says:

“Long-term improvements in life expectancy and premature mortality mask the reality of long-standing inequity in NYC’s communities of color – inequity which has been driven by a legacy of persistent injustice. This report once again confirms that critical work that must be done to reverse the continuing and, in some cases, widening health disparities between NYC’s poor and rich neighborhoods.”

A notable finding in the report is that,  “The difference in life expectancy in very high poverty neighborhoods compared to low poverty neighborhoods rose to 7.4 in 2013, compared to 5.8 in 2005, indicating a widening health disparity.”

What is a union’s role in this?  Increasingly Doctors Council is committed to providing the means by which doctors could successfully intervene on the institutional level.  The decision to get involved or speak out about structural inequality, in our view, must be both collective and ultimately successful.  Doctors Council wants to become the place where the abstract ethical responsibility to the patient becomes a collective practice.