Tuesday, January 20, 2009

I am for MedCo's Snow

I was sent this article by a reader and I have to tell you, I see both sides of this argument. Have you heard? Dave Snow, CEO of MEDCO the largest pharmacy-benefits manager has stated emphatically

"I have no patience for a doctor who says, ‘I’m above it all, I don’t want to practice cookbook medicine"

He says this when doctors use the excuse that algorithms dumb medicine down and are only needed for PAs ans NPs.

Snow is pushing for pay for performance and uses physicians' lack of knowledge against them.

Recently MEDCO polled 1000 physicians about the CYP 2C9 genotype test approved by the FDA for Warfarin dosing.....guess how many knew about the test? 3....

Yes, that is correct......3 physicians. Do you see how this could infuriate someone who is not a doctor or who has trained in the system. As I doctor, I understand that medical school doesn't prepare you for genetics, I understand that Internal Medicine residency doesn't prepare you either.

So I have a much higher threshold to get pissed at people who have dedicated 12 years of their lives to study and learn how to care for human beings and get paid crap for it, unlike Mr. Snow or most corporate attorneys/accountants/hedgefunders.

However, even my patience does wear thin. Boy, imagine if you were paid an extra 100 dollars per patient that you know the genotypes and dose warfarin appropriately. Imagine if they actually taught about the VKORC1 variation in Asians versus African Americans and dose requirements......they don't even teach that in residency....

So, you want to fix the system? Punish the medical schools, not the doctors trying their best with what they were taught. If you want doctors to learn, pay for all of them to take 6 months off to learn genetics. Or pay them in a manner such that they don't have to see 20 patients a day or more to break even!

The system is broke, everyone is blaming each other, when the real problems lies in the system itself.

1) Doctors don't get paid the way they deserve, so to make the money they deserve, the system has turned into a volume NOT a quality system

2) Medical schools do not hire clinician teachers in genetics, therefore the PhD's teach this field. Inevitably boring medical students because the clinical translation is lost....assuming they actually teach genetics in medical schools less than 34 of the near 200 medical schools do.

3) Costs soar when you don't have the time to critically think and instead you use shotgun methods, which are less efficient than algorithms. But neither is true intelligence.

4) When we know patients' genomic make up we will be able to devise much more nuanced algorithms so Mr Snow is on to something, but........

5) Personalized Medicine is not coming without this education, therefore companies looking to profit from it, would be well served by teaching doctors....not trying to punish them...

The Sherpa Says: We need to stop blaming others in the system and work to fix the system. We will only get the whole story and solution by collaborating rather than punishing any side.....



Anonymous said...

Right on, brother.

Anonymous said...

Another note that I think is important. I was reading online a couple of days about about a hematology doctor and his thoughts about genetic testing for comadin. His thoughts were, "I don't see why we have to do this. We already have (whatever the tests are---I don't remember what they are) and they provide fast and accurate results so we can provide adjusted doses."

I think that is also part of the problem. The clinicians (and not just MDs/DOs) may not have the right understanding for why this type of genetic testing (or pharmacogenetics) is important for patient care.

Maybe the GCs need to get into other departments in the clinics and help the doctors (and other allied healthcare providers) understand the genetic testing stuff. Provide a free lunch to the departments for a couple of months and try to teach the healthcare staff how and why pharmacogenetics is important for patient care.

I know of a few clinics that require a one hour lunch break.....but I have no idea how most of the country works for the clinics/hospitals.

Making information packets for healthcare providers to read is good, but talking to them one-on-one is the best way to go as you can answer questions that they may have. So maybe the GCs need to get more face time with the doctors and other healthcare providers. Afterall, medicine SHOULD be a team game. I know that some GCs don't like the lack of respect they have in the clinic. Well, this is YOUR chance GCs to gain respect. Get out there and help the other healthcare providers learn and understand why genetic testing is important and help them understand the limitations of genetic testing.

I know of a lot of pre-meds who hate the idea of "cookbook medicine." As a pre-health student myself, I actually love the idea of "cookbook medicine" as it can help make sure that all steps that SHOULD be taken are taken. Sure some "cookbook medicine" protocols will not provide the exact care that a patient in some cases may need, but as well develop more evidence based protocols, this can only help improve healthcare in my opinion.

As far as how to get medical schools to teach genetics, I don't have any idea how do that as I don't have any idea how the curriculum at the schools are developed and planned.

Anonymous said...

An important read:http://www.genomeweb.com/node/910392?emc=el&m=295911&l=3&v=dd426d8000


Andrew said...

Hm, seems to me like the idea of a "physician" is stratifying from low status technicians who memorize and apply systems to high status systems human biologists to conceive, design and create the systems. I bet I can guess which group the well-behaved, rule-following physicians will get to be.

Andrew said...

Also, algorithms are great. Publish them freely online as are all laws, and then pay physicians per billable hour like lawyers. Charity work can be provided by pro-bono and public physicians paid by the government.

Simple, and not evil.