Where the Rubber Meets the Road: Ethical Dilemmas for Middle Managers in Academic Medical Center

Dr. John Lantos

Thank you so much, Dr. Frater. And I think we're a little bit ahead of schedule, so we'll go ahead. It's also my pleasure to introduce our next speaker, Dr. John Lantos. He is the director of the Children's Mercy Bioethics Center at Children's Mercy Hospital in Kansas City. Prior to moving to Kansas City, he was a professor of pediatrics at the University of Chicago, where he served as the chief of the medical staff at La Robita Children's Hospital, chief of the Division of General Pediatrics, and associate director of the McLean Center for Children clinical medical ethics, and he's also served as president of both the American Society of Law, Medicine, and Ethics and the American Society of Bioethics and Humanities. So please join me in welcoming Dr. Lantos.

Dr. John Lantos

Thank you. Are we good to go? Thank you, Holly. Thanks so much for inviting me to speak to all the conference organizers. I'd like to start with an apology to those of you who are coming to the meeting from outside the U.S. This must seem like a very insane discussion to many of you, wondering sort of what the hell do these people worry about? I

Dr. John Lantos

understand there's a big group here from Italy. Buongiorno. Glad to see you. Hope the food in Seattle meets your needs. I'm going to take a slightly

Dr. John Lantos

different tack from many of the speakers, the three speakers before me, and talk less about the general principles that undergird children's right to health care or even about the obligations of physicians to provide such care. Because to a certain extent, that seems a little like preaching to the converted here. That is, I would guess most people here share the view that we do have an obligation to provide for children. It reminds me a little bit of that joke I just heard. How many vegans does it take to change a light bulb? The answer is, I'm better than you are.

Dr. John Lantos

Instead, I'm going to talk about how we might operationalize the right to health care or these duties and obligations within the context of the health care system that we have here today in the United States, which is, in fact, in my view, an astoundingly luxurious system where there's a remarkable degree of societal commitment to provide the resources to take care of children. Children's hospitals in the United States have become luxury palaces for the care of children. We have amazing technology available to provide all sorts of treatment and not just for people who can afford to pay. Medicaid is a $300 billion a year program. There's bipartisan political support for federally qualified health centers, community health centers designed to provide care for the poor. There are over 1,100 such centers in the United States today.

Dr. John Lantos

20 million people. And overall, children's hospitals seem to be doing pretty well. We do provide health care coverage for most children for most sorts of care. But what we do that I think is troubling and unique is to provide it through a very decentralized health care system made up of thousands of independent organizations, each of which has to make its own independent administrative decisions. about what exactly to provide, how to allocate resources, who to hire, who to promote, who to retain, who to fire, and what the content of this children's healthcare system ought to be. And these decisions made at the local level shape the healthcare system. And they're often made behind closed doors and without the sorts of scrutiny that is brought to bear on the macroeconomic decisions like what should our national health system look like and the decisions that are made on the local level by say

Dr. John Lantos

different divisions or sections within a children's hospital or different administrative domains or promotion and tenure committees are not subject to the sort of searching analysis that is often brought to bear on these other issues but that I think does reveal something about the way we think about values in allocating decisions. So I'm going to talk a little bit about some of my personal experiences as a middle manager in an academic medical center. In 1999, I was named section chief of general pediatrics at a large academic medical center. And I embarked on that task full of hope with a number of ambitious goals. When I was interviewing for the position, they said, what would you do? I said I will evaluate new models of inpatient and outpatient care. I'll develop new paradigms for medical education in an era of work hour restrictions. We'll do research on the social determinants of child health and try to develop programs to assess some of those social determinants. Some of you are smiling. Maybe you've had similar jobs yourself. Build multiple primary care sites. Create a center for pediatric advocacy, and in order to convince the administrators in my pediatrics department, the medical center, and the university to help me achieve these ambitious goals upon which everybody agreed, they said I needed to come up with a business plan.

Dr. John Lantos

So I hadn't done that before, so I did what any reasonably intelligent person would do. I looked up business plan on Wikipedia.

Dr. John Lantos

And I learned that cost and revenue estimates are central to any business plan, but costs are often underestimated and revenues overestimated, resulting in later cost overruns, revenue shortfalls, and possible non-viability. With Wikipedia as my mentor, I then developed a plan. And of course, I had to make some assumptions about what the economic circumstances that might impact my plan would look like. So I assumed only good things. I assumed a revenue growth of 5% a year where it would come from, I didn't say. Each person would have to become more productive. Productivity gains would come from efficiency rather than new hires doing clinical work. So every doctor would have to produce more dollars per day. 5% a year sounded good. I assumed there would be increased number of babies born so we would have more patients, that there would be stable malpractice insurance rates, that the stock market would go steadily upward so endowment revenue would increase. I did not assume there would be any terrorist attacks on Wall Street and I assumed a steady state of federal, a steady level of state and federal income taxes. And this allowed me to project six-figure initial deficits as I built my program. In year one, we lost almost a million dollars. But by year five, we were showing a profit of $20,862. Now, it's important to note that nobody, but nobody believed this plan.

Dr. John Lantos

But interestingly, everybody treated it with an astounding level of deference and respect. hard-nosed business sensibility, especially by calculating figures down to the last dollar. We weren't going to make 20,000 or even 20,800 in year five, but 20,862.

Dr. John Lantos

Showed admirable fiscal seriousness. Now, once the plan was in place, of course, reality set in, and I and the other section chiefs got a plaintiff memo from our department chair about our children's hospital's dire fiscal situation that said, in part, there's been a recent and unprecedented decrease in reimbursement for medical services. Other hospitals are cutting salaries, laying off faculty. I know everyone is working hard. Our billings are increased. I'm sure nobody has ever gotten a memo like this. Unfortunately, our cash for professional services continued to decrease. The total department deficit for this fiscal year is projected to be $4.5 million. Following this memo, all prior business plans were now inoperative. To everyone's shock and surprise, they had overestimated revenues and underestimated deficits, and we seemed to be heading rapidly towards bankruptcy. And the solution was to put a productivity incentive plan in place. And the metric for productivity would be the relative value unit, or RVU, a brilliant invention by some policy wonks at Harvard that was supposed to calibrate the worth of every clinical service based on these five factors that were precisely then

Dr. John Lantos

quantified for each clinical service, the time it took to provide the service, the pre-service and procedure and post-service and procedure times, the intensity of the service and procedure, practice costs, and the cost of specialty training required to learn how to do the procedure. And based on this, the relative value unit system, or RVRBS system, has been developed and is now widely used to measure clinical productivity. And under our faculty incentive plan, it was going to be productivity-based, and 20% of each faculty member's salary would be at risk one way or the other. If we increased our RVUs, we'd get 20% raises, up to 20%. If our RVUs went down, we would lose 20%. I spent a lot of time then studying this system, and I found there were some quirks in the system that maybe the Harvard Wonks hadn't worked out. Like shaving two centimeters of facial hair in less than one minute would earn three times as many RBUs as 15 minutes of a pediatrician's time evaluating a complex problem. Or reading a chest film in less than two minutes was the same as three days interpreting glucose levels for a diabetic child. But my job was not to critique the system. My job was to game the system. Within rigorous rules governing fraud and abuse, I needed to increase my section's RVUs. And I made a key discovery.

Dr. John Lantos

Earwax.

Dr. John Lantos

Turns out, you may not know this, but cleaning earwax out of a child's ears generates nearly as many RVUs as seeing a sick patient of intermediate complexity. Furthermore, the RVUs for cleaning out the earwax are over and above seeing the sick patient because it's a procedure. So you could see the sick patient clean out their ears and double your RVUs. Now, it would have been even better to have a nasal foreign body.

Dr. John Lantos

at 1.04 RVUs, but those don't walk into your office every day and almost everybody could use a good earwax cleaning. So I calculated that if we cleaned the ears on even 10% of our patients, everybody in my section would get a 20% raise. For primary care doctors, earwax was like gold. By removing earwax, we could virtually print money. I started browsing the internet, looking at the prices of sailboats.

Dr. John Lantos

So how should we think about this little parable in administrative work in a pediatric health center? Would it be a good thing or a bad thing if we pediatricians started cleaning out more ears? It was not straightforwardly fraudulent or deceptive. Though it was not going to contribute much to the health of children, unless of course it provided revenue that could be used to develop other programs, but that's a different argument, the line between appropriate and desirable activities and fraudulent gaming of the system is finer than it might seem.

Dr. John Lantos

As a society, it seems we both eagerly do, and desperately do not want doctors to alter their practices based on financial incentives. That is, we want doctors to be productive. We want health care to be cost effective. We want resources to be allocated rationally and fairly. And as patients, we all want to receive the best and the most current care. We want to reward the doctors and the health care systems that achieve these goals. We think it's okay to build incentive systems to encourage the things that lead to those goals and discourage the things that lead away from them.

Dr. John Lantos

But

Dr. John Lantos

we do not really want doctors to be simply profit maximizers. We don't want them to do things just for the money. So we want payment systems that reflect and reward good practice, but we don't want them to shape practice. We decry the overuse of medical procedures, but we reject any system that would deny us access to any procedure we want when we want it. We trust doctors, I think, generally more than we trust insurance companies, but we know that not all doctors are completely honest, honorable, or ethical. And we know that a lot of money is changing hands, so we want some oversight and accountability of the people who are making the decisions by which these dollars are changing hands. So what we want, and this ties into Doug's talk earlier, what we want is a set of somewhat contradictory things. Healthcare for all children, no out of pocket payments for parents. We sort of want it financed on a fee for service basis as the mechanism for accountability, but we want cost control. Or to put it another way, we want market discipline without true markets.

Dr. John Lantos

We want some ways of increasing efficiency and productivity without the punishments that go along with true markets and that penalize lack of efficiency or productivity. This is a challenging problem for administrators to meet these needs, so not surprisingly, Many of the best minds in medicine today are drawn away from clinical care or research and towards administration. If a young researcher or clinician is successful, he or she will be promoted to division chief or department chair and spend his or her days struggling on the bloody field of the ongoing battles between payers and providers. And the results of those battles will determine whether the neonatal intensive care unit or transplantation program where the outpatient clinic will be a profit center or a cost center and so whether each will thrive and grow or shrivel and die. In fighting these battles, the line between brilliant administration and fraudulent criminality becomes indistinct. In the years when I was division chief, Government investigations of billing fraud led to huge fines at many prestigious university hospitals. Here's just a partial list. Penn had to pay $30 million. Art's gone, so we won't get to pinpoint who exactly was responsible for that. University of Texas, 17. Pittsburgh, 17. Jefferson. You can see the list. Lots of fines. academic medical centers like ours that were struggling to operate and finance medical education systems, primary care networks, tertiary care referral centers, basic science research laboratories within a single framework. And it turned out, shocking to hear, many such centers used redundant accounting schemes, double booking, shadow files, creative coding and other mechanisms that walked a very fine line. And it got me wondering whether a sudden spike in billings for earwax removal would get me promoted or would land me in jail.

Dr. John Lantos

Now, of all the ironies that these developments engender, one of the deepest is that physicians in academic medical centers are also expected to educate the next generation of physicians and to inculcate ideals of professionalism. A recent report on professionalism by the American Association of Medical Colleges noted in the end, it is not because we have special knowledge that doctors can be trusted. Instead, we are trusted only if this knowledge and technology is firmly attached to values that are explicit, understood, and when push comes to shove, altruistic. And to learn those values, students need doctors as teachers who embody those values, and luckily there are many such doctors in academic medical centers today. Unfortunately, the way many academic medical centers are organized today, the doctors who most embody these values are having a harder and harder time surviving and thriving. Keeping the best clinicians and teachers as opposed to the best administrators or researchers on the faculty is another source of moral tension that I have faced as a division chief and that creates some of the same sort of administrative conflicts as the RVU system. That is, it demands that we walk a fine line between doing what's necessary to achieve certain ends and engaging

Dr. John Lantos

marginally ethical means. One year one of the best clinician educators in my division was coming up for reappointment. I'll call him Mark. He had been with the division for more than a decade and he was still an assistant professor. He was an African-American guy who had grown up on the south side of Chicago. He was the first person in his family to become a doctor. He had never wanted to be a researcher. He loved being a doctor. and he loved teaching students. He had an extremely busy clinical practice. His patients adored him and often sent me letters praising his work. Students also gave him great evaluations and appreciated his calm demeanor with patients, his thoroughness as a clinician, and the way he took time to work with both his patients and with students. And part of his charm was that he didn't care a bit about academic gamesmanship. He hated the hierarchies and status structures of the university. When he was coming up for reappointment, he was given the standard 15-page form to fill out that asked in great detail about his scholarly activities since his last reappointment. How many papers had he published? How many grants had he received? How many abstracts had he presented at national meetings? How many national committees had he served on? And his answers to all these questions were none.

Dr. John Lantos

He was then asked about his innovations in medical education. Had he developed any new courses, any unique and replicable approaches to medical pedagogy? Did he have a national reputation as an educator? We sat down to talk about this. He said he didn't think he needed to do new or unique things. He thought that he was teaching in the classical way, the way medicine has been taught since Hippocrates' day, by pains taking attention to detail and by a moral and emotional commitment to each patient and each student. I suggested that for his personal statement, he simply say that. That was phenomenally bad advice.

Dr. John Lantos

The Committee on Reappointment of Assistant Professors responded with disparaging hostility. Where was the scholarly work? Where was the original thinking? Where was the commitment to innovation and leadership? Note, if someone like Mark could not get promoted, this was bad for him. But it also sent a message to the students. Don't grow up to be like Mark. Don't be a primary care doc. Don't be humble. He was not rejected outright. Instead, he was reappointed for one year instead of the usual four. In essence, he was put on probation. Mark was shocked, insulted, and frightened. He came to talk to me. Was he doing something wrong? Was he going to lose his job? I suggested that the challenge was not to reshape his life, but to repackage it. Together, we wrote a new personal statement, and we had some fun with it.

Dr. John Lantos

We described the challenge of pedagogical work in primary care as one of responding to a series of interlocking philosophical, economic, political, and spiritual challenges. Primary care pediatrics, we said, was at the center of a multicultural vortex. The clinician-educated educator needed to help students develop sophisticated conceptual responses to the ontological challenges that they faced. We made sure, you'll note, that each sentence had at least two four-syllable words.

Dr. John Lantos

To understand what it meant to truly be a doctor, we said, students need to develop their own theoretical models of what it meant for a child to have an illness. Students needed to decide whether short stature, attention, lots of scare quotes, attention deficit disorder or school phobia were illnesses. And if so, how the pediatrician ought to respond. These, we said, were not abstract questions. Practicing primary care doctors had to understand the public policy. They would see children from rich patients and four poor families, children with Medicaid and private insurance. Students would need to come to understand these systems and the political philosophies behind them. Mark described his innovative educational philosophy, which was to help each student develop a personal moral philosophy about how he or she would balance self-interest as a wage earner with political or spiritual commitments to patients. Would the student choose to see patients who could not pay? How would he or she balance ideals of equity and service with the need to earn a living? And through such pedagogy, students would come to understand that the primary care practitioner must make real and important moral and political choices. By this approach, we went on. Each clinical encounter became a thing in itself and a text to be decoded.

Dr. John Lantos

Students were encouraged to discover the deeper meanings embedded in each patient's illness narrative. And through such a dual reading of patient as disease and patient as text, students would be taught how the heuristics of clinical care mapped onto the heuristics of professional development. Mark likened the physician to the poet who, as described by Goethe, needs all philosophy but must keep it out of his work and endorsed pediatrician and poet William Carlos Williams' famous statement, no ideas but in things and suggested that it applied to both poetry and the practice of medicine. This time Mark's reappointment sailed through. He was given a full four-year appointment as an assistant professor with a suggestion that he think about going for promotion to associate next round perhaps even with a dual appointment in sociology.

Dr. John Lantos

So, what to make of these two parables, the RVU story and the promotion? Getting Mark promoted and maximizing RVUs were very different administrative challenges, but they had a few common features. In both cases, the day-to-day work of practicing clinicians was subjected to a set of external standards and external demands that sought to assign value to a particular aspect of the work. In both cases, I as the mid-level administrator had to shade some truths, game some systems, and test the boundaries of morality. In both cases, I couldn't get to desirable ends without engaging in questionable means. I became ever so subtly immoral because that was what my job required. More importantly, I wasted enormous amounts of the scarcest resource around, my time and energy trying to keep my own little domain going. In both cases, I was working against people in my own organization to do this, the very people who ought to have been helping me. And these sorts of moral compromises are, it seems, the stuff of mid-level administration in an academic medical center. We seem to be having trouble meeting our moral obligations to children because we have scarce resources. But we have scarce resources because we squander our most precious resources doing this kind of nonsense. So the key question it seems to me is not do we have moral obligations to children or how do we redesign the system, but instead a much simpler question. Why is there so much bullshit around?

Dr. John Lantos

And I use that in the sense of the great philosopher Harry Frankfurt in his wonderful monograph, On Bullshit, which I commend to you all. I shouldn't have been spending so much of my time gaming RVU systems. I shouldn't have had to rewrite Marx's personal statement. He shouldn't have been struggling. He should have been winning awards rather than being put on probation. I should have been seeing patients doing research, building programs, mentoring students. And the question then of how to transform institutions rather than how to transform global or national health care systems seems to me one that deserves a lot more attention than it's getting. We need to change the institutions that we have to make them more lean, mean, efficient, and effective in carrying out the mission. that I think we all agree is a moral obligation to better care for the health of children. Thank you.