Wear the Right Uniform for the Job

A couple of weeks ago, while I was driving to the office supply store over lunch, I saw a cyclist riding toward me on the busy four-lane road. I’m very enthusiastic about active transportation, including cycling, so like many drivers, I tend to slow down and use caution around cyclists just in case they are skittish in traffic. As I approached this cyclist, though, I could see that he was wearing a helmet and a moisture-wicking shirt. His bike was kitted out with pannier bags and a headlight. His “uniform” indicated that he was no amateur bike commuter. He had clearly done this before. I waved as I passed, and I watched in the rear-view mirror as he switched lanes, signaled, and make an expert left turn behind me.

The encounter got me thinking about the value of a uniform, and that got me reflecting on the pandemic. I’m not the snappiest dresser even on my best days, but all the time at home in front of a computer screen has allowed for some pretty cavalier choices in clothing, especially from the waist down. Eighteen months in, I’ve found generally positive effects to wearing a work “uniform” of my own, mostly consisting of reasonable pants and a collared shirt. First, putting on the uniform signals to me that the day has begun, like James Joyce’s white coat signaled the beginning of his writing day (I promise this is the last time I’ll compare myself to Joyce in this blog post). The donning of a uniform is one of my strategies, along with Cal Newport’s “shut down” ritual, that helps me separate my workday from my leisure day.

Second, a uniform gives the appearance, even through Zoom or Microsoft Teams, that I mean business, much like donning a white coat does in patient-care settings. White coats, originally adopted by doctors to indicate that they were adherents to science, have been linked to improved patient perception in certain situations, in spite of the fact that infrequently laundered white coats are also potentially dangerous sources of infection in hospitals. One of my extended family members has a corporate job in which professional appearance is still very valued, and her strict dress code for her team, even for people in virtual meetings, has drawn praise from coworkers and clients. That’s not to say this can’t be taken to an extreme. In the 1990s, when the national dress code had been relaxing for decades, a friend of mine worked as a computer programmer for Ross Perot. Even though he spent his day isolated in a cubicle and rarely spoke to another employee in person, he was expected to wear a black, blue, brown, or grey suit, starched shirt, tie, and shined shoes to work every day. Needless to say, he found another job. And NBA all-timer Bill Russell famously retired early from basketball after deciding (and I’m paraphrasing) that he was tired of being a grown man wearing shorts playing a children’s game.

Finally, some evidence indicates that a proper uniform may actually improve performance. One of my high school cross country teammates often did his long weekend “base mileage” runs in jeans, and it completely freaked me out. On top of the obvious chafing issues, I could not handle the thought of just rolling out of a tractor cab on Saturday evening and loping off down a dirt road. I needed the ceremony of changing out of work clothes into shorts to help me transition. While sports apparel companies loudly tout the benefits of “moisture wicking,” breathability, compression, and aerodynamics, studies show that simply wearing an appropriate uniform, or even a good luck charm, for a sporting activity may improve performance, presumably because of psychological effects like focus and confidence.

So, even if you’re a borderline slob like me, here’s my advice as a licensed medical professional, for whatever it’s worth: wear the clothes and equipment that match your tasks for the day. If you’re going to the Oscars, wear a ball gown or tuxedo. If you’re exercising, wear whatever clothes are appropriate for the sport. And if you’re employed in knowledge work like I am, wear what you would wear to the office, even if your day will be spent at your own dining room table. You’ll feel better and perform better.

As the Medical Director of the Kansas Business Group on Health, I’m sometimes asked to weigh in on hot topics that might affect employers or employees. This is a reprint of a blog post from KBGH.

Should we punish people for inappropriate emergency room visits?

On a Saturday morning in November 2016, I woke up with a high fever and a frozen, excruciatingly painful right shoulder. I have a primary care doctor that I trust and like, but she, like most primary care docs, doesn’t work Saturdays. But I’m in the extremely privileged position of being married to a primary care physician (albeit not my primary care physician because that would be weird). My wife examined my shoulder, tsk-tsked my fever, and drove me to her clinic. One of her colleagues in the sports medicine department who happened to be in the building did a quick ultrasound of my shoulder and saw a possible effusion, or excess fluid, in the joint space, and recommended I be admitted to the hospital for a possible “septic joint,” the unglamorous medical terminology for pus in the joint space.

To make a four-day story short, I was admitted through the emergency department, went to surgery, had the shoulder drained, was seen by an infectious disease specialist who ruled out infection, continued to have fevers for a few more days, and left the hospital without a diagnosis, like around 15-20 percent of patients. But my fevers eventually subsided, and I healed up with the help of physical therapy. The problem hasn’t recurred.

I subject you to this story because I’m curious whether a modern insurance company would have considered my emergency department visit “appropriate.” I was clearly in distress. But to this day I have no diagnosis to explain my symptoms, and I can only assume that I would have eventually returned to my baseline state of health had I sweated out my fevers at home and taken over-the-counter pain medications for my shoulder.

But that’s all hindsight. My presentation really was worrisome for a septic joint, and when a patient presents with that diagnosis, we have maybe 24 hours to offer treatment before the infection causes irreversible damage.

United Healthcare, the largest health insurance company in America, decided a few months ago to start vetting emergency room bills, with the possibility of not covering a claim if the reason for the visit was not eventually deemed an emergency. Unsurprisingly, this caused an uproar not only among patients but understandably among doctors and hospitals as well. The doctors and hospitals don’t control who comes in the door, after all. They just take care of whoever walks in and try to cover the fixed costs of having a functioning 24/7 clinic open to the public. And as inefficient as emergency care can be, discouraging it could have the unintended consequence of diverting people away from needed care, and most patients already have a strong disincentive for ED use because of high-deductible plans and cost-sharing. And contrary to popular belief and the policy direction of many employers, Americans don’t actually overutilize care in comparison to patients in peer countries. So United Healthcare ultimately announced it would delay (but not abandon) implementing the new policy until after the COVID-19 pandemic has passed. (Anthem attempted a similar policy several years ago, but it is still tied up in litigation.)

On the other hand, though, it is generally accepted that the ED is a more expensive care environment than, say, a primary care doctor’s office. So if unnecessary ED visits could instead be diverted toward primary care visits, United Healthcare could save money and theoretically pass those savings on to everyone in the form of lower premiums.

So I was really interested to see Dylan Matthews’ analysis of the role of excess emergency department use in driving up healthcare costs. I cannot find a good link to his article; I got it via an email newsletter. So I’m going to do my best to outline his findings without committing outright plagiarism.

In short, Matthews found in speaking to a half-dozen healthcare finance experts from Harvard, Rutgers, and other institutions, that there is no evidence that reducing emergency department visits explicitly to save money actually works. This is, according to the experts, because rates of ED utilization have actually been steady for the last several years, and have actually dropped during and post-COVID-19. The problem with the ED, like with most of American medicine, is not utilization, but cost. And implementing a post-hoc vetting process like United Healthcare is proposing makes vulnerable patients the middle man in an astonishingly complex transaction. Some studies, like this one from 2017, show that incentives can provoke a small diversion toward primary care and way from the ED, but total costs don’t decline because the inpatient cost of the ED visit is simply shunted toward increased outpatient utilization. My personal caveat to this finding is that primary care is generally cost-effective in the long run, and that early intervention in the primary care setting is likely to lead to better outcomes. Short-term studies like the 2017 paper above don’t have the duration to detect this.

UHC and Anthem will presumably, sooner or later, get these policies going, and that will kick off a natural experiment that eventually tells us whether the policies do what they’re intended to do--decrease cost by decreasing ED use--or whether patients are harmed. What we unequivocally know is that the policies will lead to patients trying to decide if their problem is really an emergency. Is that chest pain because of your extra fries at supper, or is it a heart attack? Is that shoulder pain and fever a mystery that will never kill you, or do you really have a septic joint? It’s too early to predict what the effect of this will be. In the meantime, though, as we’ve mentioned many times before, the best way to optimize your employees’ care is to make sure they have good, low-cost access to a primary care practitioner.

We hope that insurance companies and other players in the health care marketplace can come up with more innovative ways to control cost, like addressing the outrageous prices charged for services compared to other countries, and spare patients the task of being their own health care providers and worse, small-claims adjusters.

As the Medical Director of the Kansas Business Group on Health, I’m sometimes asked to weigh in on hot topics that might affect employers or employees. This is a reprint of a blog post from KBGH.

Do Online Physician Ratings Actually Help?

Toward the end of my full-time clinical career, I attended a speech by a physician who encouraged doctors to “own” their online personas. He said we should actively manage our social media presence, our clinic websites, and our ratings by third-party sites like Angie’s List and Yelp. Against my instincts, I took his advice and Googled myself. Reader, I don’t mean to be histrionic. Many factors contributed to the end of my clinical career. But that innocent internet search did not, to put it lightly, make me excited to show up for work the next day:

I don’t share this anecdote as a bid for your pity. My experience with online ratings represents a tiny fraction of the “feedback” that a politician or a college football coach gets daily. I share the story as an entree to a question: do online physician ratings accurately reflect the quality of care people receive? If the ratings are accurate, then we should encourage our employees to use them. If they’re inaccurate, we should encourage employees (and practitioners) to ignore the ratings.

This is no idle inquiry. Some studies have suggested that up to 60 percent of patients consider online reviews important in choosing a provider. A recent national survey (paywall) of Americans aged 50 to 80, the heart of an internist’s practice like mine, revealed that more than 40 percent had looked up a physician’s rating for themselves at some time in their lives. Women, people with higher education levels, and (predictably) people with at least one chronic condition were more likely to have looked up a physician rating. The investigators in the recent study looked at several factors contributing to how prospective patients chose a physician, and online ratings came in only ninth, behind factors like “accepts my health insurance” and “convenient office location.” But the physician’s rating was still considered important almost as often as word-of-mouth reputation among family and friends, consistent with the results of smaller surveys.

But the ratings themselves are less influenced by clinical outcomes, like death, infection, or well-being, than they are by the patient’s experience. As we’ve blogged about before, denial of a patient request, especially for pain medications or lab tests, results in a dramatic decrease in patient satisfaction. That is surely poison for an online rating, regardless of the appropriateness of the denial. A very sophisticated study of dentist ratings showed that things like wait time were strongly associated with higher ratings, while raters barely mentioned clinical outcomes like infection or tooth loss. These experience-centric ratings may also reinforce biases that we already know exist. One study showed that, globally, male surgeons were rated higher on technical skills, while female surgeons were more highly rated for interpersonal skills.

It’s hard to tell if the ratings correlate with those harder clinical outcomes. A study of orthopedic surgeons’ online ratings found no correlation between ratings and total knee replacement outcomes. And one study found that the design of the rating website itself, like the presence or absence of advertisements for other doctors on the page, affected the quality of the data. But there is a hint of better outcomes in certain situations. A retrospective study showed that patients who had hip replacement surgery at hospitals highly ranked on physician rating sites did slightly better than patients at lower-ranked hospitals, for example.

If we can draw any conclusions from this muddled body of research, it seems that the most important lessons are, first, patients should understand the limitations of online reviews. A negative review of a highly skilled oncologist who has a gruff bedside manner may obscure the fact that his staff has experience in steering patients into clinical trials that may help complex cases. His staff’s skill may only be known by other providers. And second, doctors need to learn to use their online reviews as a source of quality improvement data. Someone who gives a doctor a lousy review may well have a valid complaint. The patient experience in American healthcare hardly has a sterling reputation. Instead of simply bristling at negative reviews, doctors should use the reviews as a tool to enact positive change.

As the Medical Director of the Kansas Business Group on Health I’m sometimes asked to weigh in on hot topics that might affect employers or employees. This is a reprint of a blog post from KBGH.