COMMENTARY

A Corrosive Force in Medical Care

John M. Mandrola, MD

Disclosures

October 20, 2017

It comes in a large white envelope each month. It's marked confidential.

When I hold it up to the light, I can see through the envelope. I can't see the details, but the colored graphs give it away.

It's my monthly productivity report based on relative value units (RVUs). Most employed doctors get these graphs.

These "dashboards" of value include your own productivity as well as many other graphs showing how you stack up with other doctors across the country. It tells your employer if you are a hard worker.

Doing an ablation, catheterization, or stent or valve replacement earns a bunch of RVUs.

Listening to patients, examining patients, counseling patients, or hugging patients earns very few RVUs.

Doing important research, teaching colleagues, and reading the medical evidence earns zero RVUs.

Too often, in too many medical systems, RVUs have become the primary unit of success.

No, you can't be a mean and nasty doctor. And no, you can't be a totally unskilled doctor who has too many complications.

But short of those extremes, if you make few waves, have good templates on your electronic health record so documentation is complete, and do tons of procedures, you are valuable.

If, on the other hand, you like slow, conservative medicine, or narrative notes rather than templates, or worse, if you are thoughtful and frank about silly policies, you become an outlier. If you do these things, your RVU tally usually does not reach the 75% of standard bar. Then trouble can come to you.

These trends are not so problematic for people close to the end of their career.

What's really scary, though, is that this is the milieu in which a younger generation of clinicians is learning the craft. I was shocked to learn that a major teaching center (which will remain nameless) compensates its teaching faculty solely on the basis of productivity. Imagine that. Educators whose paychecks are determined by the number of RVUs they generate rather than the bedside skills they impart to learners.

This, my friends, is happening in many of the places you go to get healthcare.

It's why I tweeted this recently.

Productivity and the RVU have no place in medical care. There needs to be a different system of valuing the care of people with disease.

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