 Dr. Daniel Bronner. He's an associate professor of medicine at Pritzker, specializing in rheumatology and geriatric and palliative medicine. He's an associate director at the McLean Center for Medical Ethics and the director of the Geriatrics Fellowship Program. His research interests include cognitive impairment, dementia, language and medicine, and the history of resuscitation, cardiac arrest, indian art. Are you telling me to stop? No. He's conducted research evaluating decision-making capacity in patients with dementia and the effect of dementia on the care of non-dementia illnesses. Today he's going to give a talk entitled Miracles and Default Design, American Medicine and Crisis and Beyond. Please join me in welcoming our final speaker, Dr. Daniel Bronner. Thank you very much. That's the right time. I added one more word, microaggressions, which is really what I'm going to be talking about. But first, I'm going to hit on some of the usual tropes that I've talked about in this conference and other places before, and sort of tie it into this sort of new interest of mine, or a side interest. So, as I've said before, the key ethical issues in American medicine, as I see it in others as well, is one, the high costs, two, the lack of access to good medical care, health disparities which highlight the problems, moral and economic. And the fourth, which people don't think about as much, and I think which medical ethics really was established to deal with, was the onslaught of medical procedures that are performed on patients without sufficient attention to their expected effectiveness. This has also been called the technological imperative, and this is something that people have recognized since the early 80s when Howard Spiro, a pioneer in the medical humanities movement, encapsulated the force which he saw driving the increasing application of technology and medicine at a conference entitled the technological imperative. And he said, and I quote, we are all encouraged to do more in the way of technological activities today than 10 or 30 years ago, simply because third party payers pay for technology and not for thinking. When you talk with the officials, they point out that it is easy to assess, it should be there, not ask, the procedures but difficult to assess the costs of a thought. And that's been, I think, one of the basic problems in medicine today. And this problem actually goes way back. Hippocrates, you know, known for his sort of the beginnings of medical ethics as we know it now, was also working in a similar system, though not quite the same, but he also worked under the precepts of the fee for service model, which is not that usually attributed to him, but here you can read this here. I'm not going to read it for you, but what he talks about here is how one should go about getting paid by a patient. And it's probably not a good idea to talk to the patient when they're really sick or perhaps dying, but you should wait until they get better and then you can extort money from them. So the fee for service model has been with us for a long time. And this is one of my recurrent themes here. I think the natural experiment that happened in the mid-60s with the onset of the passing of Medicare, and in 1966, the beginning of Medicare to pay for medical care, we see the experiment in which the AMA sort of grafted the fee for service model onto government sponsored medicine. And I see this as sort of the ultimate sort of evolution of the fee for service model in what we see today in medicine. And they created what is known as a current procedural terminology. This is the first edition, was a pretty thin volume in 1966. And this is where we first see the visit as a procedure and you see the various levels of visits. And this is something I'll get back to. But here we see the initial visit routine going all the way up to a very complete visit with different relative value units or fees being charged for those. Another important consequence of the CPT codes, I think that has not been really appreciated, is the way specialty was transformed by the CPT codes. Because what they did was they codified the notion of consultation. Prior to the institution of CPT codes in the mid-60s, specialists were still taking care of whole patients. You would take care of patients who had your disease like a cardiologist would be the, it wasn't called primary, but they would be the physician for a patient with heart disease. This changed drastically in the 60s and 70s with this notion of consultation, which was a higher fee, which was encouraged, which was noted, developed its own CPT code. And you see here the last line, when the consulting physician assumes responsibility for the continuing care of the patient, any subsequent services rendered by him is no longer, and it is him, right, is no longer considered a consultation. And so you see here that there was a big incentive for specialists not to take care of the rest of the patient. And in fact, you see the nature of specialty changing a lot after the institution of CPT codes. And of course, as I've said on several occasions, with the second edition of CPT in 1970, now a much larger volume, 70% larger, we see the listing of CPR, cardiopulmonary resuscitation for cardiac arrest as a billable procedure. And as I've said before in this forum, this is the moment when CPR becomes the default for all deaths in hospitals in the U.S. With commencement, commencing with CPT codes, we see the birth of the medical industrial complex, which Relman noted in 1980, 10 years after the second CPT code in which you see the increasing corporatization of medicine and the huge influx of money into medical care. So I'm going to talk about some of the consequences of what happened as a result of this influx. And one of these, this is a Chicago Tribune talking about Chicago history today. From a few years after the heat wave, March 14, 1999, you see the headline on the front page here, U.S. Sews UFC in Medicare Overbilling. So enlarging this a little bit. So in summary, what happened was they point out that UFC is a Midwest premier medical research institution that they've been fraudulently overbilling or upcoating. And now this was not limited to the UFC. This was a movement. University of Pennsylvania had just recently settled a few years earlier for $30 million. Our case actually began in 1996 with a sealed whistleblower complaint. And this was actually a campaign that began in earnest around 1994 after President Clinton's healthcare reform plan failed. It's a response to the just incredible increase in the amount of money that was being put into medicine by the government. And they actually, this campaign, that had billions of dollars. In fact, the Blue Cross Bullsheel in Illinois paid $144 million for their fraud. And Attorney General Janet Reno, as many people remember, placed fighting healthcare fraud as her second highest priority next to prosecuting violent crime. So the government was very serious about this. And eventually the UFC got away with only paying $10 million in basically for upcoating from 91 to 97. And they settled, as I said, for $10 million. And with this settling, what we see is a real change. People became very aware of this whole notion of fraud and how to prevent it. And many of you may recognize this card. This is a billing card. And it sort of directs you how to bill according to the note you write. You know, your level of history, exam, and DM is decision making. And it's a very complicated calculus that I've actually never mastered, I must say. That people started really instituting in the mid-90s after these fines were levied. And so you see here, this is for subsequent patient encounters. And so what we see here is the medical record becomes a support for the level of CPT code billing. This becomes sort of a very key imperative in caring for patients, especially in medical specialties which don't have actual procedures besides seeing the patient and taking care of them. And so the medical record becomes first and foremost a billing document. And proper documentation, using the right words, became the means for avoiding what became known as fraud. And people are talking a lot about fraud after these cases. And fraud awareness training became a yearly mandatory activity. And this is a little snippet from one of my emails I received about going to fraud awareness training, studying how not to do fraud. And these are some of the, now they're actually the classes are online. And this is one of the classes that I was forced to take. Just giving you the language of what you actually need to say in the chart in order not to be committing fraud. You see, the one on the left is inadequate and the one on the right is the proper documentation and so that you would not be committing fraud. And these are some of the other key documentation devices about how to document things so that one is not committing fraud. So I think there are a lot of unintended consequences of this sort of response to the skyrocketing costs of medical care. And first of all, it didn't work to decrease the amount of money that the government was spending. What happened was that people got much better at writing records that you could document care still at the highest level. And everybody's encouraged to still build the highest level because why wouldn't you if you could? What happened to the record itself though is that it becomes much harder to find the patient in the medical record because so much of the language has become generic in terms of use for justifying billing. There's also an emphasis on pathology and risk as was talked about yesterday. The higher the risk of the patient, the easier it is to bill at a higher level. And so patients, it's very hard to find patients that are not high risk. And I would say it changed the dynamic between patients and doctors, especially younger physicians in teaching institutions who were actually charged with creating this documentation. They write the notes and attending physicians a test after that. And as John Lapuma talked about burnout and prevention, I think it's hard to find a physician these days who's not at least crispy around the edges, as I like to say, in terms of their response to all these pressures about what they have to write and the amount of documentation that does not seem that helpful in actually taking care of patients. And I think in some cases what happens is that the frustration of having to document these things is taken out on patients. And I like to frame these in terms of microaggressions. And the microaggression I'm going to talk about most today is one I see in charts all the time doing geriatrics and consulting on older patients. And that is the poor historian. So what are microaggressions? Simply stated microaggressions are derogatory slides or insults directed at a target person or persons who are members of an oppressed group. And here I'm making the case that patients in the hospital can be looked upon as an oppressed group. So microaggressions communicate bias and can be delivered implicitly or explicitly. So how do microaggressions manifest? Just a little taxonomy for you. You have the microinsult, which is more of a blatant verbal or nonverbal or environmental attack on a target group. That's more obvious. Microinsults is really what we're talking about. So these are unintentional behaviors or verbal comments that convey rudeness or demean a person's racial heritage, identity, gender identity, religion, their ability or sexual orientation and identity. And I think it's a patient's ability that is really being questioned by this one. Microinvalidation, just to round it out, is verbal comments or behaviors that exclude the gait or dismiss the psychological thoughts, feelings, or experiential reality of the target group. This is the classic, you know, rejoined that I'm colorblind. I don't, you know, there's no problem here. So the poor historian as a microaggression. People, and this has been studied just a little bit, but people labeled as poor historians are often older, may have communication difficulties due to deafness, speech disturbances, cognitive dysfunction, or distraction, pain, or emotional distress. But I would say that other groups as well are often characterized and somebody should do some empirical work about this, but I'm not going to do it. So I think the poor are definitely often, if you look at who gets listed as a poor historian, they're often poor, they're often minority groups, or just the disenfranchised in general. And in addition, the problem with the term bad historian or poor historian is that the patient is not really the historian in the first place, right? The doctor or the healthcare provider, the person who is eliciting what happened and writing it down is the historian, the patient is the source, right? And so calling the patient a poor historian is actually wrong besides being a microaggression. It's often, it's also not the reality of the situation. So question like, what are other microaggressions as I've been thinking about these days? I think the term drug abuser, especially when it's used in the first line of a history and physical, is a microaggression. It's a way of denigrating the patient and calling attention to them in a negative way. I think the whole, in certain aspects, when people talk about low health literacy, I think that can be seen as a microaggression. Basically what they're saying is they don't understand what I'm telling them. As with poor historian, it puts the onus on the patient as the one who has the problem here, when actually it may be the person who's telling the person what's going on that may have the problem. Also, the notion of the non-compliant patient, the patient won't do what I tell them to do. That's the other sort of, as opposed to the notion of what's going on here, why isn't the patient taking whatever I told them to take, looking more deeply into these problems. And that's it. Thank you. You made it to the very end. Mark, thank you very much for giving me this opportunity. I have to say quickly, thanks Steve. I want to thank everybody for attending and speakers and Monica for moderating this last session. And thank you for coming to the 31st Annual McLean Conference. I'm just thinking that the dates of next year will be November 13 and 14. But that's still a little bit up in the air.