Jiffy Lube Medicine: The MBA's Take Control of Medical Care

You take your car in for an oil change and the guy who changes the oil knows only how to change oil. He is not a mechanic, because the oil change place does not need to pay a mechanic's wages to a guy who does  just one thing: change the oil. He does not--cannot--look at the brake pads,  notice the axle and wheel bearings are worn, notice the nail in your sidewall which will blow out the next time you exceed 60 MPH,  inspect the parts of the car which, if they fail, can kill you. You may natter on to him about the fact that when you turn the wheel hard, you get a shuddering and a whining which, if you knew more, or if he knew more,  might suggest your steering is about to fail. So you can drive out in your car with new oil and a whole host of lethal pathologies, undetected.

Your oil is changed and you are out the door, and you judge the experience by the amount of time you had to wait to have your oil changed and the price.

Current models of providing medical care are designing the office visit to be a sort of Jiffy Lube medical experience: Get in, get out. One task at a time. Pay and go.

The managers of medical practices are now designing their systems the same way. The endocrinologist is told not to waste his time adjusting his patient's insulin doses--let a lower paid, limited skill worker do that for a dozen patients--the physician's assistant (PA)-- who can look at the data from the computer download of the patient's home glucose testing device, write the insulin prescriptions, make some adjustments to the insulin doses,  and get the patient out the door. Change the insulin like changing the oil. Pay and go.

If you were that patient, you may have seen your "internist" last week, where you were seen by another physician's assistant, who wrote prescription renewals, but never had you take your shirt off, never listened to your heart or lungs. That PA had renewed your prescriptions for your blood pressure and for your cholesterol. Ten, twelve minutes, pay and go.

That PA did the job the MBA who designed the practice wanted done: The PA moved that patient in and out of a room in 12 minutes, generated a bill and moved on to the next patient. In an 8 hour day, at 12 minutes a patient, that's 40 patients a day. This is the Holy Grail of MBA run medical practice. Maximizing "productivity."  AKA maximizing "efficiency."  AKA minimizing wasted effort.

Of course, neither physician's assistant had you take off your shirt, so neither has looked at your skin, so they missed the melanoma on your shoulder, and neither has had you take off your shoes and socks, so they miss the swelling in your feet, and neither picks up the fact there is a nail head flush with the sole of your foot, a nail you cannot feel because you have neuropathy in your feet, because your feet are your podiatrist's job.   Neither PA has examined your eyes with an opthalmooscope, because that's your opthalmologist's job. Neither has phoned your cardiologist to ask whether you were in atrial fibrillation at the last visit, because neither listened to your heart, so neither picked up the fact that you had slipped silently into atrial fibrillation, for the first time in your life.

A week later, the undiagnosed atrial fibrillation in your heart results in a the formation of a clot in your left atrium, which plops into the left ventricle and gets catapulted to your brain, but you are lucky because it goes to the right side of your brain, rather than the left side where the speech center is, so you can still speak, although you cannot move your left arm or leg.

But, fear not, you have had efficient, state of the art medicine,  standard of care, from "providers" who are highly "productive."

If you had had a real doctor exam you, if he had taken 30 minutes, instead of the 12 minutes the PA's spent with you, you would be walking  today. That foot with the nail would not have had to get amputated. And, oh yes, the melanoma which has silently metastasized to your brain and lungs and which will kill you in two years, that might have been discovered at a curative stage,  if a real doctor had examined you. But missing that was not your endocrinologist's fault, nor the fault of his PA. Examining your skin, doing a "mole patrol," is the job of the dermatologist. 

Luckily, you have been well served by the new highly productive medically efficient form of practice:  You will not have to suffer long hobbling around on one foot, half your body paralyzed; your misery will be short lived because the melanoma will claim you quickly.


We now have efficiency in medicine, as defined by the MBA's and as administrated by the MD's with MBA's who were once obstetricians or anesthesiologists,  but are now burnt out,  and they are running hospital owned physicians' practices in areas where they have never practiced, and they are calling the shots for men with prostate cancer and people with diabetes, hypertension, cholesterol trouble and kidney, eye and nerve disease caused by the diabetes.

We have medical practice orchestrated by people who would not know good medical practice (as we were taught it  in the days of the dinosaurs) if they tripped over it.

We have medical practice which is very efficient from the perspective of the people billing for the services:  Each task has been identified, given a billing code and the insurance companies billed electronically and the payments made.  Ever code is accurate and everything is done according to the billing rules. Nothing is done according to the rules of good medical practice, as those rules were developed in the medical schools of yore.

From the patient's perspective, maybe things are not so efficient. You need to schedule ten appointments,  where before you needed only one. You need to travel, wait in the waiting rooms, ten times and even then, since each practitioner is focusing on only one ten centimeter part of you, things get missed. You needed an appointment with the eye doctor, the kidney doctor, the heart doctor, the dermatologist, the endocrinologist, the pain doctor, the orthopedist, the neurologist, the neurosurgeon.

Costs to the medical system as a whole have not diminished as a result of this approach, of multiple billings and multiple visits,  but the accounting ledgers of the people with MBA's running each of these practices have been mightily improved.

We do not have the best medical practice money can buy in this country, just the most expensive medical care.

It's not President Obama's fault.  It is difficult to identify who is at fault. There is not just one villain. There are simply people exploiting the game, making money, doing more harm than they know and more harm than they even care to know. They are just doing their jobs. Just following orders. Innocent gamers. Don't blame them.

Heaven help us all.